Osteoporosis Outpatient Clinic Research Articles

The Impact of Combination of Aerobic and Resistive Exercise on Activities of Daily Living and Risk of Fall in Osteosarcopenic Patients.

It is aimed to explain the impact of the combination of aerobic and resistive exercise on activities of daily living and the risk of falls in osteosarcopenic patients. Female and male patients over 70 years of age followed up from the osteoporosis outpatient clinic were screened. Appropriate patients were evaluated for sarcopenia gait speed, grip strength and skeletal muscle mass. Patients with sarcopenia who did not have the exclusion criteria were included in the 3-month aerobic and resistive exercise program. Changes in skeletal muscle mass measurements, physical performance and balance tests were evaluated at 1 month and 3 months. Sarcopenia was screened in 91 patients with osteoporosis and osteopenia. Sarcopenia was detected in 27 patients and 23 completed the 3-month study. The mean age of the patients was 78.4±5.7 years and the number of female patients was 16 (69.6%). There was no significant change in skeletal muscle mass measurements and Katz Activities of Daily Living Scale performed at 1 and 3 months (p>0.05). Short Physical Performance Battery (SPPB), Timed Up and Go Test (TUGT) and Berg Balance Test (BBT) were found to improve significantly in the first month, and it continued to develop in the third month (p<0.05). Although the combination of aerobic and resistive exercise in osteosarcopenic patients did not lead to a significant increase in skeletal muscle mass, It has a significant effect on physical performance and balance. It can be foreseen that this will increase the independence of the person while reducing the risk of falling.

Treatment of osteoporosis with denosumab in patients with decreased kidney function

IntroductionLittle is known about treatment of osteoporosis with denosumab (Prolia®) in patients with decreased kidney function. The aim of this retrospective case report study was to investigate effects and side-effects of such treatment.MethodsSince 2012, 75 patients with osteoporosis and decreased kidney function had been treated with denosumab (Prolia®) in the osteoporosis outpatient clinic of the department of endocrinology, Bispebjerg Hospital, University of Copenhagen, Denmark, and data were retrospectively collected from the patient records of these patients in 2021.ResultsAt baseline, the mean estimated glomerular filtration rate (eGFR) was 34 mL/min (range 9–50) and the median age was 85 years (range 45–103). 95% of the patients had had low-energy fractures, and the bone mineral density T score of the hips was on average − 2.7. All, but one, patients had normal/high parathyroid hormone (PTH) levels.The mean duration of the treatment with denosumab at the follow-up was 5.3 years (range 1.5–10). There was an annual increase of 12% and of 7% in the T score of in the lumbar spine and hip, respectively, compared to the T-scores prior to the denosumab treatment. 20% had a new fracture during the follow-up. 21% had biochemical hypocalcemia following denosumab injection, 7% developed symptoms of hypocalcemia, whereas 4% needed to be hospitalized acutely.ConclusionTreatment with denosumab of osteoporosis in patients with decreased kidney function (eGFR 9–50 mL/min), with normal/high PTH, seems in general to be well tolerated, with improvement of bone and decreased risk of new fractures.

Relationship between sacral‐abdominal wall distance and grip strength in postmenopausal osteoporotic patients

