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Reduction of risk factors for osteoporosis among adolescents and young adults.

Osteoporosis is the most common of all skeletal disorders. The most commonly accepted definition of osteoporosis is a decrease in the amount of calcified bone tissue to the point that fractures occur with minimal trauma. Researchers have shown that peak bone mass at skeletal maturity may be the single most important factor in the development of osteoporosis. At present, no satisfactory way to replace lost bone exists, and the ideal treatment for osteoporosis is prevention, which must begin early in life. The most promising approach in the primary prevention of osteoporosis is to help each person achieve as high a peak skeletal mass and bone density as genetically possible prior to skeletal maturity. Furthermore, identifying those adolescents and young adults at risk is of clinical value for prediction and counseling purposes. Recommendations for achieving the maximal bone mass prior to skeletal maturity, as well as methods of assessing and minimizing the risk factors for osteoporosis, will be discussed.

Adolescent↗

[A head-to-head comparative study for evaluation of effectiveness among drugs for osteoporosis].

Recent progress in osteoporosis treatment has realized prevention of osteoporotic fractures. However, there is no guideline regarding which agent should be used in an individual patient. In this report, we investigated the effectiveness of several drugs for osteoporosis in a head-to-head comparative study. A total of 776 osteoporotic patients were treated with alendronate (ALN, n=197), etidronate (EHDP, n=199), alfacalcidol (VD3, n=221) and vitamin K2 (K2, n=159). The control group (No, n=266) was followed without treatment. We followed their lumbar bone mineral density (LBMD), bone turnover markers (DPD or NTX or BAP) and presence or absence of incident vertebral fractures for more than 3 years. The mean age was 70 years old. The increase in LBMD after the treatment was highest in ALN treated group (8%) followed by EHDP (6%). VD3 (1-0%) and K2 (-2%). For the change in bone turnover marker after the treatment, ALN and EHDP treated groups showed significant decrease in bone resorption markers but not the VD3 and K2 treated groups. ALN group exhibited more powerful inhibition of fracture rate (Odds ratio 0.305 versus the control, p < 0.01) than the other groups (Odds ratios 0.604-0.668 versus the control p < 0.05). ALN treatment has achieved a wide range effectiveness regardless of fracture risk. On the other hand, EHDP showed significant inhibition of fracture in low risk osteoporosis. VD3 or K2 treated groups did not inhibit new fracture occurrence in low risk osteoporosis but did so in high risk osteoporosis suggesting that those agents may improve bone quality. In conclusion, ALN is thought to be the first line drug in terms of fracture prevention in osteoporosis and the other drugs should be given to the patients who could not recieve ALN.

Aged↗

Combined treatment with vitamin k2 and bisphosphonate in postmenopausal women with osteoporosis.

Vitamin K2, as well as bisphosphonates, such as etidronate, alendronate, and risedronate, is widely used in the treatment with osteoporosis in Japan. Etidronate increases the lumbar bone mineral density (BMD), and prevents new vertebral fractures, in patients with osteoporosis, while alendronate and risedronate increase the lumbar and femoral neck BMDs, and prevent new vertebral and femoral neck fractures. Vitamin K2 enhances gamma-carboxylation of bone glutamic acid residues and the secretion of osteocalcin, sustains the lumbar BMD, and prevents osteoporotic fractures in patients with osteoporosis. Bisphosphonates, such as alendronate and risedronate, rather than vitamin K2, should be initially chosen for the treatment of osteoporosis, because they are more efficacious than vitamin K2. Available evidence suggest that risedronate prevents deterioration of the connectivity of the trabeculae in ovariectomized rats, whereas vitamin K2 increase the trabecular thickness, and that a combination of risedronate and vitamin K2 has a synergistic effect on preventing the deterioration of trabecular bone architecture induced by estrogen deficiency. Some studies have shown that combined treatment with etidronate and vitamin K2 appears to be more effective than etidronate alone in the prevention of new osteoporotic vertebral fractures. Based on these findings, combined treatment with vitamin K2 and bisphosphonates may be more efficacious in the prevention new vertebral fractures than a single treatment with bisphosphonate in postmenopausal women with osteoporosis. Thus, this combined treatment should be recommended for the treatment of postmenopausal osteoporosis. It is proposed that the role of vitamin K2 should be emphasized, when used in combination with bisphosphonates, especially in patients with vitamin K deficiency.

