History Of Fragility Fracture Research Articles

IMPACTO DE LA PANDEMIA POR COVID-19 EN LA EPIDEMIOLOGÍA, MANEJO Y SUPERVIVENCIA DE LOS PACIENTES CON FRACTURA DE CADERA

The COVID-19 pandemic has forced a reorganization of health resources towards the care of patients with severe respiratory syndrome. While the incidence of traumatic pathology was reduced, this was not the case with hip fractures, and their management could be compromised. The objective of this study is to evaluate the consequences of the pandemic on the epidemiology, management and outcomes of hip fracture. Material and methods: A retrospective observational cohort study was done including patients with hip fracture treated between March 2019 and February 2021, establishing two groups for comparison, before and after the onset of the pandemic. Demographic variables, comorbidities, history of fragility fracture and hip fracture, type of fracture and type of treatment performed, surgical delay, length of hospital stay, and PCR result for SARS-CoV2 upon admission were recorded. In-hospital mortality rate and survival at 1 and 6 months were analyzed. Results: 251 patients were included, 137 (54.58%) PRE-COVID group and 114 (45.42%) POST-C group. There were no differences in demographic variables, comorbidities, type of fracture, or treatment performed. The absolute incidence was reduced by 16.8% and the relative incidence was reduced by 17.6%, this difference was significant during lockdown period and in the months o January and February, the period of maximum incidence of COVID-19. The incidence of PCR + on admission was 1.75%. No significant differences were found in surgical delay, hospital stay and mortality, survival at one month or at 6 months. Conclusion: With the COVID-19 pandemic, specific reductions in the incidence of hip fractures have been observed, without changes in its epidemiology, indicators of hospital management and in patient survival at one and 6 months.

Longitudinal Evolution of Bone Microarchitecture and Bone Strength in Type 2 Diabetic Postmenopausal Women With and Without History of Fragility Fractures-A 5-Year Follow-Up Study Using High Resolution Peripheral Quantitative Computed Tomography.

IntroductionDiabetic bone disease is characterized by an increased fracture risk which may be partly attributed to deficits in cortical bone quality such as higher cortical porosity. However, the temporal evolution of bone microarchitecture, strength, and particularly of cortical porosity in diabetic bone disease is still unknown. Here, we aimed to prospectively characterize the 5-year changes in bone microarchitecture, strength, and cortical porosity in type 2 diabetic (T2D) postmenopausal women with (DMFx) and without history of fragility fractures (DM) and to compare those to nondiabetic fracture free controls (Co) using high resolution peripheral quantitative computed tomography (HR-pQCT).MethodsThirty-two women underwent baseline HR-pQCT scanning of the ultradistal tibia and radius and a FU-scan 5 years later. Bone microarchitectural parameters, including cortical porosity, and bone strength estimates via µFEA were calculated for each timepoint and annualized. Linear regression models (adjusted for race and change in BMI) were used to compare the annualized percent changes in microarchitectural parameters between groups.ResultsAt baseline at the tibia, DMFx subjects exhibited the highest porosity of the three groups (66.3% greater Ct.Po, 71.9% higher Ct.Po.Volume than DM subjects, p < 0.022). Longitudinally, porosity increased significantly over time in all three groups and at similar annual rates, while DMFx exhibited the greatest annual decreases in bone strength indices (compared to DM 4.7× and 6.7× greater decreases in failure load [F] and stiffness [K], p < 0.025; compared to Co 14.1× and 22.2× greater decreases in F and K, p < 0.020).ConclusionOur data suggest that despite different baseline levels in cortical porosity, T2D women with and without fractures experienced long-term porosity increases at a rate similar to non-diabetics. However, the annual loss in bone strength was greatest in T2D women with a history of a fragility fractures. This suggests a potentially non-linear course of cortical porosity development in T2D bone disease: major porosity may develop early in the course of disease, followed by a smaller steady annual increase in porosity which in turn can still have a detrimental effect on bone strength—depending on the amount of early cortical pre-damage.

Assessment of previous fracture and anti-osteoporotic medication prescription in hip fracture patients.

Hip fracture prevention is an essential component in elderly patient care. History of prior fracture is a significant risk factor for subsequent hip fracture. There are variable rates of treatment for these groups of patients. The aims of this study were to make an assessment of how many hip fracture patients over a 1 year period had a previous fracture and to assess whether or not these patients were on anti-osteoporotic medication. Assessment on whether or not patients had a prior fracture using the national radiology imaging system checking radiology reports for all previous imaging performed. Checking patients bone health status using the hip fracture database for our hospital. There were 225 hip fractures in 221 patients over a 1-year period. About 42.6% of females and 35.9% of males had a history of previous fracture. Vertebral fractures were the most common type of fracture. We found 7% of patients had a contralateral hip fracture. There were 81% of patients with prior fracture, and 71% of those without prior fracture were on anti-osteoporotic medication. Vertebral fractures were the most common preceding fracture in hip fracture patients. There were many patients with a history of fragility fractures that were not on preventative medication. Overall there were good prescription rates of anti-osteoporotic medication. There were significantly higher rates of prescription amongst females compared with males.

