Osteoporosis Clinic Research Articles

Fracture liaison service model: treatment persistence 5 years later.

To analyze the long-term persistence of treatment in a fracture liaison service (FLS). Patients ≥ 50 years with a fragility fracture attended between 2012 and 2016 who were recommended for treatment to prevent new fractures were included. Baseline data included demographics, type of fracture, previous treatment, and FRAX® items. Five years later, patient records were reviewed and the following data were collected: [1] survival; [2] refracture; [3] initiation of treatment, persistence, and medication possession ratio (MPR) > 80%. We included 888 patients, mean age 75 years, 83% women, and mean follow-up 56 months. During follow-up, 135 patients (15.2%) had a refracture (109 major fractures, 50 hip refractures) and 212 patients died (23.8%); at the 5-year checkup, 657 patients (74%) had started some type of treatment. Factors associated with the start of treatment were female sex (OR 2.10; 95% CI: 1.42-3.11), previous use of bisphosphonate (OR 3.91; 95% CI: 2.23-6.86), and referral to an osteoporosis clinic (OR 1.46; 95% CI: 1.02-2.07). Persistence decreased from 70.6% at 12 months to 46.5% at 60 months. An MPR > 80% was confirmed in 449 patients, 68.3% of whom were under treatment. A total of 521 and 447 patients received treatment for at least 24 and 36 months, respectively (79.3% and 68.0% of those who started treatment). Patients with fragility fractures attended at an FLS showed optimal long-term persistence of treatment. These data can help healthcare managers better calculate the cost-effectiveness of implementing the FLS model.

Comparison of 2 fracture risk estimation processes in Alberta: a cross-sectional chart review

Background:In Canada, decisions regarding osteoporosis pharmacotherapy are based on estimated 10-year risk of osteoporotic fracture. We aimed to determine how frequently 2 common approaches (Canadian Association of Radiologists and Osteoporosis Canada [CAROC] tool and Fracture Risk Assessment Tool [FRAX]) produced different estimates and to seek possible explanations for differences.Methods:We conducted a cross-sectional chart review at a tertiary osteoporosis centre (Dr. David Hanley Osteoporosis Centre in Calgary). Included patients were women referred for consideration of osteoporosis pharmacotherapy who attended a consultation between 2016 and 2019 and whose charts contained 10-year osteoporotic fracture risk estimates using both the CAROC tool (based on bone mineral density [BMD] results) and FRAX (based on BMD results and clinically assessed fracture risk factors). Risk estimates provided on BMD reports (calculated with CAROC) and generated through osteoporosis clinic consultation (calculated with FRAX, including BMD) were categorized as low (< 10.0%), moderate (10.0%–19.9%) or high (≥ 20.0%). Estimates were considered discordant when they placed the patient in different risk categories.Results:Of 190 patients evaluated, 99 (52.1%) had discordant risk estimates. Although a similar proportion were considered high risk by BMD reports using the CAROC tool (17.9%) and clinic charts using FRAX (19.5%), the 2 methods identified different patients as being high risk. Around the crucial high-risk (20.0%) treatment threshold, discordance was present in 37 patients (19.5%, 95% confidence interval [CI] 14.5%–25.7%); discordance around the moderate-risk (10.0%) threshold was present in 69 (36.3%, 95% CI 29.5%–43.2%) patients. Disagreement regarding fracture history between BMD reports and clinic charts was observed in 19.8% of patients.Interpretation:Fracture risk estimates on BMD reports (using the CAROC tool) and those calculated in the clinical setting (using FRAX) frequently result in different risk classification. Osteoporosis treatment decisions may differ in up to half of patients depending on which estimate is used, highlighting the need for a consistent and accurate assessment process for fracture risk.

A Multicenter Study to Evaluate Harmonization of Assays for C-Terminal Telopeptides of Type I Collagen (\xdf-CTX): A Report from the IFCC-IOF Committee for Bone Metabolism (C-BM)