Aged↗

Detecting osteoporosis. Beyond the history and physical examination.

A number of developments are contributing to clinicians' understanding of osteoporosis as a clinical continuum characterized by low bone mass and increased risk of fractures rather than as a disease characterized by fragility fractures. With improved capability for accurate measurement of bone mass, the prevalence of this disease has increased to include at least 25 million Americans. The responsibility of primary care physicians to detect and treat osteoporosis has increased accordingly. Parents should be counseled regarding their children's diet and lifestyle to optimize peak adult bone mass and ensure adequate dietary calcium intake. Adults should be counseled to minimize behaviors that result in accelerated bone loss (e.g., smoking, alcohol use, anorexia, bulimia). Physicians need to be aware of the serious potential complications of osteoporosis and offer counseling to menopausal women about the disease and the benefits and risks of hormone replacement and estrogen replacement therapy. Physicians should be familiar with technologies available in their community for measuring bone mass and recognize the need to consider prescribing pharmacologic and nonpharmacologic therapies for patients with low bone mass or osteoporosis. Physicians also can educate caregivers about prevention of falls and fractures in elderly patients who are unsteady on their feet. Improved technologies for bone mass measurement and fracture risk assessment, as well as expanded options for treatment and prevention of osteoporosis, are likely to become available within the next 5 to 10 years, thereby increasing the wisdom of early detection and treatment of osteoporosis.

Absorptiometry, Photon↗

The impact of osteoporosis continuing education on nurses' knowledge and attitudes.

BACKGROUND: Osteoporosis has rapidly evolved into a severe health threat to Americans and a major public health problem. The increasing incidence of this disease and related fractures mandates that continuing education include osteoporosis content to ensure nurses provide competent education and care. An osteoporosis educational program was presented to nurses as part of a continuing education symposium on women's health issues. The program was tested to determine its effectiveness in augmenting the osteoporosis-related knowledge and attitudes of nurses. METHOD: Eighty-one RNs with educational levels varying from associate degrees to doctorates attended the continuing education program. Sixty-three of the program participants completed pretest and posttest measures. FINDINGS: The educational program significantly increased osteoporosis knowledge in this cohort of nurses. Additionally, nurses indicated they were more likely to pay attention to their own bone health as a result of attending the program. CONCLUSION: Results of this study reinforce the need for osteoporosis-related continuing education.

Adult↗

Secondary osteoporosis: a review of the recent evidence.

OBJECTIVE: To review several causes of secondary osteoporosis as well as screening recommendations for underlying disorders. METHODS: We conducted a review of the literature on many of the causes of osteoporosis that have been published during the past 15 years, focusing on those sources available from 2000 through the present. Indeed, more than two-thirds of the articles that we reviewed were printed during the past 6 years. These reports examined secondary osteoporosis in general, as well as many of the specific causes. RESULTS: Secondary osteoporosis occurs in almost two-thirds of men, more than half of premenopausal and perimenopausal women, and about one-fifth of postmenopausal women. Its causes are vast, and they include hypogonadism, medications, hyperthyroidism, vitamin D deficiency, primary hyperparathyroidism, solid organ transplantation, gastrointestinal diseases, hematologic diseases, Cushing's syndrome, and idiopathic hypercalciuria. These causes have their own pathogenesis, epidemiologic features, and effect on the skeleton. CONCLUSION: The causes of secondary osteoporosis are numerous, and an understanding of their characteristics with respect to bone density and potential fracture risk is essential in the management of osteoporosis. A heightened awareness of the possibility of their existence is necessary to provide optimal care.

Adrenal Cortex Hormones↗

Clinical reporting to primary care physicians leads to increased use and understanding of bone densitometry and affects the management of osteoporosis. A randomized trial.