AbstractBackgroundAn increase in waist circumference (WC) is a factor in lifestyle‐related diseases. The rectus abdominis muscle is a skeletal muscle that attaches to the pelvis from the xiphoid process and is thought to be affected by kyphosis deformity and posterior pelvic tilt. The purpose of this study is to examine differences between sacral‐abdominal wall distance (SAD) and WC and to determine whether they are associated with fall risk, frailty, markers of sarcopenia (grip strength and lean body mass), and spinal alignment. A secondary objective is to examine these differences by stratification by grip strength.MethodsThis retrospective study included 239 women aged 65 years or older (mean age 76.5 ± 6.7 years) attending an outpatient osteoporosis clinic. Bone mineral density and skeletal body composition (muscle mass index and trunk lean mass) were measured using dual‐energy X‐ray absorptiometry. SAD, pelvic tilt, and sagittal longitudinal axis were measured from simple X‐ray images of the spine sides. WC, grip strength, frailty, and fall risk score were investigated. Statistics were performed using Stat Flex, with two‐sided P &lt; 0.05 being significantly different.ResultsWC was correlated with SAD (R = 0.68, P &lt; 0.001). The SAD cut‐off value for a WC of 90 cm was 167 mm. The relationship between grip strength, SAD, and WC, weaker grip strength was associated with greater SAD; however, no significant difference was noted in WC. WC was not correlated with pelvic alignment but was correlated with body mass index (P &lt; 0.01). Meanwhile, SAD was correlated with body mass index, pelvic tilt, sagittal longitudinal axis (P &lt; 0.01), spinal alignment, and WC. Logistic regression analysis was performed with a grip strength of less than 18 kg as the objective variable. We found that the conditions for a grip strength of less than 18 kg were older age (P &lt; 0.001), increased SAD (P = 0.02), and decreased trunk lean body mass. There was a decrease in grip strength (P &lt; 0.05) and an increase in frailty (P &lt; 0.05) and falls (P &lt; 0.01) score in patients with SAD of 167 mm or greater.ConclusionsSAD and WC were found to be correlated; SAD was associated with body weight, posterior pelvic tilt, and anterior spinal tilt deformity, while WC was related to body weight. Increased SAD was found to be linked with decreased grip strength and increased risk of falls. This study was the first to examine a new measurement, SAD, for its utility in assessing grip strength, spinal alignment, frailty, and fall risk.

Association of Spinal Alignment and Abdominal Circumference with Sarcopenia Status and Fall Risk in Patients with Osteoporosis: A Retrospective Study.

Since vertebral kyphosis and abdominal circumference are thought to influence sarcopenia and fall risk in osteoporosis, we evaluated sarcopenia and fall risk in patients with different measurements of abdominal circumference and sagittal longitudinal axis (SVA). In this post hoc study, 227 patients aged 65 years or more who visited an outpatient osteoporosis clinic were included in the analysis. Sarcopenia was determined from lean body mass, grip strength, and walking speed by dual energy X-ray absorptiometry; SVA (median 40 mm) and abdominal circumference (median 80 cm) were compared between the four groups, each divided into two groups. Nutritional management, falls, and fall anxiety scores were also examined. The incidence of sarcopenia was significantly increased in those with abdominal circumference < 80 cm in both the SVA < 40 mm and SVA ≥ 40 mm groups (p < 0.05). Nonetheless, the fall scores of those with SVA < 40 mm were lower than those of individuals with SVA ≥ 40 mm (p < 0.01). Based on the results of this study, SVA and abdominal circumference values may predict the risk of sarcopenia and falls. More research is needed before our results can be translated into clinical practice.

Sagittal alignment cut-off values for predicting future fall-related fractures in community-dwelling osteoporotic women.

Determining the optimal cut-off value of sagittal alignment for detecting osteoporotic patients at high risk for fall-related fractures is essential for understanding fracture risk and informing clinicians and physical therapists. We determined the optimal cut-off value of sagittal alignment for detecting osteoporotic patients at high risk for fall-related fractures in this study. In the retrospective cohort study, we enrolled a total of 255 women aged ≥ 65years who visited an outpatient osteoporosis clinic. We measured participants' bone mineral density and sagittal alignment, including sagittal vertical axis (SVA), pelvic tilt, thoracic kyphosis, pelvic incidence, lumbar lordosis, global tilt, and gap score at the initial visit. The cut-off value for sagittal alignment that was significantly associated with fall-related fractures was calculated after using multivariate Cox proportional hazards regression analysis. Ultimately, 192 patients were included in the analysis. After a mean follow-up of 3.0years, 12.0% (n = 23) had fractures due to falls. Multivariate Cox regression analysis confirmed that SVA (hazard ratio [HR] = 1.022, 95% confidence interval [CI] = 1.005-1.039) was the only independent predictor of fall-related fracture occurrence. The predictive ability of SVA for the occurrence of fall-related fractures was moderate (area under the curve [AUC] = 0.728, 95% CI = 0.623-0.834), with a cut-off value of 100mm for SVA. SVA classified by cut-off value was also associated with an increased risk of developing fall-related fractures (HR = 17.002, 95% CI = 4.102-70.475). We found that assessing the cut-off value of sagittal alignment would be useful information in understanding fracture risk in postmenopausal older women.