BackgroundBiochemical bone turnover markers are useful tools to assess bone remodeling. C-terminal telopeptide of type I collagen (ß-CTX) has been recommended as a reference marker for bone resorption in research studies.MethodsWe describe the results of a multicenter study for routine clinical laboratory assays for ß-CTX in serum and plasma. Four centers (Athens GR, Copenhagen DK, Liege BE and Sheffield UK) collected serum and plasma (EDTA) samples from 796 patients presenting to osteoporosis clinics. Specimens were analyzed in duplicate with each of the available routine clinical laboratory methods according to the manufacturers’ instructions. Passing-Bablok regressions, Bland–Altman plots, V-shape evaluation method, and Concordance correlation coefficient for ß-CTX values between serum and plasma specimens and between methods were used to determine the agreement between results. A generalized linear model was employed to identify possible variables that affected the relationship between the methods. Two pools of serum were finally prepared and sent to the four centers to be measured in 5-plicates on 5 consecutive days with the different methods.ResultsWe identified significant variations between methods and between centers although comparison results were generally more consistent in plasma compared to serum. We developed univariate linear regression equations to predict Roche Elecsys®, IDS-iSYS, or IDS ELISA ß-CTX results from any other assay and a multivariable model including the site of analysis, the age, and weight of the patient. The coefficients of determination (R2) increased from approximately 0.80 in the univariate model to approximately 0.90 in the multivariable one, with the site of analysis being the major contributing factor. Results observed on the pools also suggest that long-term storage could explain the difference observed with the different methods on serum.ConclusionOur results show large within- and between-assay variation for ß-CTX measurement, particularly in serum. Stability of the analyte could be one of the explanations. More studies should be undertaken to overcome this problem. Until harmonization is achieved, we recommend measuring ß-CTX by the same assay on EDTA plasma, especially for research purposes in large pharmacological trials where samples can be stored for long periods before they are assayed.

Abstract PS9-30: The efficacy of a comprehensive bone health program in maintaining bone mineral density in postmenopausal women with early-stage breast cancer treated with endocrine therapy

Abstract Introduction: Given the recent advances in early detection, improving access to care and the introduction of more effective anti-cancer medications including endocrine therapy, targeted and immunotherapy, more women with breast cancer survive their disease. Majority of patients with breast cancer express hormone receptors (estrogen and or progesterone receptors) on cancer cells. Aromatase inhibitors (AI) are the gold standard treatment of hormone-sensitive postmenopausal women with breast cancer. Several studies had documented the accelerated bone loss associated with AI. The use of bone modifying agents like bisphosphonates and denosumab had resulted in significant improvement in bone mineral density among females treated with AI. In this paper, we study the efficacy of implementing a comprehensive program on bone health for such patients. Patients and Methods: Postmenopausal women with hormone-sensitive early-stage breast cancer treated with endocrine therapy (ET) were included. A comprehensive bone health program was implemented. The program includes extensive counselling by medical oncologist, calcium and vitamin-D supplements, increase milk intake and exercise. Patients with baseline lumbar spine or total hip T-scores ≥ -2 were given short intravenous bisphosphonate infusion every 6 months. Patients with osteoporosis are referred to and followed in a specially designed “osteoporosis clinic”. Results: Between 2013 and 2019, a total of 210 patients fulfilled the eligibility criteria and were enrolled. All were female, median (range) age 67 (43-86) years. All patients had a pathologically confirmed diagnosis of breast cancer, treated and followed up at our institution. High risk patients (n=103, 49.0%) were treated with 6-8 cycles of chemotherapy, including anthracyclines and taxanes. Following the completion of chemotherapy, all patients were treated with endocrine therapy. Patients with low-risk disease (n=107, 51.0%) were treated with upfront endocrine therapy-alone. Aromatase inhibitors, letrozole or anastrozole, were the endocrine therapy of choice in all patients. At baseline, and prior to start of AI, the median T-scores at the hip and lumber spines were -1.0 (range: -3.6, 1.9) and -1.4 (range: -3.9, 2.6), respectively. Osteoporosis was documented in 38 (18.1%) patients while 101 (48.1%) others had osteopenia; none were on any treatment or even aware of their BMD. 46 (25.3%) patients had vitamin-D deficiency while 74 (40.7%) others had vitamin-D insufficiency and none were on prior active replacement therapy or even aware of this problem. Following at least 12-months of endocrine therapy, 32 (84.2%) of patients with osteoporosis and 69 (68.3%) of those with osteopenia had a stable or higher BMD. Thus, the number of patients with osteoporosis declined to 27, 12.9% of the total cohort. On the other hand, 41 (57.7%) of those with normal baseline BMD had a drop in their follow up BMD. Vertebral fractures, presented with back pain and documented by imaging studies, were reported in 3 (11.1%) patients with osteoporosis compared to none in patients with normal BMD, p=0.021. Rib fracture and hip fracture were reported in one patient each and both had normal BMD before and after AI therapy. Conclusions: Postmenopausal women with breast cancer are at risk of osteopenia and osteoporosis. Such risk increases significantly with the use of AI. However, early interventions with modifiable risk factors, Vitamin-D supplements and use of bone-modifying agents can lower this risk. Citation Format: Razan Mansour, Ula Al-Rasheed, Akram Al-Ibraheem, Shereen Abu Jaradeh, Rashid Abdel-Razeq, Rayan Bater, Noor Mashahdani, Shrouq Tbayshat, Hikmat Abdel-Razeq. The efficacy of a comprehensive bone health program in maintaining bone mineral density in postmenopausal women with early-stage breast cancer treated with endocrine therapy [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS9-30.