BACKGROUND: A major barrier to wider use of bone densitometry has been a lack of reports that are comprehensible to primary care physicians. OBJECTIVE: To compare the effect of short technical reports and longer clinical reports on use, understanding, and acceptance of bone densitometry by primary care physicians and on management of osteoporosis. DESIGN: Randomized trial. SETTING: Osteoporosis center of a community teaching hospital. SUBJECTS: 57 primary care physicians ordering bone mineral density tests with dual x-ray absorptiometry. INTERVENTION: Physicians were randomly assigned to receive short technical reports or long clinical reports written by endocrinologists with access to clinical information. MEASUREMENTS: Physicians were interviewed by telephone after receiving at least two reports. RESULTS: Before being interviewed, physicians receiving short reports ordered a mean +/- SD of 0.72 +/- 0.71 tests per month; those receiving long reports ordered 1.30 +/- 1.21 tests per month (P = 0.002). At the first interview, 30% of physicians receiving short reports and 86% of those receiving long reports understood the bone mineral density definition of osteoporosis (P < 0.001). Receiving long reports led to more modifications in the pharmacologic treatment of osteoporosis by gynecologists (19% of patients whose reports were short and 61% of patients whose reports were long; P = 0.021) and less confusion about reports by all physicians (36% of physicians receiving short reports and 1% of those receiving long reports; P = 0.003). CONCLUSIONS: Clinical reporting of bone densitometry to primary care physicians increased use and understanding of bone densitometry, changed management of osteoporosis, and was well accepted. It may help achieve appropriate use of bone densitometry and may allow convenient dissemination of information on osteoporosis.

Absorptiometry, Photon↗

Meta-analysis: accuracy of quantitative ultrasound for identifying patients with osteoporosis.

BACKGROUND: There is increased interest in quantitative ultrasound for osteoporosis screening because it predicts fracture risk, is portable, and is relatively inexpensive. However, there is no consensus regarding its accuracy for identifying patients with osteoporosis. PURPOSE: To determine the sensitivity and specificity of calcaneal quantitative ultrasound for identifying patients who meet the World Health Organization's diagnostic criteria for osteoporosis. Dual-energy x-ray absorptiometry (DXA) was used as the reference standard. DATA SOURCES: MEDLINE (1966 to October 2005), EMBASE (1993 to May 2004), Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (1952 to March 2004), and the Science Citation Index (1945 to April 2004). STUDY SELECTION: English-language articles that evaluated the sensitivity and specificity of calcaneal quantitative ultrasound for identifying adults with DXA T-scores of -2.5 or less at the hip or spine. DATA EXTRACTION: Two authors independently reviewed articles and abstracted data. DATA SYNTHESIS: The authors identified 1908 potentially relevant articles, of which 25 met the inclusion criteria, and calculated the sensitivity and specificity of quantitative ultrasound over a range of thresholds. For the quantitative ultrasound index parameter T-score cutoff threshold of -1, sensitivity was 79% (95% CI, 69% to 86%) and specificity was 58% (CI, 44% to 70%) for identifying individuals with DXA T-scores of -2.5 or less at the hip or spine. For a T-score threshold of 0, sensitivity improved to 93% (CI, 87% to 97%) but specificity decreased to 24% (CI, 10% to 47%). At a pretest probability of 22% (for example, a 65-year-old white woman at average risk), the post-test probability of DXA-determined osteoporosis was 34% (CI, 26% to 41%) after a positive result and 10% (CI, 5% to 12%) after a negative result when using a T-score cutoff threshold of -1. Analysis of other quantitative ultrasound parameters (for example, broadband ultrasound attenuation) revealed similar estimates of accuracy. LIMITATIONS: The relatively small number of included studies limited the authors' ability to evaluate the effects of heterogeneous study characteristics on the diagnostic accuracy of quantitative ultrasound. CONCLUSIONS: The currently available literature suggests that results of calcaneal quantitative ultrasound at commonly used cutoff thresholds do not definitively exclude or confirm DXA-determined osteoporosis. Additional research is needed before use of this test can be recommended in evidence-based screening programs for osteoporosis.

Absorptiometry, Photon↗

Osteoporosis: review of guidelines and consensus statements.

UNLABELLED: This activity is designed for physicians, pharmacists, nurses, health planners, directors of managed care organizations, and payers of health services. GOAL: To understand current guidelines and consensus statements regarding the prevention, diagnosis, and treatment of osteoporosis. OBJECTIVE: List four national or international organizations involved in the development of consensus statements regarding the prevention, diagnosis, and treatment of osteoporosis. 2. Discuss the significant differences among different countries regarding the prevention and treatment of osteoporosis. 3. List the major risk factors for osteoporosis. 4. Describe the differences in the application of bone mineral density scans, biochemical markers, and ultrasound in evaluating patients with suspected osteopenia and osteoporosis. 5. Distinguish between and briefly discuss therapeutic modalities used in primary prevention, secondary prevention, and treatment of osteoporosis. 6. Discuss the advantages and disadvantages of estrogen/hormone replacement therapy. 7. Describe alternatives to estrogen/hormone replacement therapy.

