Risk Of Osteoporosis-related Fractures Research Articles

Is drug-induced bone loss acceptable in premenopausal women? A practical fracture risk modeling exercise.

It is logical that drug-induced loss of bone mass and microarchitecture in young adults increase fracture risk later in life. However, no existing data quantify how drug-induced bone loss in younger adults impacts fracture risk later in life. As such, no guidance exists to address the question "How much, if any, drug-induced bone loss in premenopausal women is acceptable?" Thus, we performed a systematic fracture risk modeling exercise examining various degrees of bone loss, and estimated the impact on 10-year major osteoporosis-related fracture risk later in life. The FRAX® tool was used in conjunction with BMD and trabecular bone score (TBS) adjustment to estimate major osteoporotic fracture probability later in life resulting from varying degrees of hypothetical premenopausal drug-induced BMD and TBS loss. The resulting 10-year fracture probabilities were assessed against the US and the UK treatment guidance to determine the amount of premenopausal BMD and TBS loss that would result in a recommendation to initiate medical treatment to reduce fracture risk later in life that would not otherwise have been recommended in the absence of premenopausal bone loss. For women whose peak bone mass is between the 5th and 50th percentiles, varying degrees of BMD and TBS loss could be tolerated without reaching treatment thresholds. The degree of tolerable bone loss was primarily dependent on baseline bone status. Those whose peak BMD and TBS are in the 50th percentile or above could tolerate a 10% reduction in BMD and TBS without reaching treatment thresholds by age 75, whereas those in the 5th percentile would reach treatment thresholds by age 75 with no drug-induced reduction in BMD or TBS. Women in the 25th percentile could tolerate a 4% BMD loss and 2% TBS decline without reaching treatment thresholds by age 75. For clinicians and regulatory bodies to assess the consequence of drug-induced premenopausal bone loss, we propose an individualized approach considering both loss of BMD and TBS in concert with baseline bone status and the resultant effect on fracture risk in later life using the assumption that such losses are irreversible.

The Role of Monocyte Percentage in Osteoporosis in Male Rheumatic Diseases.

Osteoporosis is easily overlooked in male patients, especially in the field of rheumatic diseases mostly prevalent with female patients, and its link to pathogenesis is still lacking. Attenuated monocyte apoptosis from a transcriptome-wide expression study illustrates the role of monocytes in osteoporosis. This study tested the hypothesis that the monocyte percentage among leukocytes could be a biomarker of osteoporosis in rheumatic diseases. Eighty-seven males with rheumatic diseases were evaluated in rheumatology outpatient clinics for bone mineral density (BMD) and surrogate markers, such as routine peripheral blood parameters and autoantibodies. From the total number of 87 patients included in this study, only 15 met the criteria for diagnosis of osteoporosis. Both age and monocyte percentage remained independently associated with the presence of osteoporosis. Steroid dose (equivalent prednisolone dose) was negatively associated with BMD of the hip area and platelet counts were negatively associated with BMD and T score of the spine area. Besides age, monocyte percentage meets the major requirements for osteoporosis in male rheumatic diseases. A higher monocyte percentage in male rheumatic disease patients, aged over 50 years in this study, and BMD study should be considered in order to reduce the risk of osteoporosis-related fractures.

Extra virgin olive oil consumption reduces the risk of osteoporotic fractures in the PREDIMED trial

The incidence of osteoporotic fractures is lower in countries in the Mediterranean basin. Virgin olive oil, a key component of the Mediterranean Diet (MDiet), with recognised beneficial effects on metabolism and cardiovascular health, may decrease the risk of osteoporotic fractures. The aim to this study was to explore the effect of chronic consumption of total olive oil and its varieties on the risk of osteoporosis-related fractures in a middle-aged and elderly Mediterranean population. We included all participants (n=870) recruited in the Reus (Spain) centre of the PREvención con DIeta MEDiterránea (PREDIMED) trial. Individuals, aged 55-80years at high cardiovascular risk, were randomized to a MedDiet supplemented with extra-virgin olive oil, a MedDiet supplemented with nuts, or a low-fat diet. The present analysis was an observational cohort study nested in the trial. A validated food frequency questionnaire was used to assess dietary habits and olive oil consumption. Information on total osteoporotic fractures was obtained from a systematic review of medical records. The association between yearly repeated measurements of olive oil consumption and fracture risk was assessed by multivariate Cox proportional hazards. We documented 114 incident cases of osteoporosis-related fractures during a median follow-up of 8.9 years. Treatment allocation had no effect on fracture risk. Participants in the highest tertile of extra-virgin olive oil consumption had a 51% lower risk of fractures (HR:0.49; 95% CI:0.29-0.81. P for trend=0.004) compared to those in the lowest tertile after adjusting for potential confounders. Total and common olive oil consumption was not associated with fracture risk. Higher consumption of extra-virgin olive oil is associated with a lower risk of osteoporosis-related fractures in middle-aged and elderly Mediterranean population at high cardiovascular risk.