Fracture risk and fracture prevalence in women from outpatient osteoporosis clinic and subjects from population-based sample: A comparison between GO Study and RAC-OST-POL cohorts.

The method of recruiting the study subjects is an important element of the study design. It can have a strong influence on the results. Different recruitment schedules can give a different picture of the studied phenomenon. The aim of the study was to compare bone health in a group of female patients treated for osteoporosis with a population-based sample. A cohort of women from GO Study from 1 outpatient osteoporotic clinic (n = 1442, mean age 65.8 ±6.7 years) and population-based female sample of RAC-OST-POL Study (n = 963, mean age 65.8 ±7.5 years) were studied. Mean age did not differ between groups. Mean weight, height and body mass index (BMI) in subjects from GO Study and RAC-OST-POL Study were 69.5 ±13.1 kg, 157.8 ±6.1 cm and 27.9 ±5.1 kg/m2, and 74.2 ±13.7 kg, 156.0 ±6.0 cm and 30.5 ±5.4 kg/m2, respectively, and differed significantly (p < 0.0001 for each variable). Data on clinical risk factors for osteoporosis and fractures were collected. Bone densitometry at hip was performed using a Prodigy or Lunar DPX device (GE Healthcare, Waukesha, USA). Fracture risk was established using FRAX, Garvan and POL-RISK. Mean values of T-score for femoral neck in subjects from GO Study and RAC-OST-POL Study were -1.67 ±0.91 and -1.27 ±0.91 and differed significantly (p < 0.0001). In GO Study and RAC-OST-POL Study, there were 518 (35.9%) and 280 (29.1%) subjects with fractures, respectively. The fracture frequency was significantly higher in the GO Study group (p < 0.001). Among clinical risk factors, only rheumatoid arthritis (p < 0.0001) secondary osteoporosis (p < 0.0001) and falls (p < 0.0001) were more frequent in RAC-OST-POL Study. Fracture risk established using FRAX, Garvan and POL-RISK calculators was significantly greater in patients enrolled in the GO Study than in subjects from the RAC-OST-POL population-based sample (p < 0.0001 for each variable). Differences noted between female patients treated for osteoporosis and population-based sample, especially in regard to fracture risk, reveal a strong influence of recruitment criteria on study results in the field of bone health and osteoporosis.

Changes in dual energy X-ray absorptiometry parameters in postmenopausal women with osteoporosis who received at least 12 months of denosumab treatment

Background/Aim: Denosumab is a human monoclonal antibody that binds to the receptor-activated nuclear factor kappa beta ligand (RANKL). Densosumab leads to a reduction in bone resorption by inhibiting RANKL and has been approved for treating postmenopausal osteoporosis (OP). The present study investigated real life data by evaluating the demographic data of postmenopausal patients with OP who received denosumab treatment and the changes in dual energy x-ray absorptiometry (DEXA) parameters before and after denosumab treatment.&#x0D; Methods: This retrospective cohort study included 49 postmenopausal female patients followed in our OP outpatient clinic who were treated with 60 mg subcutaneous denosumab every six months for at least 12 months. The study retrospectively analyzed and recorded patient age, body mass index, age of menopause, fracture history, antiresorptive and/or anabolic drug treatment history, and pre- and post-denosumab T-scores in addition to L1–4, femoral neck, and total hip bone mineral densities (BMDs) on DEXA scans. The changes that occurred before and after the treatment in addition to those that occurred after the treatment based on whether previous anabolic or antiresorptive agents had been used were statistically compared.&#x0D; Results: The L1–4 and total hip T-scores and L1–4 and total hip BMD values measured prior to denosumab treatment showed a statistically significant increase after denosumab treatment (P &lt; 0.001, P = 0.002, P = 0.028, and P = 0.002, respectively). No statistically significant changes in the femoral neck T-score and BMD after denosumab treatment compared to that before denosumab use (P = 0.056 and P = 0.138, respectively) were found. Furthermore, no statistically significant difference between the pre- and post-denosumab DEXA parameters in the patients who used antiresorptive agents and those who did not (P &gt; 0.05) was found. Additionally, pre- and post-denosumab parameters were not statistically significantly different between those who received and did not receive anabolic therapy before denosumab (P &gt; 0.05).&#x0D; Conclusion: Denosumab treatment for postmenopausal OP leads to a significant increase in lumbar and total hip T-scores and BMDs.