Adolescent↗

Bone densitometry as a screening tool for osteoporosis in postmenopausal women.

This report provides general information about osteoporosis and describes the use of bone densitometry as a tool to screen for, diagnose and manage osteoporosis in white postmenopausal women. Discussion is limited to white women because of lack of research on osteoporosis in men, and in women of different racial and ethnic groups. The report does not evaluate the safety and efficacy of all bone densitometry devices, but focuses on the two diffusing most rapidly in Minnesota--dual x-ray absorptiometry (DXA or DEXA) and quantitative computed tomography (QCT). Osteoporosis is a degenerative bone disease that affects approximately 24 million Americans. Of that number 33 percent are post-menopausal women who have decreased bone density due to lowered estrogen levels. Because the estimated cost of osteoporosis-related fractures in the United States is between $8 and $10 billion each year, there is great interest in the diagnosis, prevention and treatment of the disease. Of all related fractures, hip fractures pose the most serious health problem. The incidence of this fracture appears to be increasing, with 250,000 to 300,000 occurring each year Treatment options are limited, if a person's bone mass or density has deteriorated to the point where fractures may occur. Preventive measures should therefore be undertaken by all women early in life to decrease their risk of osteoporosis. Based on available evidence, the HTAC concludes that state-of-the-art bone densitometry is safe and indicated as a diagnostic and treatment aid for postmenopausal women at risk for the disease. However, bone densitometry is not indicated as a broad screening tool for all postmenopausal women, regardless of whether they are at risk for the disease.

Absorptiometry, Photon↗

[Quantitative bone ultrasound (QUS) of the heel bone for diagnosis of osteoporosis in the general community].

OBJECTIVE: The aim of the present study was to investigate how quantitative bone ultrasonometry (QUS) can detect patients at risk for osteoporosis in a general community. MATERIAL AND METHODS: 260 women aged 63 +/- 10 were examined using questionnaire, osteological history and QUS (Achilles+). RESULTS: The most frequent osteoporosis risk factors were: no estrogens, no sports and osteoporosis within the family. Risk-patients had lower QUS values compared to persons without risk-factors. There was a negative correlation of ultrasound parameters with age, but not with height or weight. Patients showed a mean loss of body height of -1.2 +/- 1.8 cm versus height in passports, which was positively correlated with QUS. 30% of patients with osteoporosis (T = -2.3 +/- 1.4 SD) had lower QUS than those without (T = -1.4 +/- 1.4 SD). 22% have had a atraumatic fracture (T = -2.5 +/- 1.4 SD), 12 patients had suffered a hip fracture (T = -2.8 +/- 1.8 SD) and 15 patients had a vertebral fracture (T = -2.6 +/- 1.6 SD). Patients on estrogens had T = -1.5 +/- 1.4 SD, which was higher than in those without HRT (T = -2.0 +/- 1.3 SD, p < 0.05). CONCLUSIONS: We conclude from this study that risk patients for osteoporosis can be detected within the community using QUS. QUS is able to detect differences between treated and untreated and can be used in clinical practice to manage patients with osteoporosis risk.

Aged↗

Osteoporosis with lymphoid nodules and hematopoietic marrow hyperplasia.

