Effectiveness of a minimal resource fracture liaison service

Purpose The purpose of this study was to investigate if a 2-year intervention with a minimal resource fracture liaison service (FLS) was associated with increased investigation and medical treatment and if treatment was related to reduced re-fracture risk. Methods The FLS started in 2013 using existing secretaries (without an FLS coordinator) at the emergency department and orthopaedic wards to identify risk patients. All patients older than 50 years of age with a fractured hip, vertebra, shoulder, wrist or pelvis were followed during 2013–2014 (n = 2713) and compared with their historic counterparts in 2011–2012 (n = 2616) at the same hospital. Re-fractures were X-ray verified. A time-dependent adjusted (for age, sex, previous fracture, index fracture type, prevalent treatment, comorbidity and secondary osteoporosis) Cox model was used. Results The minimal resource FLS increased the proportion of DXA-investigated patients after fracture from 7.6 to 39.6 % (p < 0.001) and the treatment rate after fracture from 12.6 to 31.8 %, which is well in line with FLS types using the conventional coordinator model. Treated patients had a 51 % lower risk of any re-fracture than untreated patients (HR 0.49, 95 % CI 0.37–0.65 p < 0.001). Conclusions We found that our minimal resource FLS was effective in increasing investigation and treatment, in line with conventional coordinator-based services, and that treated patients had a 51 % reduced risk of new fractures, indicating that also non-coordinator based fracture liaison services can improve secondary prevention of fractures

Patients with prostate cancer and androgen deprivation therapy have increased risk of fractures—a study from the Fractures and Fall Injuries in the Elderly Cohort (FRAILCO)

Summary Osteoporosis is a common complication of androgen deprivation therapy (ADT). In this large Swedish cohort study consisting of a total of nearly 180,000 older men, we found that those with prostate cancer and ADT have a significantly increased risk of future osteoporotic fractures. Introduction: Androgen deprivation therapy (ADT) in patients with prostate cancer is associated to increased risk of fractures. In this study, we investigated the relationship between ADT in patients with prostate cancer and the risk of incident fractures and non-skeletal fall injuries both compared to those without ADT and compared to patients without prostate cancer. Methods: We included 179,744 men (79.1 ± 7.9 years (mean ± SD)) from the Swedish registry to which national directories were linked in order to study associations regarding fractures, fall injuries, morbidity, mortality and medications. We identified 159,662 men without prostate cancer, 6954 with prostate cancer and current ADT and 13,128 men with prostate cancer without ADT. During a follow-up of approximately 270,300 patient-years, we identified 10,916 incident fractures including 4860 hip fractures. Results: In multivariable Cox regression analyses and compared to men without prostate cancer, those with prostate cancer and ADT had increased risk of any fracture (HR 95% CI 1.40 (1.28–1.53)), hip fracture (1.38 (1.20–1.58)) and MOF (1.44 (1.28–1.61)) but not of non-skeletal fall injury (1.01 (0.90–1.13)). Patients with prostate cancer without ADT did not have increased risk of any fracture (0.97 (0.90–1.05)), hip fracture (0.95 (0.84–1.07)), MOF (1.01 (0.92–1.12)) and had decreased risk of non-skeletal fall injury (0.84 (0.77–0.92)). Conclusions: Patients with prostate cancer and ADT is a fragile patient group with substantially increased risk of osteoporotic fractures both compared to patients without prostate cancer and compared to those with prostate cancer without ADT. We believe that this must be taken in consideration in all patients with prostate cancer already at the initiation of ADT

High-Impact Mechanical Loading Increases Bone Material Strength in Postmenopausal Women-A 3-Month Intervention Study.