Effects of abaloparatide-SC (BA058) on bone histology and histomorphometry: The ACTIVE phase 3 trial

There are a number of effective treatments for osteoporosis but most are in the antiresorptive class of compounds. Abaloparatide-SC is a new osteoanabolic agent, which increased bone mineral density and lowered the risk of osteoporosis-related fractures in the phase 3 ACTIVE trial. The objective of this report is to describe the effects of abaloparatide-SC 80μg on bone histology and histomorphometry in iliac crest bone biopsies from this trial in which participants were randomized to receive blinded daily subcutaneous injections of placebo or abaloparatide-SC 80μg/d or open-label teriparatide 20μg/d for 18months. Iliac crest bone biopsies were obtained between 12 and 18months. Qualitative histological analysis of biopsies from abaloparatide-SC-treated patients revealed normal bone microarchitecture without evidence of adverse effects on mineralization or on the formation of normal lamellar bone. There were no bone marrow abnormalities, marrow fibrosis nor was there presence of excess osteoid or woven bone. There were few significant differences among the three treatment groups in a standard panel of static and dynamic histomorphometric indices. The mineral apposition rate was higher in the teriparatide-treated group than in the placebo-treated group. The eroded surface was lower in the abaloparatide-SC-treated group than in the placebo-treated group. Cortical porosity was higher in both the abaloparatide-SC- and the teriparatide-treated groups than in the placebo-treated group. We conclude that histological and histomorphometric analysis of iliac crest bone biopsies from subjects who were treated for up to 18months with abaloparatide-SC showed no evidence of concern for bone safety.Trial registration: ClinicalTrials.gov number NCT01343004.

DXA-Based Measurements in Diabetes: Can They Predict Fracture Risk?

In the absence of a fragility fracture, osteoporosis is usually diagnosed from bone mineral density (BMD) measured by dual-energy X-ray absorptiometry (DXA). Osteoporosis is an increasingly prevalent disease, as is diabetes [in particular type 2 diabetes (T2D)], in part due to aging populations worldwide. It has been suggested that an increased risk of fracture may be another complication ensuing from longstanding diabetes. The purpose of this review is to concentrate on skeletal parameters and techniques readily available from DXA scanning, and their utility in routine clinical practice for predicting fracture risk. In addition to BMD, other applications and measures from DXA include trabecular bone score (TBS), skeletal geometry and DXA-based finite-element analysis, vertebral fracture assessment, and body composition. In type 1 diabetes (T1D), BMD and FRAXR (when secondary osteoporosis is included without BMD) only partially account for the excess risk of fracture in T1D. Consistent data exist to show that BMD and FRAXR can be used to stratify fracture risk in T2D, but do not account for the increased risk of fracture. However, several adjustments to the FRAX score can be made as proxies for T2D to inform the use of FRAX by primary care practitioners. Examples include using the rheumatoid arthritis input (as a proxy for T2D), lumbar spine TBS (to adjust FRAX probability) or an altered hip T-score (lowered by 0.5 units). These adjustments can improve fracture risk prediction in T2D and help to avoid systematically underestimating the risk of osteoporosis-related fractures in those with diabetes.

Aerobic exercise training modulates bone mineral status in patients with chronic obstructive pulmonary disease

Background:Chronic obstructive pulmonary disease (COPD) appears to be associated with low bone mineral density (BMD) due to long-term use of corticosteroids as a result patients with COPD are at risk for osteoporosis-related fractures and worsening pulmonary function.Objective:The present study aimed to measure the effects of treadmill walking exercises on bone mineral status in patients with COPD.Methods:Sixty patients with moderate COPD of both sexes, their age ranged from 45 to 58 years. Subjects were divided into two equal groups: training group (group A) received aerobic exercise training on treadmill for six months, where the second group (B) was considered as a control group who received no exercise training. The program consisted of three sessions per week for six months.Results:The results of this study indicated a significant increase in BMD of the lumbar spine & the radius and serum calcium & significant reduction in parathyroid hormone in group (A), while these changes were not significant in group (B).Also; there was a significant difference between both groups at the end of the study.Conclusion:Treadmill walking exercise training is an effective treatment policy to improve bone mineral status in patients with COPD.