The importance of vertebral fracture assessment in postmenaupausal patients with osteopenia

Osteoporosis is clinically defined by the presence of at least one fragility fracture. In patients without a prior history of fragility fractures, a dual-energy X-ray absorptiometry (DXA) scan represents the gold standard for the diagnosis of osteo­­po­ro­sis, based upon the bone mineral density (BMD). Although DXA is the gold standard method to assess the BMD, DXA has some important limitations especially in pa­­tients with vertebral fractures or degenerative spinal chan­­ges, where a low BMD corresponding to osteopenia does not exclude osteoporosis. The aim of this case report is to highlight that clinicians should not solely rely on the DXA scan. In these patients, additional information about the presence of vertebral fractures should be obtained with ra­dio­graphs of the spine for the diagnosis of osteoporosis.

110. Bone Mineral Density Screening in Veterans Living with HIV

BackgroundLow bone mineral density (BMD) is more prevalent in people living with HIV (PLWH) than in the general population. Although no consensus exists regarding when to start screening for BMD loss in PLWH, the Infectious Diseases Society of America (IDSA) recommends dual x-ray absorptiometry (DXA) for men aged ≥50 years, postmenopausal women, and patients with a history of fragility fracture, chronic glucocorticoid treatment, or at high fall risk. The objective of this study is to evaluate how well this guideline is being carried out in a population of veterans living with HIV (VLWH).MethodsWe retrospectively identified VLWH seen at the Veterans Affairs Medical Center (VAMC) in Houston, TX, between 2014–2018 via the VAMC HIV Registry. We extracted demographic, laboratory, and clinical variables, as well as DXA results via this registry database and subsequent chart review.ResultsWe identified 1,306 VLWH who received care between 2014–2018; 197 turned 50 years old during this time period. Of those, only 32 (16.2%) underwent DXA (2 women, 30 men). DXA revealed normal BMD in 17 (53.1%), osteopenia in 12 (37.5%), and osteoporosis in 3 (9.4%), as defined by traditional DXA T-score cutoffs. Average CD4 count at time of DXA was 698 cells/mm3 (n=30) (average CD4 for those with normal DXA was 654 [n=16] and for those with osteopenia/osteoporosis it was 749 [n=14]; t-test p = 0.47). Thirty had HIV viral load (VL) < 100 copies/mL; the remaining 2 had VLs of 11,200 and 2,980, both with normal DXAs. Vitamin D (VD) levels were available for 1,005 (77%) VLWH in the study cohort. Of those, 278 (27.7%) were VD deficient (25-hydroxy VD level of < 20 ng/mL). VD levels were available for 31 of the 32 VLWH who had DXA after turning 50 years old; the average VD level was 22.76 (24.61 [n=16] for those with normal BMD and 20.78 [n=15] for those with osteoporosis/osteopenia; t-test p = 0.30).ConclusionOur results indicate that adherence to IDSA BMD screening guidelines in VLWH can be improved. Given that nearly half of the screened patients showed evidence of BMD loss on their initial DXA, efforts should be made to increase awareness and screening in this vulnerable population. Prevention, earlier diagnosis, and treatment of BMD loss in VLWH would likely lead to decreased morbidity associated with fractures due to low BMD in this population.Disclosures All Authors: No reported disclosures

Effects of Bisphosphonates on Osteoporosis Induced by Duchenne Muscular Dystrophy: A Prospective Study

Duchenne muscular dystrophy (DMD) is a severe X-linked progressive neuromuscular disease that brings a significantly increased risk of osteoporosis and bone fractures. We prospectively evaluated the effects of oral and intravenous bisphosphonates on the bones of children with DMD. This study included a total of 52 children with DMD. They were divided into zoledronic acid (ZOL), alendronate (ALN), and control groups according to bone mineral density (BMD) and history of fragility fractures. For 2 years, all patients took calcium, vitamin D, and calcitriol. Meanwhile, 17 patients received infusions of ZOL, and 18 patients received ALN. BMD, serum levels of alkaline phosphatase (ALP) and the cross-linked C-telopeptide of type I collagen (β-CTX) were evaluated. After 24 months of treatment, the percentage changes in lumbar spine BMD were 23.2 ± 9.7% and 23.6 ± 8.8% in the ZOL and ALN groups (all P<.01 vs. baseline). The increases did not differ between the ZOL and ALN groups, but were significantly larger than those of the control group (P<.01). Serum β-CTX and ALP levels, respectively, were decreased by 44.4 ± 18.0% and 31.9 ± 26.7% in the ZOL group and by 36.0 ± 20.3% and 25.8 ± 14.4% in the ALN group (all P<.01 vs. baseline). Zoledronic acid and alendronate had similar protective effects to increase bone mineral density and reduce bone resorption in children with DMD, which were superior to treatment of calcium, vitamin D, and calcitriol. 25OHD = 25 hydroxyvitamin D; ALN = alendro-nate; ALP = alkaline phosphatase; ALT = alanine aminotransferase; BMD = bone mineral density; BP = bisphosphonate; Ca = calcium; β-CTX = cross-linked C-telopeptide of type I collagen; DMD = Duchenne muscular dystrophy; FN = femoral neck; GC = glucocorticoid; LS = lumbar spine; ZOL = zoledronic acid.