Bone adapts to loading in several ways, including redistributing bone mass and altered geometry and microarchitecture. Because of previous methodological limitations, it is not known how the bone material strength is affected by mechanical loading in humans. The aim of this study was to investigate the effect of a 3-month unilateral high-impact exercise program on bone material properties and microarchitecture in healthy postmenopausal women. A total of 20 healthy and inactive postmenopausal women (aged 55.6 ± 2.3 years [mean ± SD]) were included and asked to perform an exercise program of daily one-legged jumps (with incremental number, from 3×10 to 4×20 jumps/d) during 3 months. All participants were asked to register their performed jumps in a structured daily diary. The participants chose one leg as the intervention leg and the other leg was used as control. The operators were blinded to the participant's choice of leg for intervention. The predefined primary outcome was change in bone material strength index (BMSi), measured at the mid tibia with a handheld reference probe indentation instrument (OsteoProbe). Bone microstructure, geometry, and density were measured with high-resolution peripheral quantitative computed tomography (XtremeCT) at the ultradistal and at 14% of the tibia bone length (distal). Differences were analyzed by related samples Wilcoxon signed rank test. The overall compliance to the jumping program was 93.6%. Relative to the control leg, BMSi of the intervention leg increased 7% or 0.89 SD (p = 0.046), but no differences were found for any of the XtremeCT-derived bone parameters. In conclusion, a unilateral high-impact loading program increased BMSi in postmenopausal women rapidly without affecting bone microstructure, geometry, or density, indicating that intense mechanical loading has the ability to rapidly improve bone material properties before changes in bone mass or structure. © 2018 The Authors. Journal of Bone and Mineral Research Published by Wiley Periodicals Inc

Association between recurrent fracture risk and implementation of fracture liaison services in four Swedish hospitals: A cohort study

Structured secondary preventions programs, called fracture liaison services (FLSs), increase the rate of evaluation with bone densitometry and use of osteoporosis medication after fracture. However, the evidence regarding the effect on the risk of recurrent fracture is insufficient. The aim of this study was to investigate if implementation of FLS was associated with reduced risk of recurrent fractures. In this retrospective cohort study, electronic health records during 2012 to 2017 were used to identify a total of 21,083 patients from four hospitals in Western Sweden, two with FLS (n = 15,449) and two without (n = 5634). All patients aged 50 years or older (mean age 73.9 [SD 12.4] years, 76% women) with a major osteoporotic index fracture (hip, clinical spine, humerus, radius, and pelvis) were included. The primary outcome was recurrent major osteoporotic fracture. All patients with an index fracture during the FLS period (n = 13,946) were compared with all patients in the period before FLS implementation (n = 7137) in an intention‐to‐treat analysis. Time periods corresponding to the FLS hospitals were used for the non‐FLS hospitals. In the hospitals with FLSs, there were 1247 recurrent fractures during a median follow‐up time of 2.2 years (range 0–6 years). In an unadjusted Cox model, the risk of recurrent fracture was 18% lower in the FLS period compared with the control period (hazard ratio = 0.82, 95% confidence interval [CI] 0.73–0.92, p = .001), corresponding to a 3‐year number needed to screen of 61, and did not change after adjustment for clinical risk factors. In the hospitals without FLSs, no change in recurrent fracture rate was observed. Treatment decisions were made according to the Swedish treatment guidelines. In conclusion, implementation of FLS was associated with a reduced risk of recurrent fracture, indicating that FLSs should be included routinely at hospitals treating fracture patients. © 2020 The Authors. Journal of Bone and Mineral Research published by American Society for Bone and Mineral Research

Hip fracture risk and safety with alendronate treatment in the oldest-old

Background. There is high evidence for secondary prevention of fractures, including hip fracture, with alendronate treatment, but alendronate’s efficacy to prevent hip fractures in the oldest-old (≥80 years old), the population with the highest fracture risk, has not been studied. Objective. To investigate whether alendronate treatment amongst the oldest-old with prior fracture was related to decreased hip fracture rate and sustained safety. Methods. Using a national database of men and women undergoing a fall risk assessment at a Swedish healthcare facility, we identified 90 795 patients who were 80 years or older and had a prior fracture. Propensity score matching (four to one) was then used to identify 7844 controls to 1961 alendronate-treated patients. The risk of incident hip fracture was investigated with Cox models and the interaction between age and treatment was investigated using an interaction term. Results. The case and control groups were well balanced in regard to age, sex, anthropometrics and comorbidity. Alendronate treatment was associated with a decreased risk of hip fracture in crude (hazard ratio (HR) 0.62 (0.49–0.79), P < 0.001) and multivariable models (HR 0.66 (0.51–0.86), P < 0.01). Alendronate was related to reduced mortality risk (HR 0.88 (0.82–0.95) but increased risk of mild upper gastrointestinal symptoms (UGI) (HR 1.58 (1.12–2.24). The alendronate association did not change with age for hip fractures or mild UGI. Conclusion. In old patients with prior fracture, alendronate treatment reduces the risk of hip fracture with sustained safety, indicating that this treatment should be considered in these high-risk patient

Type 2 diabetes and risk of hip fractures and non-skeletal fall injuries in the elderly: A study from the Fractures and Fall Injuries in the Elderly Cohort (FRAILCO)