Pharmacotherapy decisions among postmenopausal women attending a group medical consultation or a one-on-one specialist consultation at an osteoporosis center: an observational cohort study.

Group medical consultations for osteoporosis are time-efficient and highly accepted by patients, but effects on treatment decisions are unknown. We aimed to compare women's decisions to initiate or decline osteoporosis pharmacotherapy after attending either a group or transitional one-on-one osteoporosis consultation. In this observational study, we prospectively evaluated postmenopausal women referred to an osteoporosis clinic who attended a group medical visit and compared their decisions regarding pharmacologic osteoporosis treatment with retrospective data from a cohort of women who attended a traditional consultation. Both consultation types involved interaction with a specialist physician, individualized fracture risk estimation (using FRAX®), and education regarding fracture consequences and available osteoporosis medications. Both forms of consultation emphasized shared decision-making; however, group consultation attendees did not receive personalized treatment recommendations from the physician. We reviewed the records of 125 women (median age 63 years) who attended a group consultation and 83 women (median age 64 years) who attended a traditional consultation between 2016 and 2019. Twenty-four (19%) of the group cohort and 16 (19%) of the traditional cohort were at high 10-year risk of major osteoporotic fracture (FRAX® ≥ 20.0%). A similar proportion planned to initiate pharmacologic therapy after the group and traditional consultations (23% vs 16%, p = 0.22); these proportions were comparable among women at high risk (42% vs 50%, p = 0.75) and moderate risk (19% vs 15%, p = 0.77), but a higher proportion of low-risk women planned to initiate therapy after the group consultation (18% vs 0%, p = 0.009). Patient decisions to initiate pharmacologic treatment made during a group visit are similar to those made during traditional one-on-one consultation. The group consultation model represents an alternative to one-on-one assessment for delivering osteoporosis consultative services.

Osteoporosis treatment rate following hip fracture in a community hospital.

Currently, a significant care gap for osteoporosis therapy exists post-hip fracture despite advances in pharmacologic therapy. We evaluate the effectiveness of the OGT at the Oakville Trafalgar Memorial Hospital (OTMH), Ontario, Canada, in reducing the care gap and initiating pharmacologic therapy in hip fracture patients prior to hospital discharge. We also evaluated the incidence of atypical femoral fracture (AFF) separately. A retrospective chart review of patients 59 years and older with a hip fracture admitted to OTMH from January 1, 2016, to February 1, 2017, was conducted. The primary outcome was the proportion of hip fracture patients discharged from the hospital with appropriate treatment for their underlying osteoporosis. A sub-analysis was completed reporting the incidence of AFF among older adults. A total of 197 patients with a hip fracture were identified, 134/197 (68%) patients were seen by the OGT, 98/134 (73%) of these patients were started on pharmacologic therapy prior to discharge, and 120/134 (89%) of patients seen by the OGT were on treatment within 3 months of discharge following assessment in the complex osteoporosis clinic. Sixty-three patients of the 197 (63/197) (32%) of the hip fracture patients were seen by a hospitalist, and treatment rates prior to discharge were 5%. Only 6/197 patients had experienced an AFF during the study period, and all patients with an atypical femoral fracture had been on long-term bisphosphonate therapy. All of the patients with an AFF had thigh or groin pain for several weeks to months prior to the development of the atypical femoral fracture, providing an opportunity to stop therapy and possibly prevent the development of a complete AFF. The OGT was able to initiate anti-osteoporosis therapy in significantly more patients in comparison to usual care, and higher treatment rates are possible with an OGT.

PRIMARY HYPERPARATHYROIDISM AND SERUM CALCIUM IN BREAST CANCER PATIENTS EVALUATED FOR LOW BONE MASS - A SINGLE CENTER EXPERIENCE.