Prevalence and clinical characteristics of X-linked hypophosphatemia in Paraná, southern Brazil.

The aim of this cross-sectional study was to estimate the prevalence of XLH in Paraná, a state in southern Brazil, and report the clinical features and complications of the disease. We invited all endocrinologists (n = 205), nephrologists (n = 221), orthopedic surgeons (n = 1020), and pediatricians (n = 1000) in Paraná to fill out an electronic survey with information on patients with X-linked hypophosphatemia (XLH), and searched the records of the state's health department for all calcitriol prescriptions in 2018. In all, 244 (10%) specialists responded to the email, of whom 18 (7.4%) reported to be taking care of patients with XLH and answered the online survey. A total of 57 patients with XLH were identified (prevalence 5 per million inhabitants). The median age at diagnosis was 22 years, and 42.2% were children and adolescents. Fifteen patients had genetic testing showing a PHEX mutation. Overall, 91.2% had bone deformities, 30.8% had a history of fragility fractures, and 22.4% had renal complications. This study demonstrated a prevalence of XLH of 5 cases per million inhabitants in the state of Paraná, a rate lower than the one reported in other countries. Manifestations of renal calcification and bone fragility were frequent among the patients. This is the first epidemiological study evaluating the prevalence and clinical presentation of XLH in Latin America.

Effects of bisphosphonates on osteoporosis induced by Duchenne muscular dystrophy: A prospective study

ABSTRACT Objective: Duchenne muscular dystrophy (DMD) is a severe X-linked progressive neuromuscular disease that brings a significantly increased risk of osteoporosis and bone fractures. We prospectively evaluated the effects of oral and intravenous bisphosphonates on the bones of children with DMD. Methods: This study included a total of 52 children with DMD. They were divided into zoledronic acid (ZOL), alendronate (ALN), and control groups according to bone mineral density (BMD) and history of fragility fractures. For 2 years, all patients took calcium, vitamin D, and calcitriol. Meanwhile, 17 patients received infusions of ZOL, and 18 patients received ALN. BMD, serum levels of alkaline phosphatase (ALP) and the cross-linked C-telopeptide of type I collagen (β-CTX) were evaluated. Results: After 24 months of treatment, the percentage changes in lumbar spine BMD were 23.2 ± 9.7% and 23.6 ± 8.8% in the ZOL and ALN groups (all P Conclusion: Zoledronic acid and alendronate had similar protective effects to increase bone mineral density and reduce bone resorption in children with DMD, which were superior to treatment of calcium, vitamin D, and calcitriol. Abbreviations: 25OHD = 25 hydroxyvitamin D; ALN = alendro-nate; ALP = alkaline phosphatase; ALT = alanine aminotransferase; BMD = bone mineral density; BP = bisphosphonate; Ca = calcium; β-CTX = cross-linked C-telopeptide of type I collagen; DMD = Duchenne muscular dystrophy; FN = femoral neck; GC = glucocorticoid; LS = lumbar spine; ZOL = zoledronic acid

Characteristics of sagittal spine alignment in female patients with distal radius fractures due to fall

ObjectivesDistal radius fractures occur due to reflex clasp when falling. Recently, attention has been focused on the strong relationship between sagittal spine alignment and falls. Therefore, we investigated the parameters of sagittal spinal alignment in distal radius fractures in female patients. Patients and methodsThe subjects were group D: 28 female patients with distal radius fractures aged 50 years or older (mean age: 69.3 years), and group C: 26 healthy female patients without a history of fragility fractures (mean age: 70.5 years). Height, body weight, and body mass index (BMI) were measured as physical indices. As parameters of sagittal spinal alignment, the sagittal vertical axis (SVA), pelvic tilt (PT), pelvic incidence (PI), sacral slope (SS), lumber lordosis (LL), and thoracic kyphosis (TK) were measured on lateral whole-spine plain radiographs in a standing position. The measured physical indices and sagittal spinal alignment parameters were compared between groups. ResultsHeight, weight, and BMI did not differ significantly between the two groups. Among the sagittal spinal alignment parameters, PT, PI, SS, LL, and TK did not differ significantly between groups, whereas SVA was significantly higher in group D than in group C (P < 0.05). ConclusionIn this study, SVA was significantly higher in group D than in group C. As SVA increased, the center of gravity of the body shifts forward, which can cause the body to lose balance and fall. This study suggested that an increase in SVA is associated with distal radius fractures.