Questions remain about whether the increased risk of fractures in patients with type 2 diabetes (T2DM) is related mainly to increased risk of falling or to bone‐specific properties. The primary aim of this study was to investigate the risk of hip fractures and non‐skeletal fall injuries in older men and women with and without T2DM. We included 429,313 individuals (aged 80.8 ± 8.2 years [mean ± SD], 58% women) from the Swedish registry “Senior Alert” and linked the data to several nationwide registers. We identified 79,159 individuals with T2DM (45% with insulin [T2DM‐I], 41% with oral antidiabetics [T2DM‐O], and 14% with no antidiabetic treatment [T2DM‐none]) and 343,603 individuals without diabetes. During a follow‐up of approximately 670,000 person‐years, we identified in total 36,132 fractures (15,572 hip fractures) and 20,019 non‐skeletal fall injuries. In multivariable Cox regression models where the reference group was patients without diabetes and the outcome was hip fracture, T2DM‐I was associated with increased risk (adjusted hazard ratio (HR) [95% CI] 1.24 [1.16–1.32]), T2DM‐O with unaffected risk (1.03 [0.97–1.11]), and T2DM‐none with reduced risk (0.88 [0.79–0.98]). Both the diagnosis of T2DM‐I (1.22 [1.16–1.29]) and T2DM‐O (1.12 [1.06–1.18]) but not T2DM‐none (1.07 [0.98–1.16]) predicted non‐skeletal fall injury. The same pattern was found regarding other fractures (any, upper arm, ankle, and major osteoporotic fracture) but not for wrist fracture. Subset analyses revealed that in men, the risk of hip fracture was only increased in those with T2DM‐I, but in women, both the diagnosis of T2DM‐O and T2DM‐I were related to increased hip fracture risk. In conclusion, the risk of fractures differs substantially among patients with T2DM and an increased risk of hip fracture was primarily found in insulin‐treated patients, whereas the risk of non‐skeletal fall injury was consistently increased in T2DM with any diabetes medication. © 2016 American Society for Bone and Mineral Research

Fall risk assessment predicts fall-related injury, hip fracture, and head injury in older adults

Objectives To investigate the role of a fall risk assessment, using the Downton Fall Risk Index (DFRI), in predicting fall‐related injury, fall‐related head injury and hip fracture, and death, in a large cohort of older women and men residing in Sweden. Design Cross sectional observational study. Setting Sweden. Participants Older adults (mean age 82.4 ± 7.8) who had a fall risk assessment using the DFRI at baseline (N = 128,596). Measurements Information on all fall‐related injuries, all fall‐related head injuries and hip fractures, and all‐cause mortality was collected from the Swedish Patient Register and Cause of Death Register. The predictive role of DFRI was calculated using Poisson regression models with age, sex, height, weight, and comorbidities as covariates, taking time to outcome or end of study into account. Results During a median follow‐up of 253 days (interquartile range 90–402 days) (>80,000 patient‐years), 15,299 participants had a fall‐related injury, 2,864 a head injury, and 2,557 a hip fracture, and 23,307 died. High fall risk (DFRI ≥3) independently predicted fall‐related injury (hazard ratio (HR) = 1.43, 95% confidence interval (CI) = 1.39–1.49), hip fracture (HR = 1.51, 95% CI =1.38–1.66), head injury (HR = 1.12, 95% CI = 1.03–1.22), and all‐cause mortality (HR = 1.39, 95% CI = 1.35–1.43). DFRI more strongly predicted head injury (HR = 1.29, 95% CI = 1.21–1.36 vs HR = 1.08, 95% CI = 1.04–1.11) and hip fracture (HR = 1.41, 95% CI = 1.30–1.53 vs HR = 1.08, 95% CI = 1.05–1.11) in 70‐year old men than in 90‐year old women (P < .001). Conclusion Fall risk assessment using DFRI independently predicts fall‐related injury, fall‐related head injury and hip fracture, and all‐cause mortality in older men and women, indicating its clinical usefulness to identify individuals who would benefit from interventions

One-year supplementation with Lactobacillus reuteri ATCC PTA 6475 counteracts a degradation of gut microbiota in older women with low bone mineral density