OBJECTIVE: In 1983 Vigorita reported 3 cases of osteoporosis associated with intramedullary lymphoid nodules. We present 8 patients with osteoporosis and lymphoid nodules (LN) in whom we studied the clinical, biological and histological features and the course of the disease. METHODS: Three men (mean age 52 yrs., range 43-68 yrs.) and 5 women (mean age 60 yrs., 49-66 yrs.), 6 of them with osteoporosis with fracture and 2 with osteoporosis on bone densitometry (T score < -2.5 SD) were enrolled in this study. The following parameters were studied: immunobinding with IG determination, phosphorus and calcium levels, PTH, 25 and 1-25 OH D3, osteocalcin, urinary deoxypyridinoline, histomorphometry, tests for autoanti-bodies, HIV, HTLV, EBV and CMV serology. The results were compared with those of 20 patients with osteoporosis but without LN. Five patients underwent a second BMB a mean of 2 years after the first. RESULTS: Five patients had asthenia, 4 had joint pain and 3 had hyperlymphocytosis. Immunologic and virologic investigations were negative in all cases. Bone marrow was hypercellular (59.9 +/- 5.3 vs 40.1 +/- 13%, p: 0.001). At the second BMB, LN were absent but bone marrow was still hypercellular. In all cases, no cause of demineralization was found and osteoporosis progressed rapidly (an average of 3 vertebral compression fractures in three months, with increased resorption (ES 6.5 +/- 1.6 vs 3 +/- 1.2, p: 0.05) with decreased calcification rate (CR 0.62 +/- 0.07 vs 0.79 +/- 0.1, p: 0.04). CONCLUSION: Some interesting questions are raised by this study. Did an undiscovered viral infection cause the asthenia and joint pain via cytokines or PTHrp in our patients, and can activated lymphocytes perhaps modify bone remodeling?

Adult↗

Development and validation of the Osteoporosis Risk Assessment Instrument to facilitate selection of women for bone densitometry.

BACKGROUND: Although mass screening for osteoporosis is not recommended among postmenopausal women, there is no consensus on which women should undergo testing for low bone mineral density. The objective of this study was to develop and validate a clinical tool to help clinicians identify which women are at increased risk for osteoporosis and should therefore undergo further testing with bone densitometry. METHODS: Using Ontario baseline data from the Canadian Multicentre Osteoporosis Study, we identified all cognitively normal women aged 45 years or more who had undergone testing with dual-energy x-ray absorptiometry (DXA) at both the femoral neck and the lumbar spine (L1-L4). Participants who had a previous diagnosis of osteoporosis or were taking bone active medication other than ovarian hormones were excluded. The main outcome measure was low bone mineral density (T score of 2 or more standard deviations below the mean for young Canadian women) at either the femoral neck or the lumbar spine. Logistic regression analysis and receiver operating characteristic (ROC) analysis were used to identify the simplest algorithm that would identify women at increased risk for low bone mineral density. RESULTS: The study population comprised 1376 women, of whom 926 were allocated to the development of the tool and 450 to its validation. A simple algorithm based on age, weight and current estrogen use (yes or no) was developed. Validation of this 3-item Osteoporosis Risk Assessment Instrument (ORAI) showed that the tool had a sensitivity of 93.3% (95% confidence interval [CI] 86.3%-97.0%) and a specificity of 46.4% (95% CI 41.0%-51.8%) for selecting women with low bone mineral density. The sensitivity of the instrument for selecting women with osteoporosis was 94.4% (95% CI 83.7%-98.6%). Use of the ORAI represented a 38.7% reduction in DXA testing compared with screening all women in our study. INTERPRETATION: The ORAI accurately identifies the vast majority of women likely to have low bone mineral density and is effective in substantially decreasing the need for all women to undergo DXA testing.

Absorptiometry, Photon↗

Postmenopausal osteoporosis treatment guidelines.

BACKGROUND: Several years ago, Osteoporosis Australia published Guidelines for the management of osteoporosis. Since then significant advances in our understanding of the treatment of osteoporosis have been published. The importance of this is heightened as early diagnosis is now possible with precise methods of bone density measurement. OBJECTIVE: This article presents updated guidelines developed on behalf of Osteoporosis Australia for the treatment of postmenopausal osteoporosis to help general practitioners identify those women at risk and to review current treatment strategies. DISCUSSION: Osteoporosis and its associated problems are major health concerns in Australia, especially with an ageing population. While important principles of management are still considered to be maximising peak bone mass and prevention of postmenopausal bone loss by oestrogen therapy, new clinical trial data about drugs such as raloxifene and the bisphosphonates have recently become available and the relative role of various agents is gradually becoming clearer.

Accidental Falls↗

[Evaluation of the risk of osteoporosis in postmenopausal patients in the Hospital Luis Castelazo Ayala of the Mexican Social Security Institute, using a risk factor questionnaire].