Osteoporosis as a result of the long-term administration of glucocorticoids in patients suffering from acantholytic pemphigus

Goal. To study the prevalence of glucocorticoid-induced osteoporosis in patients suffering from acantholytic pemphigus and risk of osteoporosis-related fractures. Materials and methods. The study involved 26 patients including 12 patients suffering from acantholytic pemphigus. The patients underwent dual-energy X-ray absorptiometry (DXA) for calculating bone mineral density (BMD) as well as T and Z scores. To assess the ten-year probability (absolute risk) of fractures, the FRAX model was applied. Major results. Glucocorticoid-induced osteoporosis was diagnosed in 33.3% of the AP patients receiving a glucocorticoid therapy, and osteopenia was also diagnosed in 33.3% of them; an increased risk of osteoporosis-related fractures was observed in all of the patients over 40, which entails the need in early diagnostics of pathologic bone changes and prevention of complications such as osteoporosis-related fractures. Conclusion. A high share of complications (83.3%) related to systemic GCS stipulates the need in increased cooperation between dermatologists and allied specialists.

Comparison of Bone Mineral Density, T-Scores and Serum Zinc between Diabetic and Non Diabetic Postmenopausal Women with Osteoporosis.

Context:Postmenopausal osteoporosis is a public health problem. Diabetics are at increased risk of osteoporosis-related fractures. Zinc (Zn) has a role in collagen metabolism, and its levels are altered in diabetes.Aims:The aim was to compare bone mineral density (BMD), T-score and serum Zn between diabetic and nondiabetic postmenopausal women with osteoporosis to see if they influence increased fracture risk in diabetes.Settings and Design:It is a cross.sectional study conducted at Department of Biochemistry, Jawaharlal Nehru Medical College, Belgaum.Materials and Methods:Thirty type 2 diabetic and 30 age-matched (aged 45-75 years) nondiabetic Dual energy X-ray absorptiometry (DEXA) confirmed postmenopausal osteoporotics were included from January 2011 to March 2012. Serum Zn was analyzed by atomic absorption spectrophotometry.Statistical Analysis Used:Mean and standard deviation of the parameters of the two groups were computed and compared by unpaired Student's t-test. Relationship between variables was measured by Karl Pearson's correlation co-efficient. A statistical significance is set at 5% level of significance (P < 0.05).Results:T-score was significantly higher in diabetics compared with nondiabetics (−2.84 ± 0.42 vs. −3.22 ± 0.74) P < 0.05. BMD and serum Zn of diabetics showed a significant positive correlation with body mass index (BMI).Conclusions:Type 2 diabetic postmenopausal osteoporotics have a higher T-score than the nondiabetics. High BMI in type-2 diabetes mellitus (T2DM) may contribute to high BMD and may be a protective factor against zincuria. Increased fracture risk in T2DM could be due to other factors like poor bone quality due to hyperglycemia rather than BMD. Strict glycemic control is of paramount importance.

Risk of Osteoporotic Fractures With Angiotensin II Receptor Blockers Versus Angiotensin-Converting Enzyme Inhibitors in Hypertensive Community-Dwelling Elderly

Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) are used to treat hypertension; however, in vivo and clinical studies suggest that ARBs and ACE inhibitors may exert different effects on bone. The association between long-term use of ARBs and ACE inhibitors and fracture requiring medical attention is limited. We conducted a population-based, retrospective cohort study with propensity score matching using administrative databases in Ontario, Canada, to examine the risk of osteoporosis-related fractures in hypertensive elderly treated with ARBs versus ACE inhibitors. We identified a cohort of newly treated hypertensive patients aged 66 years and older who initiated an ACE inhibitor from May 1, 2004, to March 31, 2012, and matched them to ARB users on propensity score, sex, and age at drug initiation. The primary outcome was hip fracture, and secondary outcomes were non-hip major osteoporotic fractures (other femoral, clinical vertebral, forearm, wrist, humerus) and other osteoporotic fractures (pelvis, clavicle, patella, shoulder, upper arm, tibia, fibula, ankle, scapula, ribs, sternum, trunk). We calculated hazard ratios (HRs) using Cox proportional hazards model with robust standard errors. Of the 87,635 patients who initiated treatment, 28,819 (32.9%) started ARBs and 58,816 (67.1%) started ACE inhibitors. Among new ARB users, 27,815 (96.5%) were successfully matched to ACE inhibitor users. Without dose adjustment, no significant association was observed for ARBs relative to ACE inhibitor users for hip fractures (HR = 0.88; 95% confidence interval [CI] 0.70-1.11), with a decreased risk of other major osteoporotic fractures (HR = 0.81; CI 0.70-0.93) and no significant association for other osteoporotic fractures (HR = 0.88; CI 0.74-1.05). When adjusted for dosage, there was no significant difference between the effects of ARBs and ACE inhibitors on hip (HR = 0.99; CI 0.78-1.25), other major osteoporotic (HR = 0.87; CI 0.75-1.01), and other osteoporotic fractures (HR = 0.90; CI 0.74-1.08).

How long should we treat?

Osteoporosis is a chronic disease, for which effective drugs are available. These drugs have reduced the risk of osteoporosis-related fractures in robust trials of 3-5 years duration. There is no evidence of anti-fracture efficacy for treatments of longer duration. The consequences of stopping treatments are very different for the different molecules. Bisphosphonates can be safely discontinued after 3-5 years of treatment if there was optimal adherence and if patients are no longer osteoporotic. This discontinuation cannot be applied in patients with recent fractures or for other treatments. Safety of prolonged treatment is a huge concern which must be managed appropriately. The decision of a prolonged treatment is driven by the underlying risk of fracture. This risk must be assessed regularly in order to share with the patient the benefit-risk ratio of prolonged treatment.

Patient care services: What pharmacists do

Patient care services: What pharmacists do

APhA honors outstanding achievements at Annual Meeting

Each year, APhA recognizes exceptional contributors to the profession at the Annual Meeting. The following award winners will be honored at APhA2014 in Orlando.

Ancestral differences in femoral neck axis length: Possible implications for forensic anthropological analyses

In forensic anthropological contexts, very few methods of estimating ancestry from the postcranial skeleton are available. The cranium is widely recognized to show the greatest ancestral variation, and is often regarded by forensic anthropologists as the only reliable bone for estimating ancestry from unidentified skeletal remains. Several studies have demonstrated ancestral variation in aspects of the femur, but none have shown significant predictive power for discriminating multiple groups, and have therefore not gained wide acceptance by forensic anthropologists. Skeletal health experts (particularly bone densitometrists), however, have long recognized a relationship between proximal femur geometry (especially hip axis length) and osteoporosis-related fracture risk. Moreover, fracture risk has been noted to vary between ancestral groups. Here, we investigate whether measurements that are related to fracture risk might also be used to estimate ancestry from unidentified skeletal remains. Specifically, we investigate ancestral differences in femoral neck axis length (FNAL) and find significant differences between European, Asian and African groups in both women and men. FNAL was largest in European groups followed by African and then Asian groups. The greatest discriminating power was found between European and Asian groups, but was also significant between European and African groups. These differences may have utility in estimating ancestry in forensic anthropological contexts.

Validation of the Male Osteoporosis Risk Estimation Score (MORES) in a Primary Care Setting

Primary care physicians are positioned to promote early recognition and treatment of men at risk for osteoporosis-related fractures; however, efficient screening strategies are needed. This study was designed to validate the Male Osteoporosis Risk Estimation Score (MORES) for identifying men at increased risk of osteoporosis. This was a blinded analysis of the MORES, administered prospectively in a cross-sectional sample of men aged 60 years or older. Participants completed a research questionnaire at an outpatient visit and had a dual-energy X-ray absorptiometry (DXA) scan to assess bone density. Sensitivity, specificity, and area under-the-curve (AUC) were estimated for the MORES. Effectiveness was assessed by the number needed-to-screen (NNS) to prevent one additional major osteoporotic fracture. A total of 346 men completed the study. The mean age was 70.2 ± 6.9 years; 76% were non-Hispanic white. Fifteen men (4.3%) had osteoporosis of the hip. The operating characteristics were sensitivity 0.80 (95% confidence interval [CI], 0.52-0.96); specificity 0.70 (95% CI, 0.64-0.74), and AUC of 0.82 (95% CI, 0.71-0.92). Screening with the MORES yielded a NNS to prevent one additional major osteoporotic fracture over 10 years with 259 (95% CI, 192-449) compared to 636 for universal screening with a DXA. This study validated the MORES as an effective and efficient approach to identifying men at increased risk of osteoporosis who may benefit from a diagnostic DXA scan.

