Revista de Osteoporosis y Metabolismo Mineral

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Category: 4

Sclerostin and bone in diabetes mellitus type 2

In the current number, García-Martín et al.1 from the working group of Dr. Muñoz of Granada report that blood levels of sclerostin – the protein coded for by the gene SOST, which inhibits the osteoblast Wnt pathway – depend on the sex, the age and the renal function of patients with diabetes mellitus type 2 (DM2). They also demonstrate, contrary to expectations, a negative relationship with the markers for bone remodelling, and a positive relationship with bone mineral density (BMD). Finally, they show that blood levels of sclerostin are lower in patients with DM2 and osteoporosis irrespective of the presence or absence of fractures.
DM2 is a disease of high prevalence – up to 12-15% of the adult population in our country2 – and with an enormous impact on morbi-mortality and quality of life. Its relationship with micro-vascular complications – retinopathy, nephropathy and diabetic neuropathy – and macro-vascular complications – coronary artery, peripheral arterial and cerebrovascular disease – is well known. Most recently, new complications have been recognised to be clearly related to diabetes, among which osteoporosis or diabetes-related metabolic bone disease is a notable example.

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Diabetes mellitus type 2 and osteoporosis

Osteoporosis and diabetes mellitus are two diseases with high prevalence which are associated with an increase in the risk of fragility fractures, and with a substantial impact on the morbidity and the mortality of the population in general. Although various observational studies have investigated the association between the two, the mechanism by which diabetes favours the appearance of fractures has not been properly established.
Most of the epidemiological studies carried out in patients with type 2 diabetes have shown an increase in bone mineral density1 in spite of which there is an increased risk of fracture of 1.5 for hip fracture, proximal humerus and distal radius2. In terms of the risk of vertebral fracture, the results are less uniform, although most of the studies also show an increase in risk3,4.
Hyperglycemia exerts both direct effects on bone cells, especially the osteoblasts, and indirect effects through the formation of products deriving from glycation.
In vitro, high levels of glycemia stimulate or inhibit osteoblast proliferation as a function of the phase of the cell cycle. The differentiation of these cells is especially suppressed, which is shown in the decrease in the production of osteocalcin, of the deposit of calcium and in bone mineralisation. The expression of the receptors for parathormone and vitamin D are also reduced. In addition, the hyperglycemia affects the functionality of the osteoblasts through the induction of an osmotic response mediated by its sensitivity to the acid medium induced by the lactate5.

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Osteoporosis during pregnancy and breastfeeding

Both generalised and regional osteoporosis are diseases which, exceptionally, are associated with pregnancy and breastfeeding, although, undoubtedly, diseases that are underdiagnosed.
Compensatory physiological mechanisms allow, in the majority of cases, those requirements necessary for the formation and mineralisation of the foetal skeleton and the nutrition of the new born to be met, overcoming this period without major difficulties 1. However, some mothers experience bone demineralisation which may become complicated with fractures2, and a small group suffers regional demineralisation which temporarily disables them3v.
The fundamental problem in these situations is the diagnosis since, on the one hand, some of the associated symptoms may be attributed to ”normal” problems related to gestation, such as pelvic pain, which are frequently seen in the typical clinical picture during the third quarter of pregnancy, while on the other, there is the impossibility of carrying out diagnostic procedures such as DXA during pregnancy.

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Variables which influence concentrations of sclerostin in patients with diabetes mellitus type 2 and its association with bone metabolism

Background and objectives: Diabetes mellitus type 2 (DM2) is associated with an increased risk of fractures whose underlying mechanisms are complex. The objective of this study was to analyse the variables which influence blood concentrations of sclerostin and the relationship with bone metabolism in a group of DM2 patients.
Patients and methods: A transversal study of 76 patients with DM2. Clinical data, basic biochemical parameters, calciotropic hormones, markers for bone remodelling, vertebral X-rays and bone mineral density (BMD) were gathered. Blood concentrations of sclerostin were determined using ELISA (Biomedica, Austria).
Results: The males had higher concentrations than the females (63.15±27.03 vs 43.14±17.08 pmol/L, p<0.001). We found positive relationships between sclerostin and age in males with DM2 (r=0.338, p=0.031) and between sclerostin and creatinine in the whole sample (adjusted for age: r=0.362, p<0.001). Also, it had a negative relationship with bone alkaline phosphatase (BAP) (r=-0.259, p=0.029), carboxy-terminal telopeptide of type 1 collagen (CTX) (r=-0.356, p=0.002) and tartrate-resistant acid phosphatase 5ββ(TRAPβ) (r=-0.289, p=0.013). BMD in the lumbar spine, femoral neck and total hip were positively associated with sclerostin (r=0.373, r=0.492, r+0.524, p<0.001) adjusted for age. Blood levels of sclerostin were lower in patients with DM2 and osteoporosis than those who were non-osteoporotic (42.96±19.16 vs 56.95±25.98 pmol/L, p=0.041).
Conclusions: Sex, age and renal function are determining factors of levels of sclerostin in the circulation of patients with DM2. There is a negative relationship with remodelling markers and a positive one with BMD. Blood levels of sclerostin are lower in patients with DM2 and osteoporosis.