Osteoporosis has a great impact on the population due to economic and health implications. For these reasons there is great interest to find the best prevention, diagnosis and treatment criteria. Postmenopausal women are at increased risk due to estrogen deficiency that is present in this stage of life. Through an oral interview the risk of osteoporosis in postmenopausal women was evaluated. The questionnaire was applied to 150 postmenopausal patients, questioning age, ethnic group, history of rheumatoid arthritis, use of estrogenic replacement therapy and body weight. Osteoporosis risk considered when a punctuation of 6 or greater. It was found that 85 of the patients had a punctuation of 6 or greater, with a mean punctuation of 7.5, indicating the risk of osteoporosis in our population. The most important factors that increased the punctuation and the risk to present osteoporosis were body weight and the lack of estrogen replacement therapy. We consider that these kind of questionnaires may be useful to detect the population at risk for osteoporosis and in base to this the adequate exams for diagnosis must be ordered.

Body Weight↗

Osteoporosis management in long-term care. Survey of Ontario physicians.

OBJECTIVE: To survey physicians in Ontario regarding their approach to diagnosis and treatment of osteoporosis among residents of long-term care facilities. DESIGN: Mailed questionnaire covering physician demographics; current clinical practice relating to osteoporosis; and perceived barriers to prevention, diagnosis, and treatment of the disease. SETTING: Long-term care facilities in Ontario. PARTICIPANTS: Medical directors of long-term care facilities. MAIN OUTCOME MEASURES: Demographic variables; physician attitudes; and practices concerning awareness, diagnosis, and treatment of osteoporosis. RESULTS: Respondents returned 275 of 490 questionnaires, for a response rate of 56.1%. Most respondents (92.4%) were family physicians; 28.7% were caring for more than 100 patients in long-term care. Most (85.8%) saw from one to 10 hip fractures yearly in their practices. Although 49.6% of respondents estimated the prevalence of osteoporosis to be 40% to 80% among their long-term care patients, 45.5% said that they did not routinely assess their patients for the disease, and 26.8% do not routinely treat it. Half (50.9%) of physicians would treat patients at high risk based on clinical history; 47.9% if patients had a vertebral compression fracture on plain x-ray examination; 43.8% if patients were highly functional; 42.0% if osteoporosis were confirmed with bone mineral densitometry; and 30.0% if patients had a recent fracture. Perceived barriers to initiating treatment included cost of therapy, patient or family reluctance to accept therapy, and time or cost of diagnosis. CONCLUSION: Although physicians are aware that patients in long-term care facilities are at high risk for osteoporosis and hip fractures, the disease remains underdiagnosed and undertreated.

Aged↗

Evaluation and treatment of postmenopausal osteoporosis.

Osteoporosis is a prevalent condition among elderly women and is associated with an increased risk for fractures. With the burgeoning size of the elderly population, a practitioner is likely to face many questions regarding the evaluation and management of postmenopausal osteoporosis. This review discusses and compares available therapies. All women should have adequate calcium and vitamin D intake. Women diagnosed as having osteoporosis should be evaluated for secondary causes of osteoporosis and risk factors for falls. For women with postmenopausal osteoporosis, therapy with hormone replacement, bisphosphonates (alendronate sodium or risedronate sodium), raloxifene hydrochloride, or calcitonin should be considered. The results of ongoing studies will help refine the strategies used for management of postmenopausal osteoporosis.

Aged↗

Guidelines for treatment of osteoporosis in men.

BACKGROUND: Osteoporosis is associated with significant morbidity and mortality in men. Published randomised controlled trials assessing the benefits of therapy in men with osteoporosis are limited, but those available need to be used to develop management guidelines. OBJECTIVE: To present evidence based guidelines for the treatment of osteoporosis in men. DISCUSSION: It is estimated that 30-60% of men presenting with spinal fractures have another illness contributing to their bone disease. Therefore assessment and treatment of coexisting medical conditions is a vital part of management of osteoporosis. While primary prevention of fractures remains crucial, treatment to ensure further fractures do not occur is equally important. Alendronate is the treatment of choice for men with osteoporosis and fractures, with cyclical etidronate an appropriate alternative and testosterone replacement therapy is indicated in hypogonadal men presenting with osteoporosis.

Calcitriol↗