Prevalence of Sarcopenia and Its Association with Quality of Life, Postural Stability, and Past Incidence of Falls in Postmenopausal Women with Osteoporosis: A Cross-Sectional Study.

In this cross-sectional analysis of 61 postmenopausal osteoporosis patients who regularly visited an osteoporosis outpatient clinic, we aimed to clarify the prevalence of sarcopenia and its related clinical factors. Of 61 patients (mean age 77.6 ± 8.1 years), 24 (39.3%) had osteosarcopenia and 37 (60.7%) had osteoporosis alone. Age, nutritional status, and the number of prescribed drugs were associated with the presence of sarcopenia (p = 0.002, <0.001, and 0.001, respectively), while bone mineral density (BMD) and % young adult mean BMD were not (p = 0.119 and 0.119, respectively). Moreover, patients with osteosarcopenia had lower quality of life (QOL) scores, greater postural instability, and a higher incidence of falls in the past year than patients with osteoporosis alone. In contrast, BMD status showed no correlation with the nutritional status, QOL score, postural instability, or incidence of falls in the past year. In conclusion, the incidence of sarcopenia was relatively high among postmenopausal osteoporosis female patients in an osteoporosis outpatient clinic. Our results suggest that in addition to routine BMD evaluation, assessment and management of sarcopenia may be promoted at osteoporosis outpatient clinics to limit the risk of falls and prevent consequent fragility fractures in osteoporosis patients.

STEADI Self-Report Measures Independently Predict Fall Risk.

Falls are a significant contributor to disability and death among older adults. Despite practice guidelines to increase falls screening in healthcare settings, preventive care for falls continues to be infrequently delivered. Simplifying screening by relying on self-report of balance, gait, or strength concerns, alone may increase the frequency of falls screening. We assessed the diagnostic accuracy of self-report measures of gait, strength, and balance from the Centers for Disease Control and Prevention’s Stopping Elderly Accidents, Deaths, and Injuries (STEADI) for identification of fall risk. The criterion standard for fall risk was the Timed Up-and-Go (TUG). Assessments were conducted with 95 adults aged 65 years or older in an outpatient osteoporosis clinic between May 2015 and September 2016. Receiver operating characteristic curve analysis found that two self-report questions (“I feel unsteady with walking” and “I need my arms to stand from a chair”) had high discriminatory ability (AUC 0.906; 95% CI 0.870–0.942) to identify those at high fall risk; additional questions did not substantially improve discrimination. These findings suggest that two self-report questions identify those at risk of falling who would benefit from interventions (e.g., physical therapy). Performance testing as part of routine falls screening of older persons in the outpatient setting may be unnecessary.

Comparing three machine learning approaches to design a risk assessment tool for future fractures: predicting a subsequent major osteoporotic fracture in fracture patients with osteopenia and osteoporosis.

Major osteoporotic fractures (MOFs), defined as hip, wrist, spine and humerus fractures, can have serious consequences regarding morbidity and mortality. Machine learning provides new opportunities for fracture prediction and may aid in targeting preventive interventions to patients at risk of MOF. The primary objective is to develop and compare several models, capable of predicting the risk of MOF as a function of time in patients seen at the fracture and osteoporosis outpatient clinic (FO-clinic) after sustaining a fracture. Patients aged > 50years visiting an FO-clinic were included in this retrospective study. We compared discriminative ability (concordance index) for predicting the risk on MOF with a Cox regression, random survival forests (RSF) and an artificial neural network (ANN)-DeepSurv model. Missing data was imputed using multiple imputations by chained equations (MICE) or RSF's imputation function. Analyses were performed for the total cohort and a subset of osteopenia patients without vertebral fracture. A total of 7578 patients were included, 805 (11%) patients sustained a subsequent MOF. The highest concordance-index in the total dataset was 0.697 (0.664-0.730) for Cox regression; no significant difference was determined between the models. In the osteopenia subset, Cox regression outperformed RSF (p = 0.043 and p = 0.023) and ANN-DeepSurv (p = 0.043) with a c-index of 0.625 (0.562-0.689). Cox regression was used to develop a MOF risk calculator on this subset. We show that predicting the risk of MOF in patients who already sustained a fracture can be done with adequate discriminative performance. We developed a user-friendly tool for risk calculation of subsequent MOF in patients with osteopenia.