Genetic confirmation for a central role for TNFα in the direct action of thyroid stimulating hormone on the skeleton

Clinical data showing correlations between low thyroid-stimulating hormone (TSH) levels and high bone turnover markers, low bone mineral density, and an increased risk of osteoporosis-related fractures are buttressed by mouse genetic and pharmacological studies identifying a direct action of TSH on the skeleton. Here we show that the skeletal actions of TSH deficiency are mediated, in part, through TNFα. Compound mouse mutants generated by genetically deleting the Tnfα gene on a Tshr(-/-) (homozygote) or Tshr(+/-) (heterozygote) background resulted in full rescue of the osteoporosis, low bone formation, and hyperresorption that accompany TSH deficiency. Studies using ex vivo bone marrow cell cultures showed that TSH inhibits and stimulates TNFα production from macrophages and osteoblasts, respectively. TNFα, in turn, stimulates osteoclastogenesis but also enhances the production in bone marrow of a variant TSHβ. This locally produced TSH suppresses osteoclast formation in a negative feedback loop. We speculate that TNFα elevations due to low TSH signaling in human hyperthyroidism contribute to the bone loss that has traditionally been attributed solely to high thyroid hormone levels.

Tu1141 Mucosal Healing of Small Bowel Crohn's Disease After Anti-TNFα Therapy Assessed by Capsule Endoscopy

BACKGROUND:Inflammatory bowel disease (IBD) patients have an increased risk of osteoporosis related fractures. Necessity of bone density measurement in IBD patients is not clearly defined, however, the risk of fracture increases among them. Fracture Risk Assessment Tool (FRAX) score computes the 10-years probability of the major osteoporotic fractures and particularly hip fracture. Clinical FRAX (c-FRAX) does not include the bone mineral density (BMD) measurement. We aimed to compare the value the c-FRAX to FRAX enhanced with dual x-ray absorptiometry (DEXA) (bmd-FRAX) in IBD patients. METHODS:169 consecutive IBD patients (128 Crohn's disease (CD) and 41 ulcerative colitis (UC); female/male: 88/81) were included into the study. Mean age of the patients was 35.9±11.7 years, 7.6% of them was postmenopausal women. FRAX-scores were calculated with the online tool using a Hungarian algorithm. Bone mineral density measurements were performed by DEXA. Calculations were performed using SPSS statistics 15.0 software. RESULTS:In patients under 40 the c-FRAX score regardingmajor osteoporotic fracture riskwas significantly higher compared to bmd-FRAX (1,9±1,1 vs. 1,4±0,8, p,0,01). The same difference was observed computing the probability of hip fractures (c-FRAX: 0,4±0,7 vs. bmd-FRAX: 0,3±0,5; p ,0,05). In a subgroup analysis the fracture risks have not differed in CD vs. UC patients. Major fracture risk c-FRAX and bmd-FRAX were 3,0±3,4% es 2,4±2,7% in CD and 3.4±3.4% and 2.5±2.4% in UC patients (non-significant (NS)). Clinical FRAX and bmd-FRAX showing hip fracture risk were 0.8±1.5% and 0.6±1.4% in CD and 0.8±1.3% and 0.4±0.7% in UC, respectively (NS). We did not observe any correlation between FRAX scores and calcium intake, physical activity, severity, extentand duration of the disease. Subgroup analysis regarding steroid use and body mass index has not been performed due to the FRAX system included in these parameters. CONCLUSION:Guidelines regarding IBD associated osteoporosis advise to perform the DEXA measurements in patients with some special risk factors for bone loss. In our study the fracture risk according to FRAX scores completed with DEXA were lower than clinical FRAX especially in patients younger than 40 years. Our results suggest that DEXA enhanced FRAX may have an advantageous role in preventing over medicating young IBD patients.