SUMMARYThe bone health guidelines for breast cancer (BC) patients recommend bone mineral density (BMD) testing. Patients with low BMD and elevated serum calcium levels (SCLs) are further evaluated for primary hyperparathyroidism (PHPT). We aimed to determine the prevalence of PHPT in treated BC patients with low BMD and analyze the association of SCLs with histopathologic tumor features and cancer treatment. This retrospective study included postmenopausal BC patients examined at Osteoporosis Clinic between 2013 and 2020. Clinical and BMD data were collected from patient medical records. Patients with biochemical suspicion of PHPT underwent standard parathyroid imaging procedures. Nine out of 137 (6.6%) patients were diagnosed with PHPT; 8/9 patients underwent parathyroidectomy and one patient was advised to follow-up. Among the rest of 128 non-PHPT patients, higher SCLs showed a trend of positive association with higher tumor grade and axillary lymph node involvement, and received immunotherapy, although without statistical significance. We found a higher prevalence of PHPT in treated BC patients compared to the general population. Higher SCLs show a trend of positive correlation with some more aggressive histopathologic tumor features and with immunotherapy. The results of this study suggest that assessment of SCLs should be routinely performed to rule out PHPT in treated BC patients with low BMD.

Autonomy begets adherence: decisions to start and persist with osteoporosis treatment after group medical consultation.

Adherence and persistence with osteoporosis pharmacotherapy is low, possibly reflecting lack of confidence in physicians' treatment recommendations. We evaluated treatment decisions, decisional confidence, and 12-month treatment adherence among women who attended a group bone health consultation that fostered autonomous decision-making. We prospectively assessed postmenopausal women referred to an osteoporosis clinic who chose to attend a group medical visit in lieu of one-on-one consultation. The group visit was facilitated by a specialist physician and nurse, involving estimation of 10-year major osteoporotic fracture risk (using FRAX®) and extensive education regarding fracture consequences and potential advantages and disadvantages of pharmacotherapy. No direct advice was given by the specialist. Post-consult, participants made an autonomous decision regarding treatment intent and followed up with their family physician to enact their chosen plan. Intentions to initiate pharmacotherapy were assessed immediately post-consult. Treatment status and decisional confidence were evaluated 3 and 12 months later. Three-month treatment status was considered to reflect final treatment decision. Persistence was defined as proportion of participants on treatment at 3 months who remained treated at 12 months. One hundred one women (mean (SD) age, 62.7 years (5.8); median (IQR) FRAX®, 10.7% (8.3-17.6)) participated. Immediately post-consult, 27 (26.7%) intended to initiate treatment. At 3 months, 23 (22.8%) were treated, and at 12 months, 21 (91.3%) remained persistent. Of 89 questionnaire respondents at 12 months, 85 (95.5%) reported confidence in their treatment decision. When postmenopausal women are provided with individualized fracture risk estimates and enabled to make autonomous decisions regarding pharmacotherapy, ultimate decisions to receive treatment are made with confidence and result in high persistence at 12 months.

Risk factors predicting osteosarcopenia in postmenopausal women with osteoporosis: A retrospective study.

There is growing interest in “osteosarcopenia” as the coexistence of osteoporosis and sarcopenia exacerbates negative outcomes. However, limited information is available regarding the risk factors of osteosarcopenia development in patients with osteoporosis. Therefore, we retrospectively reviewed 276 consecutive patients with postmenopausal osteoporosis who regularly visited Showa University Hospital. Patients were eligible for the study if they were ≥65 years of age and underwent dual-energy X-ray absorptiometry, blood sampling, and physical performance assessment. Patients were divided into the osteosarcopenia and osteoporosis alone groups according to the diagnostic criteria of the Asian Working Group for Sarcopenia. Of the 276 patients with osteoporosis, 54 patients (19.6%) had osteosarcopenia. Patients in the osteosarcopenia group had a greater risk of frailty than did those in the osteoporosis alone group (odds ratio 2.33; 95% confidence interval, 1.13–4.80, P = 0.028). Low body mass index seemed to be the strongest factor related to the development of osteosarcopenia, and none of the patients in the osteosarcopenia group were obese (BMI ≥27.5 kg/m2). Multiple logistic analyses revealed that patients aged 65–74 years who had comorbidities such as kidney dysfunction and high levels of HbA1c were at risk of developing osteosarcopenia. Thus, we strongly recommend the assessment of the key components of the diagnosis of osteosarcopenia in an osteoporosis clinic for patients with low body mass index. Furthermore, appropriate assessments, including comorbidities, will help in identifying patients at greater risk of developing osteosarcopenia.