Short-Term Impact of Staying Home on Bone Health in Patients With Osteoporosis During a State of Emergency Declaration Due to COVID-19 in Kanagawa, Japan.

BackgroundOn April 16, 2020, the Japanese government declared a state of emergency due to the spread of COVID-19 infection, leading prefectural governors to announce a stay-at-home order for 39 days until May 25, 2020. As physical inactivity is a risk factor for osteoporosis, we investigated the short-term impact of the stay-at-home order on bone health among patients with osteoporosis in our hospital in Kanagawa prefecture.MethodsThirty patients with osteoporosis with no delays in their regular medication who received care at our hospital’s osteoporosis outpatient clinic within one month after the end of the state of emergency were included. Lumbar spine and femur proximal bone mineral density (BMD) were measured at the last follow-up date (May 25 to June 30, 2020; 0M) and six (6M) and 12 months (12M) before the last follow-up using dual-energy X-ray absorptiometry. Bone alkaline phosphatase (BAP), Tartrate-resistant Acid Phosphatase 5b (TRACP5b), calcium and phosphorus were assessed at the same time points.ResultsSerum BAP concentrations were significantly lower at 0M than 12M (p=0.040), but were comparable between 0M and 6M (p=0.527). Serum TRACP5b was significantly lower at 6M than 12M (p=0.009), but was similar between 0M and 6M (p=1.000). Serum calcium and phosphorus did not differ among the time points (p=0.516 and p=0.358, respectively). Similarly, lumbar spine and femoral neck BMD were comparable (p=0.679 and p=0.076, respectively).ConclusionBone health in patients with osteoporosis was maintained during the short-term COVID-19 stay-at-home order among patients who experienced no delays in medication. However, larger and long-term studies are needed.

Relationship Between Muscle Mass of the Lower Limbs and Falls Caused by Spinal Misalignment in Women Aged 70 Years: A Retrospective Study.

This retrospective study was conducted from 2015 to 2016 at the osteoporosis outpatient clinic of Showa University School of Medicine. This study aimed to investigate the association between lower-limb muscle mass and spinal misalignment-related falls in elderly women. Poor spinal alignment affects gait and balance, reducing the quality of life. Negative correlations between age-associated skeletal muscle loss and spinal sagittal alignment have been reported. This study included 127 women with osteoporosis aged more than 70 years. The correlation between lower-limb skeletal muscle index (SMI) and sagittal vertical axis (SVA) was calculated using radiographic measurements. Spinopelvic parameters, including SVA, sacral slope, pelvic tilt (PT), pelvic incidence, and lumbar lordosis, were measured. Lower-limb SMI was measured using whole-body dual-energy x-ray absorptiometry and calculated as SMI=nonfat mass/height2. The balance function was evaluated using the single-leg stance test. Data were analyzed using the Kruskal-Wallis and Mann-Whitney U tests; significance level was set at P<0.05. Bivariate and multivariate logistic regression analyses were used to determine correlations. Participants were classified into the balance and mismatch groups on the basis of a threshold SVA value of 50 mm. The groups did not differ significantly in age, height, weight, pelvic incidence, or sacral slope. Lumbar lordosis significantly decreased and PT and lower-limb SMI significantly increased in the mismatch group compared with the balance group. Lower-limb SMI was significantly correlated with increased SVA in bivariate and multivariate regression analyses. Patients with PT ≥20 degrees and SVA ≥50 mm had significantly increased lower-limb SMI. Increased SVA is associated with increased lower-limb SMI, which negatively affects standing balance. An increased lower-limb SMI may represent a novel compensatory mechanism for poor spinal alignment in elderly women with osteoporosis. Level III.