Abbreviations: FN: femoral neck; LS: lumbar spine; TH: total hip; CTX: carboxy-terminal telopeptide of type 1 collagen; DXA: dual X-ray absorptiometry; BAP: bone alkaline phosphatase; GF: glomerular filtration; BBG: basal blood glucose; HbA1c: glycated haemoglobin; BMI: body mass index; PTH: parathormone; OC: osteocalcin; TRAPβ: tartrate-resistant acid phosphatase 5β; 25(OH)D: 25-hydroxyvitamin D.

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Gene study (OPG, RANKL, Runx2 and AGE receptors) in human osteoblast cultures from patients with type 2 diabetes mellitus and hip fracture. Influence of levels of glucose and AGEs

Introduction: Diabetes mellitus (DM) type 2 is associated with a higher risk of osteoporotic fracture. Many factors have been indicated as possible mechanisms responsible for this, among which are changes in bone remodelling which may be induced by variations in circulating glucose or by the presence of non-oxidative advanced glycosylation end products (AGEs). The aim of this work has been to evaluate whether these variations generate changes in the expression of genes related to osteoblast differentiation and activity (OPG, RANKL, Runx2 and AGER) in primary cultures of human osteoblasts (hOB).
Material and methods: 12 patients were studied, belonging to three groups: 4 with osteoporotic fracture, 4 with osteoporotic fracture and DM type 2, and 4 patients with osteoarthritis, but who were not osteoporotic or diabetic (control group), with an average age of 80 ± 8, 84 ± 10 and 66 ± 11 years, respectively. Primary cultures of hOB from trabecular bone were carried out, to which were applied different stimuli over 24 hours. The gene study was carried out using real-time PCR.
Results: The genetic expression of RANKL was seen to increase in the diabetic group, although not to a significant degree, in the cultures which were high in glucose and high in glucose supplemented by AGEs (1.9 and 4.6 times higher vs control conditions; 2.3 and 4.4 times vs control group, respectively). The RANKL/OPG ratio stayed constant in the control group, however, in the diabetic group an increase was seen in all experimental conditions. In the case of Runx2 we found a significant increase in expression in the diabetic group with respect to the control group in the culture high in glucose and AGEs (OA = 1.08 ± 0.43; OP+DM = 3.33 ± 0.73; p = 0.039). No significant changes in the expression of OPG and AGER with respect to the control condition were observed for any of the culture conditions, in any of the patient groups.
Conclusions: The presence of a hyperglycaemic environment and AGEs alters the genetic expression of RANKL, of the RANKL/OPG ratio and Runx2 in osteoblast cultures from diabetic patients with hip fractures. These variations could generate changes in bone remodelling which could explain, at least partly, the lower bone resistance and the increase in the incidence of non-traumatic fractures in these patients.

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Osteogenic effects of PTHrP (107-111) loaded in bioceramics in a model of bone regeneration after a cavitary defect in the femur of a rabbit

Introducción: Parathyroid hormone-related protein (PTHrP), which is abundant in bone tissue, is an important modulator of bone formation. It has been shown that PTHrP (107-111), called osteostatin, loaded into mesoporous ceramic material SBA-15 exerts osteogenic action in vitro.
Objective: To confirm if this material and a functionalised version of the same material (C8-SBA-15) promote bone regeneration in a model of a cavitary defect in a rabbit femur.
Materials and methods: Histological, immunohistochemical and computerised microtomography (µCT) studies were carried out in order to achieve the aims of the study.
Results: After the implantation of the biomaterials no significant levels of inflammation or bone resorption were observed (at 4 and 8 weeks). At 8 weeks the bioceramics not loaded with osteostatin were found to be separated from the bone medulla by a fibrous capsule which diminished significantly in the presence of the peptide. An increase was observed (using µCT) in bone neo-formation at different distances from the biomaterials, principally in those loaded with the osteostatin. These results were also confirmed by immunohistochemistry of osteoblast markers.
Conclusion: Our results suggest that the use of these osteostatin-loaded bioceramics are a good strategy for accelerating bone regeneration.