The evolution of an FLS in search of excellence: the experience of Gran Canaria.

To assess the consolidation of an FLS after its implementation as well as the problems that have arisen over time. The program for secondary fracture prevention was implemented in 2012. Initially manned by the same staff assigned to the rheumatology department, a part-time support nurse was added in 2016. Patients were identified from the emergency registry and, more recently, from among those admitted for hip fracture and treated in a monographic osteoporosis clinic. The baseline visit consisted of a consultation with the nurse, as well as DXA and bone metabolism analytics. Patients were referred to their primary care physician to start treatment. Of the 2416 attended patients, 30% presented forearm fractures, 27% hip, 20% humerus, 10% spine, and 11% other fractures. In comparison with 2012, in 2019, the monthly average of patients had doubled, with an increased in the number of hip and spine fractures and an increase in the percentage of captured patients. The performance of DXA fell from 100 to 52%, and fewer patients were referred to the osteoporosis clinic. One in four patients was referred to a fall prevention school. Despite implementing consolidating measures at the unit (the addition of a support nurseand the establishment of a solid alliance with primary care), the involvement of primary care nurses and starting initial prescriptions at the hospital are pending. We present herein the achievements made by our FLS and the difficulties within the Spanish public health system over an 8-year period.

Implementation of a fracture liaison service and its effects on osteoporosis treatment adherence and secondary fracture at a tertiary care academic health system.

To assess the effects of implementation of a fracture liaison service at a tertiary care academic medical center on osteoporosis treatment adherence and secondary fracture rates. We retrospectively reviewed over 6000 patients age 50years or greater during a 5-year time period (2013-2018). Patients were identified as having a fragility fracture on presentation to the emergency department at the Wake Forest Baptist Medical Center and referred to our osteoporosis clinic using the electronic medical record. Data were collected regarding those patients who were recommended treatment, started treatment, maintained adherent to treatment, and those who sustained a secondary fracture. 6178 patients were identified as having a fragility fracture and referred to the osteoporosis clinic. 2631 of these patients successfully had a scheduled outpatient appointment at the osteoporosis clinic, of which 1937 attended their initial appointment and 1840 of these patients were prescribed treatment. Of the 1840 patients who were initially prescribed medication, 1416 (76.96%) initiated their treatment, and 1156 (81.64%) remained adherent to treatment. Fifteen patients (1.05%) on treatment sustained a secondary fracture after initiation of therapy. Implementation of a fracture liaison service at a tertiary care academic medical center is feasible and is associated with high rates of treatment implementation/adherence and low incidence of secondary fracture.

P195 Outcome of blood analysis and spinal radiology secondary marker assessments of osteoporosis (OP) patients seen in the bone health service in a large urban London borough