Recent studies have shown that probiotic supplementation has beneficial effects on bone metabolism. In a randomized controlled trial (RCT) we demonstrated that supplementation of Lactobacillus reuteri ATCC PTA 6475 reduced bone loss in older women with low bone mineral density. To investigate the mechanisms underlying the effect of L. reuteri ATCC PTA 6475 on bone metabolism, 20 women with the highest changes (good responders) and the lowest changes (poor responders) in tibia total volumetric BMD after one-year supplementation were selected from our previous RCT. In the current study we characterized the gut microbiome composition and function as well as serum metabolome in good responders and poor responders to the probiotic treatment as a secondary analysis. Although there were no significant differences in the microbial composition at high taxonomic levels, gene richness of the gut microbiota was significantly higher (P &lt; 0.01 by the Wilcoxon rank-sum test) and inflammatory state was improved (P &lt; 0.05 by the Wilcoxon signed-rank test) in the good responders at the end of the 12-month daily supplementation. Moreover, detrimental changes including the enrichment of E. coli (adjusted P &lt; 0.05 by DESeq2) and its biofilm formation (P &lt; 0.05 by GSA) observed in the poor responders were alleviated in the good responders by the treatment. Our results indicate that L. reuteri ATCC PTA 6475 supplementation has the potential to prevent a deterioration of the gut microbiota and inflammatory status in elderly women with low bone mineral density, which might have beneficial effects on bone metabolism

The outcome of an automated assessment of trabecular pattern in intraoral radiographs as a fracture risk predictor

Objectives: This study aims to investigate if automated analyses of the trabecular pattern in intraoral radiographs independently contribute to fracture risk assessment when other risk factors incorporated in the Fracture Risk Assessment Tool (FRAX) are taken into account. A secondary aim is to explore the correlation between the automated trabecular pattern assessment in intraoral radiographs and Trabecular Bone Score (TBS). Methods: A total of 567 intraoral radiographs from older females participating in a large population-based study (SUPERB) based in Gothenburg, Sweden, were selected to analyse trabecular pattern using semi-automated and fully automated software. Associations between trabecular pattern analysis and incident fractures were studied using Cox proportional hazard model, unadjusted and adjusted for FRAX risk factors (previous fracture, family history of hip fracture, smoking, corticosteroids, rheumatoid arthritis, without and with bone mineral density (BMD) of the femoral neck). In addition, the correlation between trabecular pattern analysis and TBS of the lumbar spine was investigated using Pearson correlation analysis. Results: Neither the unadjusted nor the adjusted trabecular pattern analysis in intraoral radiographs was significantly associated with any fracture or major osteoporotic fracture (MOF). A weak correlation was found between semi-automated trabecular pattern analysis and TBS. No correlation was found between the fully automated trabecular pattern analysis and TBS. Conclusions: The present study shows that semi-automated and fully automated digital analyses of the trabecular pattern in intraoral radiographs do not contribute to fracture risk prediction. Furthermore, the study shows a weak correlation between semi-automated trabecular pattern analysis and TBS

Young adult male patients with childhood-onset IBD have increased risks of compromised cortical and trabecular bone microstructures

Background Young adults with childhood-onset inflammatory bowel disease (IBD) have increased risks of low areal bone mineral density and low skeletal muscle mass. Volumetric BMD (vBMD), bone geometry and microstructures, in addition to possible associations with skeletal muscle index (SMI) and physical exercise have been scarcely studied in this patient group. Patients and methods In total, 49 young adult male patients with childhood-onset IBD and 245 age- and height-matched young adult male controls were scanned with high-resolution peripheral quantitative computed tomography. Bone geometry, vBMD, and bone microstructures were calculated as median values and compared between the patients and controls. Multivariable linear regression analyses were performed to determine the independent associations among IBD diagnosis, SMI (kg/m2), and physical exercise. Results The group of young adult patients had, in comparison with the controls, significantly smaller median cortical area (126.1 mm2 vs151.1 mm2, P < .001), lower median total vBMD (296.7 mg/cm3 vs 336.7 mg/cm3, P < .001), and lower median cortical vBMD (854.4 mg/cm3 vs 878.5 mg/cm3, P < .001). Furthermore, the patients compared with the controls had lower median trabecular volume fraction (16.8% vs 18.2%, P < .001) and thinner median trabeculae (0.084 mm vs 0.089 mm, P < .001). The differences between the patients with IBD and controls persisted in multivariable analyses that included adjustments for SMI and physical exercise. Conclusions Young adult men with childhood-onset IBD are at increased risk of having reduced bone quality in both the cortical and trabecular bone structures compared with normative matched controls