Using Common Random Numbers in Health Care Cost‐Effectiveness Simulation Modeling

To identify the problem of separating statistical noise from treatment effects in health outcomes modeling and analysis. To demonstrate the implementation of one technique, common random numbers (CRNs), and to illustrate the value of CRNs to assess costs and outcomes under uncertainty. A microsimulation model was designed to evaluate osteoporosis treatment, estimating cost and utility measures for patient cohorts at high risk of osteoporosis-related fractures. Incremental cost-effectiveness ratios (ICERs) were estimated using a full implementation of CRNs, a partial implementation of CRNs, and no CRNs. A modification to traditional probabilistic sensitivity analysis (PSA) was used to determine how variance reduction can impact a decision maker's view of treatment efficacy and costs. The full use of CRNs provided a 93.6 percent reduction in variance compared to simulations not using the technique. The use of partial CRNs provided a 5.6 percent reduction. The PSA results using full CRNs demonstrated a substantially tighter range of cost-benefit outcomes for teriparatide usage than the cost-benefits generated without the technique. CRNs provide substantial variance reduction for cost-effectiveness studies. By reducing variability not associated with the treatment being evaluated, CRNs provide a better understanding of treatment effects and risks.

Osteoporotic Hip Fracture in the Elderly Patients: Physicians' Views

Osteoporotic hip fracture is a major healthcare problem, which is associated with a significant mortality, morbidity and socioeconomic burden in elderly patients (1). Recently, this type of fracture affects about 20,000 adults annually in Korea (2). The incidence in 2008 was 139/100,000 men, and 286/100,000 women (3). The residual lifetime risk of osteoporosis-related fracture for individuals over age 50 was 23.8% in men and 59.5% in women. That risk of osteoporotic hip fracture was 5.3% in men and 12.3% in women (2,3). These rates in Korea are compatible with those in Japan; 5.6% in men and 20.0% in women (4). Unlike other developed countries (5), the incidence of osteoporotic hip fracture seems to increase in Korea (6). Usually, the initial care of the hip fracture starts with a medical evaluation at the emergency room. Hip fractures almost always require a surgical intervention, which should be performed as early as possible, because delayed surgery is associated with excess mortality and prolonged hospitalization. However, a cautious medical evaluation and immediate clearance should be performed to reduce perioperative complications. Internal fixation and hip replacement arthroplasty are common surgical treatments. The proportion of hip replacement arthroplasty increased while that of internal fixation decreased annually during the 5 yr in Korea. The surgery usually is followed by a comprehensive multidisciplinary management including rehabilitation and/or nursing home care. Pneumonia, urinary tract infection, and sore develop in more than 20% of patients after a hip fracture operation. To prevent these complications, the patients should ambulate as early as possible after the operation. The risk of complications increases especially in patients who have predisposing factors such as old age, malignancy, and previous history of venous thromboembolism. Additionally, venous thromboembolism is a life-threatening complication. In western countries, this complication is a common cause of death and medical prophylaxis is routinely recommended. However, the medication frequently causes a serious bleeding and infection. Korean patients have a low incidence of symptomatic venous thromboembolism and quite a few fatal pulmonary embolism. Thus, medical thromboprophylaxis should be done cautiously in patients at risk. In most patients, mechanical prophylaxis using intermittent pneumatic compression can prevent venous thromboembolism (7). Delirium is another frequent complication affecting 20% to 30% of elderly patients after hip fracture surgery (8), which is frequently undetected in clinical practice. The rate of non-detection ranges from 30% to 60%. Delirium may have serious consequences for the patient and the family members if not promptly diagnosed and treated. It is frequently prolonged or persistent, resulting in increased morbidity and mortality. Therefore, an early diagnosis by close monitoring and prompt treatment should be performed to reduce hospital stay and cost. Sufficient pain management is important to decrease the risk of delirium as well as to encourage early ambulation. About 50% of senile patients, who experience a hip fracture, will have a second fracture within 3 to 5 yr. Immediate initiation of osteoporosis treatment and educational program decrease the risk of subsequent fracture. Therefore, osteoporosis treatment is important even after hip fracture treatment. However, only 25% to 33% of patients are prescribed for osteoporosis treatment after the first hip fracture. Internationally, a comprehensive systematic approach has been suggested to prevent the secondary fracture (9, 10). Physicians should check vitamin D-25 level and dual-energy X-ray absorptiometry (DXA) if these tests were not done in the last 2 yr. If the patient has osteoporosis, start the osteoporosis treatment immediately. Physicians should check and modify medications, which can make a patient more prone to falls, and discuss environmental modifications of poor lighting and trip hazards at home with patients and their family members. Although an interest on the secondary prevention has been increased in Korea (11), the preventive programs are not been activated well yet. The 30-day mortality rate after hip fracture surgery is about 10%. Approximately 15% of patients die within 6 months and 20% within 1 yr, which are about 3.5 fold higher compared with those of general population (6). Moreover, the mortality rate increases far much higher, if the patient already had medical comorbidities or has postoperative complications. In conclusion, Korean populations are rapidly aging and osteoporotic hip fractures are projected to increase drastically. Osteoporotic hip fracture appears as a significant public health problem with serious socioeconomic burden. Physicians should aware that a comprehensive approach reduces incidence, morbidity and mortality of hip fractures.