A service evaluation of e-triage in the osteoporosis outpatient clinic\u2014an effective tool to improve patient access?

SummaryWe introduced an electronic triage system into our osteoporosis service to actively manage referral demand in a busy outpatient service. Our study demonstrated the effectiveness of e-triage in supporting alternative management pathways, through use of virtual advice and direct to investigation services, to improve patient access.PurposeOsteoporosis referrals are increasing with awareness of the potential for prevention of fragility fracture and with complex decision making around management with long-term bisphosphonate therapy. We examined whether active triage of referrals might improve referral management processes and patient access to osteoporosis services.MethodsWe implemented electronic triage (e-triage) of referrals to our osteoporosis service using the Northern Ireland electronic health care record. This included the option of ‘advice only’, direct to investigation with DXA or face-to-face appointments at the consultant-led complex osteoporosis service. We anticipated that there was scope to manage patient flow direct to investigation, or to provide referring clinicians with clinical advice without the need for a face-to-face assessment, at the consultant-led specialist service.ResultsWe reviewed e-triage outcomes of 809 referrals (692 F; 117 M) to osteoporosis specialist services (mean age 65 ± 16.5 years) over a 12-month period. There was a high degree of agreement for the triage category between the referring clinician and specialist services (741/809). 73.3% attended a face-to-face appointment at the consultant-led clinic, while active triage enabled direct to investigation (18.4%) or discharge (8.3%) in the remainder. The mean time between receipt of an electronic referral and e-triage was 3 days over the 12-month period as compared with 2.1 days (median 1.1 days) when annual leave periods were excluded.ConclusionE-triage supports effective referral management in a busy osteoporosis service. Efficiency is limited by reliance on a sole clinician and 5 day working at present. There is scope to further improve systems access through multidisciplinary team working, virtual clinics and future information technology developments.

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.

The Impact of Smoking on Bone Metabolism, Bone Mineral Density and Vertebral Fractures in Postmenopausal Women

Background: Smoking is recognized among the risk factors for osteoporosis, but only few studies have comprehensively explored its influence on bone metabolism and strength. We aimed to evaluate smoking effects on calcium-phosphate metabolism, bone mineral density (BMD) and fracture risk in postmenopausal women. Methods: Our sample included 1067 postmenopausal women who arrived to our osteoporosis outpatient clinic. Anamnestic data, smoking habits (categorized as never, former, and current; and by smoking intensity and duration), biochemical parameters, lumbar/femoral BMD, and presence of vertebral fractures were recorded. In a subsample of 357 women, the changes in BMD after a 2-yr follow-up period were also assessed. Results: Current smokers had shorter reproductive age, lower body mass index, and higher prevalence of heavy alcohol consumption than former/never smokers. They also had lower PTH values and weaker linear association between serum vitamin D and parathyroid hormone (current β = −0.11[SE = 0.004]; former β = −0.14[SE = 0.01]; never β = −0.20[SE = 0.003]; p < 0.01 for all). Baseline BMD did not reflect differences based on smoking habits, duration or intensity. However, after 2 years, only current smokers significantly worsened in femural BMD. After adjustment for confounders, the chance of having sustained vertebral fractures at the first evaluation increased by 74% (95% confidence interval:1.07–2.83) in current compared with never smokers, especially among heavy smokers. Conclusions: Smoking may negatively affect bone by inhibiting vitamin D-parathyroid hormone axis, reducing estrogen exposure, promoting risky health behaviors, and accelerating bone loss, especially at the femur. No significant differences were observed in these outcomes among former smokers, suggesting that quitting smoking has beneficial effects on bone health.