P0902DAILY TERIPARATIDE TREATMENT AND PHARMACOKINETICS IN HEMODIALYSIS PATIENTS WITH LOW BONE MASS

Abstract Background and Aims Daily 20µg teriparatide (PTH1-34) is an osteoanabolic agent approved for use treating osteoporosis. However, there are few reports about concerning use of this agent in hemodialysis patients. Method We conducted an observational study, single centre study on 5 patients with low bone mineral density (BMD) and low iPTH levels defied as iPTH below 60 pg/mL, who were treated with recombinant human PTH1-34; teriparatide 20 µg 3 times per week between January 2012 and January 2015. All patients were 20 years of age or older, had undergone regular hemodialysis treatment and were without skeletal malignancies and bone metastasis. Low BMD in this study was defined either as BMD T-score -2.5 at the lumbar spine (LS) or /and femoral neck (FN) and distal one –third radius (RS) analyzed by dual-energy X-ray absorptiometry (DXA), or BMD T-score of -2.5 to -1.0 with history of fragility fractures. We analyzed the biochemical data including bone metabolic makers (intact amino-terminal propeptide of type I collagen (iP1NP), bone alkaline phosphatase (BAP), and tartrate-resistant acid phosphatase-5b (TRACP-5b) at baseline, and after 3, 6, and 12 months of teriparatide treatment. BMD at LS and FN were evaluated at 6months of treatment. Results Data from five patients (mean age: 69.2±7.4years; mean hemodialysis time: 23.2±6.2years) were reviewed. Laboratory data at baseline were iPTH: 34.2±24.2 pg/mL, BAP: 13.0±4.9 µg/L, iP1NP: 45.3±14.3 ng/mL, TRACP-5b: 350±201 mU/dL, corrected Ca (cCa): 9.7±0.3 mg/dL, and P:4.1±0.7 mg/dL. Baseline BMD T-score at LS and FN were -2.8±1.7 and -3.0±0.6, respectively. During a 12 month- teriparatide treatment, mean cCa levels significantly decreased from 9.7±0.3 to 9.1±0.2 mg/dL at 3 months (P &amp;lt; 0.05) and returned to 9.5±0.4 mg/dL at 12 months. As for bone metabolic markers, BAP and iP1NP significantly increased from baseline by 31.3±12.9 (P &amp;lt; 0.05) and 47.4±14.5% (P &amp;lt; 0.05) at 6 months of teriparatide treatment, while TRACP-5b significantly decreased by 10.5±2.5% at 3 months, which did not reach a statistical significance. BMD changes from baseline at LS and FN were 2.1±2.5% and 1.2±1.5% at 6 months of treatment with a significant change at LS. Pharmacokinetics of Teriparatide The time-course of changes in plasma teriparatide acetate concentration was evaluated in one patient who had undergone parathyroidectomy 20 years before enrollment in this study and her serum endogenous iPTH level was undetectable at baseline. After teriparatide injection, serum teriparatide acetate levels peaked at 30 minutes at 157.2 pg/mL, and then rapidly decreased to undetectable levels at 240 minutes. Conclusion We report that teriparatide improved LS and FN BMD in hemodialysis patients with low iPTH. Pharmacokinetics showed this agent might not accumulate in dialysis patients and can be used safely. Adequate Ca supplementation might be needed to adjust serum Ca levels.

MON-363 Massive Bony Exostoses and Diffuse Osteosclerosis Secondary to Hepatitis C: Case Report