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Pregnancy-associated osteoporosis. Presentation of 5 cases and long term monitoring

Background: Pregnancy-associated osteoporosis (PAO) is a clearly described and relatively frequent entity, although there are few studies which have carried out long term monitoring of the disease.
Material and methods: 5 women affected by osteoporosis who were monitored over the long term, between 4 and 16 years. In all the patients a questionnaire on lifestyle and risk factors was completed and a physical examination carried out, as well as densitometry after the pregnancy and subsequently every year during the follow up period. At the end of this period, a lateral X-ray of the dorsal and lumbar spine was performed.
Results: In 3 cases there was a spontaneous fracture as the first manifestation of PAO, while in 2 cases a very low densitometric value was observed, without fractures, in the immediate postpartum period. All the patients received calcium and vitamin D supplements, and in 3 cases a biphosphonate (risedronate) was indicated. No new fractures were observed in any of the cases over the follow up period. The bone mineral density (BMD) increased in the lumbar spine in all the patients, but in one a decreased measurement was observed in the hip, both in the femoral neck and the total hip. None of the patients became pregnant again in the period of the study.
Conclusions: While none of the patients with PAO studied over the long term suffered a new fracture, and in all an increase in the bone mineral density in the lumbar spine was observed, which makes us think that there is a recovery of DMO over time, in one case there was a considerable decrease in bone mineral density in the proximal femur, for which reason we believe that it is advisable to carry out long term monitoring of these patients.

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Cobb angle, vertebral deformity and fractures in alcoholic patients

Background: Hypercyphosis and vertebral deformity are related to vertebral fractures. There are no studies in chronic alcoholics.
Objective: To analyse the relationship which exists between the Cobb angle and different degrees of vertebral deformity, and bone mass and various variables related to bone metabolism in chronic alcoholic patients.
Material and methods: 57 alcoholic males aged 52 ± 12 years were included. The Cobb angle was calculated and the degree of vertebral deformity of T7, T8, T9 and T10 was measured using MorphoXpress® and thoracic X-ray. The bone mass in the spine and hip were determined using a DXA Hologic Walthan 2000, and exiting clinical fractures with the clinical history. In addition, the nutritional state, the degree of alcoholism, variables of hepatic function, the presence of hepatic cirrhosis, and bone metabolism, were analysed. The results were also studied in 20 controls of similar age and of the same sex.
Results: The patients had a greater Cobb angle in comparison with the controls ( 30 ± 9º vs 17 ± 5º, respectively, p<0.001). Those with cirrhosis had lower bone mass than those without in the lumbar vertebrae (p<0.01) and femoral neck (p=0.02). The deformities in T7, T8, T9 and T10 were associated with a greater cyphosis, longer period of consumption and with existing vertebral fractures (p<0.01), non-vertebral fractures (p<0.002) and hip fractures (p<0.001). There were 65 existing fractures, 46 in the rib, 12 vertebral and 7 in the hip. The patients with a higher Cobb angle had more vertebral (p<0.01) and non-vertebral (p=0.04) fractures, as well as a longer period of alcohol consumption (p=0.02).
Conclusions: Chronic alcoholics have greater cyphosis than the controls. Wedge or biconcave vertebral deformities are related with a greater cyphosis, higher consumption of alcohol and existing fractures. In this series a higher Cobb angle is related to existing vertebral fractures. The most intensive drinkers had a higher Cobb angle and more fractures.

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Seasonal variation in vitamin D levels in patients attending in Basic Healthcare Center