Clinical decision support system for the management of osteoporosis compared to NOGG guidelines and an osteology specialist: a validation pilot study

BackgroundAlthough osteoporosis is an easily diagnosed and treatable condition, many individuals remain untreated. Clinical decision support systems might increase appropriate treatment of osteoporosis. We designed the Osteoporosis Advisor (OPAD), a computerized tool to support physicians managing osteoporosis at the point-of-care. The present study compares the treatment recommendations provided by OPAD, an expert physician and the National Osteoporosis Guideline Group (NOGG).MethodsWe performed a retrospective analysis of 259 patients attending the outpatient osteoporosis clinic at the University Hospital in Iceland. We entered each patient’s data into the OPAD and recorded the OPAD diagnostic comments, 10-year risk of major osteoporotic fracture and treatment options. We compared OPAD recommendations to those given by the osteoporosis specialist, and to those of the NOGG.ResultsRisk estimates made by OPAD were highly correlated with those from FRAX (r = 0.99, 95% CI 0.99, 1.00 without femoral neck BMD; r = 0.98, 95% CI, 0.97, 0.99 with femoral neck BMD. Reassurance was recommended by the expert, NOGG and the OPAD in 68, 63 and 52% of cases, respectively. Likewise, intervention was recommended by the expert, NOGG, and the OPAD in 32, 37 and 48% of cases, respectively. The OPAD demonstrated moderate agreement with the physician (kappa 0.51, 95% CI 0.41, 0.61) and even higher agreement with NOGG (kappa 0.69, 95% CI 0.60, 0.77).ConclusionPrimary care physicians can use the OPAD to assess and treat patients’ skeletal health. Recommendations given by OPAD are consistent with expert opinion and existing guidelines.

Identification of asymptomatic frailty vertebral fractures in post-menopausal women.

Vertebral fractures are associated with persistent pain, disability and mortality. However, around two thirds of women with vertebral fractures are unaware of them. We aimed to analyze which factors could mostly be associated to the presence of vertebral fractures in post-menopausal women, and evaluate the effectiveness of current screening criteria for the detection of vertebral fractures in an outpatient setting. We evaluated 1132 post-menopausal women referred to the osteoporosis outpatient clinic of the Geriatrics Department of Padova. For each participant we assessed: anthropometric data, femoral and lumbar bone mineral density (BMD), dorso-lumbar X-rays, bone metabolism markers. Current recommendations for X-ray examinations by SIOMMMS (Società Italiana di Osteoporosi, Metabolismo Minerale e Malattie dello Scheletro) and ISCD (International Society of Clinical Densitometry) versus routine X-ray examinations were considered, and fracture risk was assessed through the derived FRAX (DeFRA) tool. Of the women included in our study, 28% presented vertebral fractures, most of these previously unknown (82.8%). Lumbar BMD did not differ between patients with and without vertebral fractures. According to SIOMMMS guidelines, 50% of patients <60 years with unknown vertebral fractures would have been excluded from spinal X-ray examination. According to ISCD recommendations, the number of patients excluded reached 94.6% in the <60 age-group and 84.9% in the 60-70 age-group. The under-identification of vertebral fractures led to the 10-year risk of fractures computed by DeFRA being underestimated by around 15%. BMD, particularly in the lumbar site, may not properly predict the presence of vertebral fractures in post-menopausal women. Improvement of the current recommendations for spinal X-ray examination may lead to early identification and better management of patients with vertebral fractures.

Sequential Treatment Reduces the Acute Phases of Adverse Effect of Zoledronic Acid in First Time Users

Objective: To investigate whether sequential regimen such as traditional anti-reabsorption medications followed by zoledronic acid could reduce the side effects after initiation of zoledronic acid in postmenopausal osteoporosis patients. Methods: A total of 156 postmenopausal osteoporosis patients who presented at our osteoporosis outpatient clinic were enrolled in this study. They were randomly divided into four groups: the control group, alendronate group, calcitonin group, and raloxifene group. All participants were treated with Caltrate 600 mg per day and calcitriol 0.25 ug per day as a baseline treatment, followed by administrating 5 mg/100 mL of zoledronic acid intravenously for one single time three months afterwards. During the abovementioned course of three months, the alendronate group received 70 mg of alendronate sodium orally once a week, the calcitonin group received nasal spray form of salmon calcitonin 10iu daily, the raloxifene group received 60mg of raloxifene orally daily, and the control group received nothing but only the baseline treatment. We tested parameters such as β-cross, blood calcium level, renal function both pre and post zoledronic acid treatment. We also documented those side effects that typically occurred within one week of treatment initiation, which included the proportion, severity, onset time, and duration of the fever, demand for pain medication, severity of bone and joint pain, flu-like symptoms, arrhythmia, blood calcium level, and kidney function impairment. We also evaluated how willing the patients were to receive a second dose of zoledronic acid. Then we did comparative analysis between control group and sequential group. Results: The side effects such as fever, bone and joint pain, flu-like symptoms after zoledronic acid treatment in alendronate group and calcitonin group were all significantly lower than that in control group, while raloxifene group showed no significant difference compared to that in the control group. The proportions of patients who needed NSAIDs in the alendronate group and the calcitonin group were significantly lower than that in control group. However, the raloxifene group showed no significant difference in the NSAIDs demand from that of the control group. The percentages of patients who consented to a second dose of zoledronate therapy in the alendronate, calcitonin and raloxifene groups were significantly higher than that in the control group. Conclusions: Sequential treatment with alendronate sodium or calcitonin can significantly reduce the side effects such as fever, bone/joint pain, flu-like symptoms caused by first-time zoledronic acid therapy. Raloxifene sequential treatment does not seem to have decreased or increased the side effects of zoledronic acid treatment. Also, sequential treatment can improve the patient compliance with a second dose of zoledronic acid.