Introduction:Acquired osteosclerosis due to hepatitis C is a rare complication. While there are previously published case reports of this condition, to our knowledge this is the first case reported with diffusely increased osteosclerosis and prominent bony exostoses.Clinical Case:A 52-year old woman was evaluated in the Metabolic Bone Clinic for non-radiating left hip pain and visibly prominent hard, non-tender masses at the lateral aspect of her bilateral hips and proximal humerus. She denied history of fragility fractures, radiation exposure, risk factors for sexually transmitted diseases or substance abuse. Laboratory evaluation showed vitamin D deficiency with a value of 18 ng/mL (reference range: 25-100 ng/mL), elevated alkaline phosphate of 426 IU/L (reference range: 30-116 IU/L) and markedly increased serum C-telopeptide with a value of 1901 pg/mL (reference range: <1008 pg/mL). Plain radiographs showed multiple exostoses at the pelvis, hip, and shoulders. MRI showed extensive thoracic spine endplate sclerosis and increased sclerosis throughout the pelvis and proximal femurs. Massive calcifications adjacent to the greater trochanters were also identified. A total body bone scan revealed intensely increased uptake in multiple bones consistent with a “super scan.” Bone biopsy showed sclerotic bone with extensive remodeling. Computed tomography of the chest, abdomen, and pelvis was negative for malignancy. Given the symmetric nature of these lesions and diffusely increased uptake, the diagnosis of metabolic bone disease was considered. Further testing revealed hepatitis C Ab positivity confirmed with HCV Quant PCR 1553475 IU/mL (reference range: undetected). Pathologic findings were attributed to hepatitis C and treatment for hepatitis c was initiated with subsequent improvement in alkaline phosphate to 273 IU/L.Clinical Lessons:Osteosclerosis represents a little-known complication of hepatitis C. It is postulated that hepatitis C itself or other unknown agents may stimulate hepatic growth factors that increase osteoblast action. The radiographic and bone scan findings are classic for acquired osteosclerosis seen as increased cortical thickening with an intensely increased uptake in multiple bones. It frequently affects the lower extremity and this condition may take years to develop. Bone formation markers such as alkaline phosphate are typically elevated and bone biopsies show increased rates of remodeling as seen in our patient. While bisphosphonates may improve the serum markers for bone formation, they have not been shown to reverse or halt the progression of skeletal changes. Thus far, there has been a single case report showing improvement in sclerosis following treatment for hepatitis C with ribavirin and interferon. Natural history, progression and treatment of this condition have not been well established.

Assessment of Risk Factors for Fractures in Patients with Type 2 Diabetes over 60 Years Old: A Cross-Sectional Study from Northeast China.

Aims Previous evidence has demonstrated an increased fracture risk among the population with type 2 diabetes mellitus (T2DM). This study investigated the prevalence of bone fractures in elderly subjects (with and without type 2 diabetes) and identified any fracture risk factors, especially the risk factors for common known fractures in particular diabetic populations. Methods This cross-sectional study was conducted with community-dwelling people over 60 years old in nine communities from the city of Shenyang, which is the capital of Northeast China's Liaoning Province. A total of 3430 elderly adults (2201 females, mean ± standard deviation age 68.16 ± 6.1 years; 1229 males, 69.16 ± 6.7 years) were included. Our study measured the heel bone mineral density (BMD) and used the timed “up and go” (TUG) test and other indicators. In addition, we performed logistic regression analysis to explore the risk factors for fractures in the general population and the diabetic population and to analyze the differences. Results The results revealed that a total of 201 elderly persons (5.8%), with an average age of 70.05 ± 6.54 years, suffered from a history of fragility fractures, which affected more females (74.6%) than males (p = 0.001). The prevalence of fractures in the T2DM population was 7.3%, which was much higher than the 5.2% in non-T2DM population (p = 0.001). The prevalence of fractures in the T2DM population was 7.3%, which was much higher than the 5.2% in non-T2DM population (p = 0.001). The prevalence of fractures in the T2DM population was 7.3%, which was much higher than the 5.2% in non-T2DM population (p = 0.001). The prevalence of fractures in the T2DM population was 7.3%, which was much higher than the 5.2% in non-T2DM population (T‐score≤−2.5 (OR 1.750) were independent risk factors for fragility fractures in the non-T2DM population, but they were not risk factors in the T2DM population. Conclusions This study found that low BMD and slow TUG time were independent risk factors for fractures in non-T2DM patients, while no associations were found in the T2DM population. Patients with T2DM have a higher risk for fractures even when they have sufficient BMD and a short TUG time. TUG and BMD underestimated the risk for fractures in the T2DM population.

Fragility fractures and delayed wound healing after tooth extraction in Japanese older adults.

Fragility fractures can cause delayed wound healing after tooth extraction, which contributes to an increased risk of osteomyelitis of the jaw. We evaluated whether a history of fragility fracture was associated with increased risk of delayed wound healing after tooth extraction in older adults in Japan. Of 5352 people aged 50-89years in the 2014 basic resident registry of the town of Obuse, the present study included 376 subjects (190 men and 186 women) who completed a structured questionnaire and measurement of the bone mineral densities (BMDs) of the bilateral femoral neck. Delayed wound healing after tooth extraction was self-reported. Fragility fractures were confirmed via examination of hospital medical records. Logistic regression analyses adjusted for age and gender were used to evaluate association of clinical variables with delayed would healing after tooth extractions. Odds ratios (ORs) and the 95% confidence intervals (CIs) of all possible associated variables for the presence of delayed wound healing were calculated. Subjects with a history of fragility fractures had a significantly higher risk of delayed wound healing compared with those without previous fragility fractures (OR 2.68; 95% CI 1.11-6.46, p = 0.028). This association still remained after adjusted for all other variables (OR 2.70; 95% CI 1.10-6.60, p = 0.030). Delayed wound healing was not significantly associated with the BMD of the femoral neck. History of fragility fracture may be associated with increased risk of delayed wound healing after tooth extraction in Japanese men and women aged 50-89years.