Increased risk of osteoporosis-related fractures in patients with irritable bowel syndrome

We sought to determine whether patients with irritable bowel syndrome (IBS) have an increased risk of osteoporosis and related fractures using the Nationwide Emergency Department Sample (NEDS). Patients with IBS had increased adjusted odds of osteoporosis and osteoporotic fractures compared to the non-IBS control group, controlling for known risk factors for osteoporosis. Screening measures to identify osteoporosis in this group are advised. Ulcerative colitis, Crohn's disease, and celiac disease have well-described augmented risk of osteoporosis and related fractures. We sought to determine whether IBS also indicates an increased risk of osteoporosis and related fractures. The 2008 NEDS database was used to determine the adjusted odds of osteoporosis and related fractures in IBS patients. Only fractures (pathologic wrist (733.12), vertebrae (733.13), and femur fractures (733.14), traumatic wrist (813.x), vertebrae (805.x-806.x), and hip fractures (820.x-821.x)) with a secondary diagnosis of osteoporosis (733.0x) were included in the analysis. A multivariate logistic regression analysis was performed, controlling for known risk factors for osteoporosis and related fractures. We identified 317,857 ED visits in patients with a diagnosis of IBS. Of these, 17,752 carried a diagnosis of osteoporosis and 694 IBS patients had a concurrent diagnosis of a pathologic fracture of the wrist, hip, or vertebrae. A total of 1,503 IBS patients had a concurrent diagnosis of a traumatic fracture of the wrist, hip, or vertebra. Overall, patients with IBS had an increased adjusted odds of osteoporosis (odds ratio (OR) 4.28, 95% confidence interval (CI) 4.21-4.35) and osteoporotic fractures (OR 2.36, CI 2.26-2.47) compared to the non-IBS control group. The highest adjusted odds of fracture was seen at the wrist (OR 2.41, CI 2.10-2.77 compared to controls). IBS patients are at an increased risk of osteoporosis and related fractures. Screening measures to identify osteoporosis and prevent fractures are advised.

High serum sclerostin predicts the occurrence of osteoporotic fractures in postmenopausal women: The center of excellence for osteoporosis research study

Sclerostin regulates bone formation by inhibiting Wnt pathway signaling. Low circulating sclerostin levels cause high bone mass. We hypothesized that postmenopausal women with increased sclerostin levels have a greater risk for osteoporosis-related fractures. We examined the association between circulating sclerostin together with bone turnover markers and osteoporosis-related fracture risk in 707 postmenopausal women, in a population-based study with a mean follow-up period of 5.2 ± 1.3 years. Multivariate Cox proportional hazards regression models were used to analyze fracture risk, adjusted for age, body mass index, and other confounding risk factors. High sclerostin levels were strongly associated with increased fracture risk. After adjustment for age and other confounders, the relative fracture risk was more than sevenfold among postmenopausal women for each 1-SD increment increase in sclerostin level. Women in the highest quartile of sclerostin levels had about a 15-fold increase in fracture risk. Results were similar when we compared sclerostin at the 1-year visit to an average of two to three annual measurements. Fracture risk attributable to sclerostin levels was 56.6% in the highest quartile. Only high levels of bone resorption markers (plasma cross-linked C-terminal telopeptide of type 1 collagen [p-CTx], urinary CTx [u-CTx], and urinary N-telopeptide of type 1 collagen [u-NTx]) were predictive of osteoporosis-related fractures but at much lower hazard ratio (HR) values than that of serum sclerostin. Associations between sclerostin levels and fracture risk were independent of bone mineral density and other confounding risk factors. High sclerostin levels are a strong and independent risk factor for osteoporosis-related fractures among postmenopausal women. © 2012 American Society for Bone and Mineral Research.