The Role of Health Education in Improving Patient Compliance with Zoledronic Acid

Objective: To define the role of health education in improving patient compliance with Zoledronic Acid for osteoporosis treatment and management and draw closer attention of patients and physicians to the importance of health education. Methods: A total of 198 postmenopausal patients with osteoporosis who were admitted by the osteoporosis outpatient clinic of our hospital and had the first administration of Zoledronic Acid in 2015 were invited to participate in the follow-up visit that involved questions concerning the frequency of health education and the questionnaire survey on osteoporosis in 2015 and the administration of Zoledronic Acid during the past three years. The patients were divided into five groups according to the frequency of health education to compare the survey results of each group in 2015 and 2018 and investigate the differences in the scores and frequency of administration among the five groups. Results: Among the 198 patients, there were 182 attending the follow-up visit. In terms of the frequency of health education (FREQ = 0, 1, 2, 3, 4), these patients were divided into five groups of 47, 63, 35, 18 and 19 members respectively. After three years of treatment, the questionnaire score of each group was higher than the pre-treatment level and the difference showed statistical significance (p < 0.05, respectively); compared to those who had never received health education (FREQ = 0), the patients who had participated in health education activities at different levels (FREQ = 1, 2, 3, 4) scored significantly higher in the questionnaire survey and increased the frequency of administration of Zoledronic Acid on average; particularly, those who had received health education and Zoledronic Acid treatment twice and above benefited the most. Conclusion: Health education is an effective approach to influence a patient’s knowledge connected to relevant diseases in a positive way and improve patient compliance with Zoledronic Acid treatment. An enhanced health education program can be developed to assist the patients in chronic disease management.

Implementation of a fall screening program in a high risk of fracture population.

Falls are the most common cause of fracture in persons with osteoporosis. However, osteoporosis care rarely includes assessment and prevention of falling. We thus sought to assess the feasibility of a fall screening and management program integrated into routine osteoporosis care. The program was developed and offered to patients with osteoporosis or osteopenia seen at an outpatient clinic between May 2015 and May 2016. Feasibility was measured by physical therapist time required to conduct screening and ease of integrating the screening program into the usual clinic workflow. Self-report responses and mobility testing were conducted to describe the fall and fracture risk profile of osteoporosis patients screened. Effects on fall-related care processes were assessed via chart abstraction of patient participation in fall prevention exercise. Of the 154 clinic patients who presented for a clinic visit, 68% met screening criteria and completed in two thirds of persons. Screening was completed in a third of the time typically allotted for traditional PT evaluations and did not interfere with clinic workflow. Forty percent of those screened reported falling in the last year, and over half had two or more falls in the past year. Over half reported a balance or lower extremity impairment, and over 40% were below norms on one or more performance tests. Most patients who selected a group exercise fall prevention program completed all sessions while only a quarter completed either supervised or independent home-based programs. Implementation of a fall risk screening program in an outpatient osteoporosis clinic appears feasible. A substantial proportion of people with osteoporosis screened positive for being at risk of falling, justifying integration of fall prevention into routine osteoporosis care.