323. Fragility Fracture Risk in HIV: Awareness Among Primary Care Providers

BackgroundRecommendations on screening HIV-infected (+) patients for bone disease exist. We sought to characterize awareness of and adherence to HIV-specific recommendations and assess risk factors for fracture in this population.MethodsPrimary care provider (PCP) and ID specialist awareness of screening recommendations was assessed using an anonymous electronic survey. We conducted interviews of 45 HIV+ patients and chart review. We calculated risk using the fracture risk assessment tool (FRAX). Email notifications were sent if an indication dual-energy x-ray absorptiometry (DXA) scans was identified. Chart review was repeated 12 months later to assess response. Statistical methods included chi-square and Fisher’s exact test for categorical data, and t-tests or Wilcoxon rank-sum tests for continuous data. A multivariate logistic regression examined the relationship between adult fragility fractures and covariates.ResultsNo immunologic or virologic factors or exposure to specific antiretroviral therapies (ART) were associated with FFX (Table 1). FRAX score (hip, major osteoporotic fracture) successfully predicted FFX history (P = 0.002, P = 0.001, respectively). Overall, 35 (78%) patients qualified for DXA; 23 (66%) were men, only 8 (23%) had a previous DXA. Following provider notification, an additional 5 patients had DXA ordered. DXA was recommended for all patients with FFX, compared with 68% without a fracture (P = 0.02). In logistic regression modeling, increasing age, male sex, and months of ART therapy were associated with FFX (Table 2). Twenty-seven providers responded to the pre-intervention survey, of whom only 35% were aware of screening recommendations for HIV+ patients. Of the 18 providers who responded post-intervention, 63% were aware of these recommendations (Table 3).ConclusionA brief educational intervention resulted in increased awareness of HIV-specific screening recommendations, but this translated into adherence to a lesser extent. HIV+ men were more likely to have a history of fragility fracture compared with females. No specific ART or immunologic marker predicted fracture risk or history. Fostering a greater understanding of unique characteristics and risks in this population is crucial to ensure appropriate preventive care. Disclosures All authors: No reported disclosures.

Secondary prevention of osteoporotic fractures: evaluation of the Lille University Hospital's Fracture Liaison Service between January 2016 and January 2018.

A Fracture Liaison Service (FLS) was implemented at Lille University Hospital in 2016. The main purpose of this study was to assess the performance of the FLS using criteria proposed by the International Osteoporosis Foundation (IOF). The criteria used were patient identification, patient evaluation, post-fracture assessment timing, vertebral-fracture identification, blood and bone mineral density (BMD) testing, falls prevention, multifaceted health and lifestyle risk-factor assessment, and medication initiation and review. Between January 2016 and January 2018, 736 patients (≥ 50years old) with a recent history of fragility fracture (≤ 12months) were identified. The identification rate for hip fractures was 74.2%. However, patient evaluation for all type of fractures was quite low (30.3%) since many patients failed to attend the FLS unit. The reasons for non-attendance were refusal, agreed but subsequently failed to attend, and still waiting to be seen. In all, 256 patients (76.6% female, mean (SD) age 74.3 (11.0) years) were seen at the FLS. Mean (SD) post-fracture assessment timing was 13.3 (9.3) weeks. Of the 139 patients seen for a non-vertebral fracture, 103 were assessed for vertebral fractures, and at least one new vertebral fracture was found in 45 of them (43.7%). Osteoporosis medication was prescribed for 243 (94.9%) patients. The main osteoporosis drug prescribed was zoledronic acid (60.2%). Secondary prevention of osteoporotic fractures has improved since the implementation of the FLS. However, patient identification, patient evaluation, and post-fracture assessment timing still need to be improved.

SUN-514 Severe Hypophosphatemia and Worsening Secondary Hyperparathyroidism Following Treatment with Denosumab