Abstract Background Almost all national/international OP management guidelines emphasise the importance of ruling out ‘secondary markers’ of OP, that is, biochemical, haematological, serological and hormonal blood anomalies that might indicate underlying undetected diagnoses that might contribute to bone loss and/or fracture risk. Moreover, these assessments may identify sub-optimally controlled established diagnoses. Identifying vertebral fragility fractures (VFFs) at baseline/initial review is scarcely undertaken despite numerous studies that indicate the predictive capacity of the high risk of fractures at any site conferred by the presence of moderate-to-severe VFFs. There is little in the literature on rates of 'secondary marker' anomalies and VFFs at initial review appointments in OP clinics, the data of which is essential to understand when developing OP services and management pathways. We assessed the rates of blood test abnormalities and VFFs in OP patients seen at the bone health clinic, Croydon Health Services NHS Trust. Methods We conducted a retrospective review of OP patients seen between February-June 2018 at Purley Memorial Hospital. We assessed the results of secondary markers of OP blood tests: FBC, U&amp;Es, LFTs, ESR, CRP, TFTs, HbA1c/fasting glucose, immunoglobulins, electrophoresis, coeliac antibodies, vitamin-D, calcium, phosphate, alkaline phosphatase, PTH, vitamin-B12, folate and ferritin and when required testosterone, FSH, LH, magnesium, cortisol, urinary calcium and urinary paraproteins. We also reviewed for the presence of moderate-to-severe VFFs using thoracolumbar spine X-rays (Ghent classification). Results 201 patients were included. Mean age was 70 years (range:37-96), with approximately 9:1 female:male ratio. 45% (90/201) had blood test abnormalities on secondary marker testing identifying new diagnoses: 5% had coeliac antibodies, 3% hypercalcaemia &amp; hyperparathyroidism, 3% hypothyroidism, 2% haematological disorders (3 MGUS and 1 myeloma), 30% (6/21 male cohort) had testosterone deficiency, 20% vitamin-D deficiency, 12% had either vitamin-B12, folate or ferritin deficiency. Of the 18% with pre-existing thyroid-disorders, a third of these patients were not euthyroid. 30% (29/90) of patients with blood abnormalities had multiple anomalous results. In total, 48% (96/201) patients were identified with moderate-to-severe VFFs; 71% (68/96) of these had either more VFFs than previously known by the patient/referrer (35%) or -the majority- had newly identified VFFs (65%). Conclusion Just under half-of-subjects had blood test anomalies indicating previously unknown diagnoses that could lead to bone loss and increased fracture risk if left unaddressed. Almost 1/3 of these had multiple abnormalities increasing their risk even further. The commonest diagnoses included endocrinopathies (especially hypothyroidism), vitamin deficiencies (especially vitamin D), coeliac disease and haematological disorders. Given the incidences of these issues, it is essential that OP services undertake thorough 'secondary marker' investigations to identify and improve the overall management of OP patients. Furthermore, there was a high rate of VFFs (48%) with almost half of these patients being newly identified at the clinic and 25% having had more VFFs than previously known. Therefore, 1/3 of the whole cohort had previously unknown moderate-to-severe VFFs. This clearly indicates that VFFs are being underdiagnosed in OP patients despite the important prognostic and predictive value that the presence of VFFs confer when assessing patients' fracture risk. Disclosures R. Rajak Honoraria; Speaker fees from Roche, Eli Lilly, Amgen, Internis. Chair fees Roche, Eli Lilly, Norvartis, Abbvie, UCB. S. Mahendrakar None. A. Perren None. M. Zaman None.

On nutrition for performance in medicine: Med Life with Dr. Horton.

![Figure][1]</img>![Figure][1]</img> Jillian Horton: Your work looks at the intersection of physician health and nutritional sciences. How did you end up in this field? Maryam Hamidi: I was working in an osteoporosis clinic. One day, a friend who worked at Air Canada reached out to me and said

Incorporation of a patient navigator into a secondary fracture prevention program identifies barriers to patient care.

Patient navigation improves outcomes in various clinical contexts, but has not been evaluated in secondary fracture prevention. We retrospectively reviewed charts of patients, age 50 + from April to October, 2016 hospitalized with fragility fracture contacted by a patient navigator. Patients were identified using an electronic tool extracting data from electronic medical records which alerted the patient navigator to contact patients by phone post-discharge to schedule appointments to "High-Risk Osteoporosis Clinic" (HiROC) and Dual-energy X-ray Absorptiometry (DXA) scan. Primary outcome was transition from hospital to HiROC. We also compared completion of DXA, five osteoporosis-associated in-hospital laboratory tests (calcium, 25-hydroxy vitamin D, complete blood count, renal, and liver function), osteoporosis medication prescription and adherence, and other patient characteristics to historical controls (2014-2015) without patient navigation. Comparisons were made using Chi-square, Fisher's Exact, two-sample t test or Wilcoxon Rank Sum test, as appropriate. The proportion of patients transitioning to HiROC with and without patient navigation was not different (53% vs. 48%, p = 0.483), but DXA scan completion was higher (90% vs. 67%, p = 0.006). No difference in medication initiation within 3months post discharge (73% vs. 65%, p = 0.387) or adherence at 6months (68% vs. 71%, p = 0.777) was found. Patients attending HiROC lived closer (11 vs. 43 miles, p < 0.001) and more likely to follow-up in surgery clinic (95% vs. 61%, p < 0.001). Patient navigation did not improve transition to HiROC. Longer travel distance may be a barrier-unaffected by patient navigation. Identifying barriers may inform best practices for Fracture Liaison Service programs.

Fractures following percutaneous vertebral augmentation: The procedure or the underlying disease?