Introduction We present a case of a patient with osteoporosis and chronic kidney disease (CKD)-induced secondary hyperparathyroidism who developed severe hypophosphatemia and increasing parathyroid hormone (PTH) level after receiving Denosumab. Clinical Case 90-year-old male with CKD stage 3 presented for hyperparathyroidism evaluation in 2015. Baseline GFR was 39 - 47 ml/min/1.73 m2. PTH was 320 pg/ml (8 - 97 pg/ml) with normal calcium and low vitamin D (25-D) 14 ng/ml (30 - 100 ng/ml). Repeat PTH was 299 pg/ml; 25-D 23 ng/ml and 24-hr urine calcium was 8 mg (100 - 300 mg). Hyperparathyroidism was concluded to be due to CKD and Vitamin D deficiency. Vitamin D was replaced and PTH decreased to 262 pg/ml. With fragility fracture history, dual-energy X-ray absorptiometry (DXA) scan was obtained and resulted with a T-score of -2.8 SD at the femoral neck. Denosumab (60 mg) was started after 25-D normalized in 3/2016. Follow-up laboratory analysis in 8/2016 revealed PTH 512 pg/ml, calcium 8.9 mg/dl (8.5 - 10.1 mg/dl), 25-D 44.7 ng/ml and phosphate 1.3 mg/dl (2.5 - 4.5 mg/dl), previously 2.1 mg/dl. Alkaline phosphate 104 U/l (45 - 117 U/l), calcitriol 63.9 pg/ml (19.9 - 79.3 pg/ml) and fibroblast growth factor 23 (FGF-23) 188 RU/ml (44 - 215 RU/ml). 24-hr urine calcium was 27 mg and phosphate >90 mg/dl. Serum phosphate improved with supplementation and Cinacalcet started for high PTH. After the second Denosumab injection, low phosphate (1.2 mg/dl) recurred and PTH remained high (510 pg/ml). With recurrent effects, Denosumab was switched to bisphosphonate as GFR was stable >40 ml/min/1.73 m2. PTH normalized to 78 pg/ml and phosphate stable (2-2.4 mg/dl) on Cinacalcet and off Denosumab. Discussion Hypophosphatemia is a rare side effect of Denosumab, a monoclonal antibody to RANK-L. PTH mildly increase with Denosumab secondary to hypocalcemia. In our patient, there was a significant rise in PTH level and a decline in phosphate following Denosumab administration with no effect on calcium level. There are very few reports of these combined adverse events in the literature. The proposed mechanism is that the irreversible blockade by Denosumab results in low bone turnover which then causes increase in PTH and then increase urinary phosphate excretion. This mechanism can apply to CKD patients with secondary hyperparathyroidism when given a blocking agent like Denosumab, there is a further increase in PTH in the setting of low bone turnover. If not closely monitored, it can be detrimental. Elevated FGF-23 can downregulate 1-alpha-hydroxylase and increase urinary phosphate but unlikely in our patient given its normal level. Conclusion Severe hypophosphatemia may be a rare side effect of Denosumab, particularly in CKD patient with secondary hyperparathyroidism. Therefore, phosphate and PTH should be monitored closely after Denosumab administration to prevent adverse events.

MON-LB090 Red-Hipopara, Real Life Experience in 322 Patients with Hypoparathyroidism in Argentina

Hypoparathyroidism (HPT) is a rare disorder characterized by hypocalcemia and absent or deficient PTH. Few data are available on the natural history and correct management of this disease. Aim: Describe clinical characteristics, treatment, and complications in a group of patients with hypoparathyroidism from 6 referral centers for endocrinological diseases. Secondary, describe how many patients reached guidelines recommendations for rhPTH (1-84) treatment (Brandi ML. JCEM. 2016). M & M: In this retrospective study patients with a diagnosis of HPT of ≥6 months were eligible for inclusion. Patients with pseudohypoparathyroidism were excluded. Demographics, etiology, management, hospitalizations, clinical manifestations and biochemical and DXA values were collected.Results:322 HPT patients were included; mean age was 55.2 ± 16.8 years, 85,7% were women. Mean ageat diagnosis was 43.8 ± 16.8 years and mean follow up time was 4.9 ± 5.1 years. Regarding etiology 90%were post-surgical (50.3% for thyroid cancer, 41% for multinodular goiter, 2.7% primary hyperparathyroidism;3.4% secondary hyperparathyroidism and 2.3% cervical cancer). Non-surgical etiology included: 5 DiGeorge Syndrome, 9 autoimmune and 16 idiopathic. Non-surgical patients were significantly younger (45 ± 19.5 vs.56.3 ± 16.1 years; p<0.01) and were younger at diagnosis (45.1 ± 15.9 vs. 31.4 ± 20.5 years;p<0.01).Treatment regimens were determined by the patients’ physician, per usual clinical practice, and most patients were receiving calcium supplementation (mean daily dose:2019 ± 1426 mg), vitamin D ( mean weekly dose 34.368 ± 55.278 UI) and calcitriol ( mean daily dose: 0.498 ± 0.279 mcg). 13 patients were receiving teriparatide ( 1-34 human parathyroid hormone). 25.7% had a history of hypocalcemia requiring hospitalization, 4.6% had fragility fracture history (wrist, hip, humerus, vertebra or tibia) and 4.3% has a history of seizures. Only 41.9% had a renal ultrasound done and 15.5 % had positive findings ( kidney stones and nephrocalcinosis). 54% had 24-hour urine calcium excretion measured and almost half of them had hypercalciuria confirmed (56.3%). Only 18,3% patients had central nervous system imaging performed,and 38.9% had basal ganglia calcification. Finally, 38.8% met criteria to rhPTH (1-84) treatment according to the guideline; most of them because their daily oral calcium requirements exceeded 2.5 g of calcium. Conclusion: Although these patients were followed by experienced physicians, clinical management and monitoring was heterogeneous and probably insufficient to assess all the potential complications of this chronic disease. Being aware of this situation is the first step to improve our medical management of HPT in the future Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. s presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

Patient Perceptions and Preferences for Osteoporosis Treatment

Despite the high prevalence, morbidity, and treatment costs for osteoporosis-related fractures, studies have shown that patients infrequently receive the recommended treatment for low bone density (LBD). This study investigated patient perceptions about evaluation, management, and willingness to pursue osteoporosis treatment to further elucidate potential barriers to LBD treatment. A survey was prospectively administered to patients over 50 years old addressing patient history of fragility fractures and osteoporosis evaluation and treatment, medication administration preferences, and willingness to start a new medication to treat or prevent future fragility fractures. Three hundred twenty-five patients completed surveys (63.1% women, 36.9% men; mean age, 64.1 years). Patients reported the following: 50.8% had taken supplements or medication for LBD. Patients who had never taken LBD prescription medications were asked about their willingness to take these medications if physician-recommended. The mean response on a 0 to 10 scale was 7.3 ± 3.2, which was not significantly different between fracture or bone density subgroups. Several barriers to taking LBD medications were identified: 85.7% said no medical provider had prescribed them; 14.0% stated they already took too many medications; 10.4% were afraid of potential side effects; 4.3% had conflicting provider recommendations; and 1.8% cited financial concerns. Patients held a favorable opinion on taking LBD medications when prescribed. Although 29.8% of patients had an abnormal dual-energy x-ray absorptiometry (DEXA) result, 85.7% of all patients reported that no medical provider had prescribed LBD medications. A sizeable gap remains between current practice and optimal osteoporosis education and management. Despite the large reported and increasing prevalence of osteoporosis in patients with upper extremity fragility fractures, the rate of treatment for LBD remains suboptimal.

Bone mineral density, bone turnover markers, and incident fractures in de novo kidney transplant recipients

Kidney transplant recipients are at increased risk of fractures. This prospective observational study investigated whether areal bone mineral density (aBMD) as assessed by dual-energy x-ray absorptiometry can predict incident fragility fractures in de novo kidney transplant recipients and whether bone turnover markers increase diagnostic accuracy. Parameters of bone mineral metabolism including parathyroid hormone (PTH), fibroblast growth factor 23, sclerostin, calcidiol and calcitriol, and bone turnover markers were assessed in blood samples collected immediately prior to kidney transplantation in 518 adult recipients. aBMD was measured at several skeletal sites within 14 days posttransplant. Thirty patients had a history of a fragility fracture at the time of transplantation, and osteopenia or osteoporosis at the femoral neck was observed in 77%. Bone turnover markers were inversely correlated with aBMD at all skeletal sites. Low aBMD and low PTH were associated with history of fragility fracture at the time of transplantation, independent of age, gender, and comorbidity. During a median post-transplant follow-up of 5.2 years, 38 patients sustained a fragility fracture, corresponding to a fracture incidence of 14.1 per 1000 person-years. Low aBMD at the hip and lumbar spine were associated with incident fractures, independent of classical determinants, including history of fracture. PTH and bone turnover markers at the time of transplantation failed to predict incident fractures. In conclusion, aBMD is low, correlates inversely with bone turnover, and predicts incident fractures in de novo kidney transplant recipients.

Factors Influencing Serum Homocysteine Levels in Postmenopausal Osteoporotic Females – Comparison to Urinary Collagen Crosslinks –

ABSTRACTPurpose: The correlation between serum levels of homocysteine and bone mineral density remains controversial. The aim of this study was to identify the potential factors associated with the levels of serum total homocysteine (S-Hcy) and urinary N-terminal telopeptide of type I collagen (U-NTX) in female osteoporotic patients.Materials and Methods: This cross-sectional study included 163 female osteoporotic patients, aged between 48 and 91 years, who had never been treated with anti-osteoporosis therapy. Background data including spine and hip bone mineral density, ongoing therapy for the metabolic disease, aortic calcification score as evaluated by lateral lumbar X-ray film, and recent fragility fracture history were obtained. S-Hcy, U-NTX levels, and creatinine clearance were measured.Results: Multiple linear regression analysis revealed a significant correlation between S-Hcy levels and aortic calcification score (p = 0.022), creatinine clearance (p = 0.004), and recent fracture history (within 1 year after fracture) (p = 0.028); conversely, U-NTX levels correlated significantly with total hip bone mineral density (p < 0.0001) and recent fracture history (p = 0.0007).Conclusions: S-Hcy levels had no correlation with bone mineral density, but were associated with the degree of aortic calcification, renal function, and fracture events. These confounding factors should be taken into consideration when the relationship between S-Hcy and bone mineral density is discussed.