Introduction: We report cases of three patients who had vertebral compression fractures (VCFs) that occurred temporally close to and at levels adjacent to prior percutaneous vertebral augmentation (PVA) of vertebral fractures. Our objective is to evaluate the association between PVA and new/adjacent-level vertebral fractures. Case Series: Case 1 presented to our Osteoporosis (OP) Clinic with a previous diagnosis of OP, briefly on alendronate. Following this, she had a compression fracture (CF) at L3 followed by balloon kyphoplasty (BK). She was then on teriparatide for two years. Following this, over a span of several months, she had CFs (T8-L2) requiring BK, with seven of those fractures within six months. Case 2 presented for evaluation in the setting of CFs. She had never received antiresorptive therapy. She underwent BK at T12 and L1, and was noted to have a new T11 fracture 3–4 weeks later. Case 3 presented with a prior history of CF at L3 requiring vertebroplasty. Later, over the course of one year, she had a CF of T12 treated with BK, followed by new vertebral fractures at T11 and L1 also treated with BK, and finally CF at T10, which was also treated with BK. Conclusion: These cases illustrate that new fractures my occur sooner and at adjacent levels following PVA, demonstrating a possible association between the two. Given the mixed data regarding this, we would like to emphasize the need for clinicians to complete a thorough OP work-up and discuss the risks and benefits of these procedures with patients

Medication Non-adherence in Patients with Osteoporosis: Implications for Clinical Pharmacists and Osteoporosis Care Providers.

Poor adherence to the prescribed therapy leads to low bone mineral density and enhance the development of osteoporosis complications and unnecessary hospitalization. To explore factors associated with medication non-adherence in patients with osteoporosis. Findings would help guide the development of future pharmaceutical care interventions aim at improving health outcomes for patients with osteoporosis. The study was conducted at an outpatient osteoporosis clinic at the Royal Medical Services Hospital. Variables including socio-demographics and medical factors were collected using medical records and custom-designed questionnaire. Medication adherence was assessed using the validated 4-item Morisky Medication Adherence Scale. Logistic regression was performed to develop a model with variables that best predicted medication non-adherence in patients with osteoporosis in Jordan. A total of 296 patients participated in the study. Most of the study participants (72.3%) were found non-adherent. Patients were found less likely to adhere to the prescribed medications with each unit increase in the number of prescribed medications (OR = 2.503, CI = 1.103-5.680) and if they did not have a trust in the efficacy of the medications (OR = 5.544, CI = 0.990-31.058). Medication adherence for patients with osteoporosis has considered scope for improvement in Jordan. Simplifying dosage regimen in addition to taking patients' preferences when selecting the medications should be taken into account in future interventions designed to improve health outcomes for patients with osteoporosis.

Loss-of-Function Mutations in the ALPL Gene Presenting with Adult Onset Osteoporosis and Low Serum Concentrations of Total Alkaline Phosphatase.

ABSTRACTHypophosphatasia (HPP) is a rare inherited disorder characterized by rickets and low circulating concentrations of total alkaline phosphatase (ALP) caused by mutations in ALPL. Severe HPP presents in childhood but milder forms can present in adulthood. The prevalence and clinical features of adult HPP are poorly defined. The aim of this study was to evaluate the prevalence and clinical significance of low serum total alkaline phosphatase (ALP) levels in a clinic‐based population of adult osteoporotic patients. We searched for patients with low ALP in a cohort of 3285 patients referred to an osteoporosis clinic over a 10‐year period and performed mutation screening of ALPL in those with low ALP (≤40 U/L) on two or more occasions. These individuals were matched with four clinic controls with a normal ALP. We also evaluated the prevalence of low ALP and ALPL mutations in 639 individuals from the general population from the same region. We identified 16/3285 (0.49%) clinic patients with low ALP and 14 (87.5%) had potentially pathogenic variants in ALPL. Eight of these individuals were heterozygous for mutations previously described in HPP and 2 were heterozygous for novel mutations (p.Arg301Trp and p.Tyr101X). These mutations were not found in clinic controls or in the general population. Eight patients with low ALP, including 4 with ALPL mutations, were treated with bisphosphonates for an average of 6.5 years. In these individuals, the rate of fractures during treatment was comparable to that in normal ALP clinic controls who were treated with bisphosphonates. We conclude that heterozygous loss‐of‐function mutations in ALPL are common in osteoporosis patients with low ALP. Further studies are required to determine how best these individuals should be treated. © 2019 The Authors. Journal of Bone and Mineral Research published by American Society for Bone and Mineral Research.

Pentapeptide-decorated silica nanoparticles loading salmon calcitonin for in vivo osteoporosis treatment with sustained hypocalcemic effect

Patients with osteoporosis are at a constant risk of bone fracture, and traditional treatment involves the administration of anabolic or antiresorptive drugs. At present, antiosteoporosis drugs, including salmon calcitonin (sCT), face many challenges such as short half-life and limited therapeutic efficiency to suppress bone loss and increase bone mass. Therefore, strategies to prolong the action time of antiosteoporosis drugs in vivo and improve their efficacy are essential. In this study, pentapeptide-decorated silica nanoparticles were synthesized and loaded with sCT (SiO2-Pep@sCT) to improve the therapeutic efficiency. Cytotoxicity and proliferation tests confirmed that SiO2-Pep@sCT had excellent biocompatibility. Biomarkers, including alkaline phosphatase activity, calcium flux, and calcified nodules, showed that SiO2-Pep@sCT promoted osteogenic differentiation in osteoblasts. Further, in vivo evaluations revealed that SiO2-Pep@sCT can efficiently prolong the half-life of sCT (from 30.5 to 69.3 min), leading to the maintenance of serum calcium in the normal physiological range in 48 h after single injection. For long-term treatment, micro-CT analysis showed that SiO2-Pep@sCT can enhance trabeculation and accelerate the process of bone repair during osteoporosis. Thus, the SiO2-Pep nanoparticle with uniform charge spatially distributed on the surface might be a potential drug/protein carrier for treating osteoporosis or other clinic diseases.

The Evaluation of an Osteoporosis Clinic in a Community Hospital Setting: a Retrospective Chart Review and Telephone Survey.

BackgroundPatients who have suffered fragility fractures are at an increased risk for subsequent fractures. The Osteoporosis (OP) Clinic at Markham Stouffville Hospital (MSH) was set up in July 2015 to screen, diagnose, and treat patients with fragility fractures. The goal of this study was to identify differences in OP screening and treatment initiation between patients seen in the OP clinic versus usual care.MethodsA retrospective cohort study and telephone interview was conducted on 40 patients who had sustained a hip fragility fracture between September 2015 and July 2016. 20 of those patients were referred to the OP clinic, while the remaining patients received usual care.ResultsAt the end of the intervention, 16/20 patients in the OP clinic group were appropriately placed on a bisphosphonate/RANKL inhibitor versus only 6/20 patients in the usual care group (p < .01).ConclusionsA significant care gap exists in secondary fracture prevention between the osteoporosis clinic and usual care groups. Better screening and subsequent intervention are needed for patients with fragility fractures. This study highlights the efficacy of an outpatient OP clinic in a community hospital setting.

Androgen Deprivation Therapy for Prostate Cancer: Specialty Clinic Collaboration and the Electronic Medical Record Can Improve Bone Health Monitoring.

Patients with prostate cancer on androgen deprivation therapy are at increased risk for iatrogenic osteoporosis, minimal trauma fractures and reduced bone density. We created a high risk osteoporosis clinic to manage patients at risk for these complications. A quality improvement initiative involving a best practice advisory and provider education program was implemented to enhance care of patients with prostate cancer. Fishbone diagrams were constructed to reveal causes of suboptimal bone health management. A best practice advisory was created for gonadotropin-releasing hormone agonist orders in the Epic electronic medical record to encourage referrals to the high risk osteoporosis clinic. Discussions were held with urology clinic staff regarding fracture risk. Referral rates were assessed via periodic chart reviews. Baseline referral rate to the high risk osteoporosis clinic was 4%. Final review indicated that 113 patients with prostate cancer were seen in the urology clinic from March 2017 to April 2018, of whom 67 were referred to the high risk osteoporosis clinic. At the end of the study period the referral rate had increased to 59%. Among the 113 patients 32 received antiresorptive therapy, 75% of whom had been referred to the high risk osteoporosis clinic. Of 67 patients referred to the clinic 48 had dual energy x-ray absorptiometry completed or pending and 50 had vitamin D levels obtained or pending. Of 46 patients not referred to the clinic 7 had dual energy x-ray absorptiometry completed and 3 had vitamin D levels obtained or pending. Use of a best practice advisory and urology nursing staff education program increased high risk osteoporosis clinic referrals. A higher proportion of patients referred to the clinic had bone health monitored compared to patients without this referral.