Background: Previous reports have shown a high prevalence of vitamin D deficiency among different populations in our country. However fewer longitudinal studies about seasonal changes in serum vitamin D have been published. The aim of the present study was to determinate seasonal variation in serum vitamin D in patients attending in Basic Healthcare Center.
Patients and method: Prospective longitudinal cohort study of 82 patients attending in Basic Healthcare Center. In all cases, serum levels of calcium, 25OHD and PTH were determined during January, February and March (Period 1) and September and Octuber (Period 2).
Results: Serum calcium levels did not differ between Period 1 and Period 2. During Period 1, 50.6% presented 25OHD levels < 15 ng/ml and 3.65% presented 25OHD levels > 30 ng/ml. During Period 2, 25OHD levels increased (31.88 vs 15.75 ng/ml, p < 0,001). Prevalence of patients with 25OHD levels < 15 ng/ml decreased (2.7 vs 50.6%, p < 0,001) and prevalence of patients with 25OHD levels > 30 ng/ml increased (50.68 vs 3.65%, p< 0,001). Negative correlation between 25OHD and PTH concentrations during both periods was observed.
Conclusions: These results show vitamin D deficiency during winter months in the majority of patients attending in Basic Healthcare Center. The prevalence of patients with vitamin D deficiency decreased after summer, however only half of the patients reached optimal vitamin D levels. Based on our results, to guarantee optimum vitamin D levels in the general population, the promotion of sanitary policies is recommended.

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Osteointegration and biocompatibility in vivo of bio-inspired silicon carbide ceramics in an experimental model in rabbits

Background: The new generation of materials for implants should imitate the hierarchical structures found in nature. Bio-inspired silicon carbide ceramic (bioSiC) is a ceramic produced from wood, which has a similar structure to bone, with a unique property of interconnected porosity, which allows the internal growth of tissue and favours angiogenesis.
Objectives: To evaluate the biocompatibility and osteointegration of bioSiC in femoral bone defects in an experimental model in rabbits.
Material and methods: 36 cylinders of bioSiC were obtained through pyrolysis of sapelli wood and infiltration with molten silicon of the resulting carbon preform. Eighteen cylinders were coated with Si-HA by pulsed laser deposition. The cylinders were implanted in femoral condyles of rabbits which were sacrificed at 1, 4 or 12 weeks. The samples were analysed histologically using an optical microscope and computerised microtomography to assess bone growth.
Results: The bioSiC implants showed good osteointegration, there being both outward growth (ongrowth) and inward growth (ingrowth). At 4 weeks from implantation the integration was almost complete, with no difference from that seen at at 12 weeks. The coating did not improve the value of any parameter with respect to the non-coated implants.
Conclusions: BioSiC ceramics produced from porous wood have good osteointegration and their interconnected porosity is colonised by bone tissue. In addition, they do not require the bioactivity of a coating to improve the apposition of neoformed bone. BioSiC stands as a material to be taken into account in biomedical applications.

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Could the FRAX® index modify the treatment of osteoporosis?

Introduction: The FRAX® index is an algorithm devised by the WHO which, by evaluating risk factors, calculates the absolute risk of suffering any osteoporotic fracture or hip fracture in the subsequent 10 years. The aim of this work is to ascertain the risk of fracture in patients with suspected osteoporosis, using the FRAX® tool, and to ascertain how therapeutic decisions would be modified if these criteria were used.
Patients and method: The patients were drawn from a list of densitometries (DXA) carried out in the Hospital of Torrevieja during the first quarter of 2009. Using simple random sampling 110 women were selected, of whom 90 participated in this study. The FRAX® tool was applied to all of them, recording the treatment for osteoporosis which they were following, and the service which had initiated the prescription. A value of >10% for the principal fracture, and a value of 3% for a hip fracture, were considered to indicate a high risk of fracture.
Results: Fifteen patients (16.66%) had a FRAX® index with a high risk of fracture. Only 23% of patients in treatment had a FRAX® index with a high risk of fracture. 40% of those patients with a high risk FRAX® index were not taking any specific treatment.
Conclusions: The use of the FRAX® tool may change the indication for treatment in many patients in whom the decision had been based only on bone densitometry.

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Expression of RANKL and OPG in primary osteoblasts

Objective: Osteoblasts are specialized cells responsible for bone formation. Furthermore, these cells modulate osteoclast formation and maturation, mainly by the production of RANKL and OPG. We previously reported that the bone tissue of osteoporotic patients showed increased RANKL expression and RANKL/OPG ratio when compared to osteoarthritic patients. Thus we decided to explore whether this aberrant expression may be related to an abnormal expression of these genes by osteoblasts. The aim of this study was to explore the transcriptional levels of these factors in primary osteoblasts.
Methods: Primary human osteoblasts (hOBs) were obtained by the primary explant technique from bone tissue of patients undergoing hip replacement surgery for hip fractures (n=28) or osteoarthritis (n=26). Patients with secondary osteoporosis, fractures due to high-energy trauma or secondary osteoarthritis were excluded. RANKL and OPG gene expression was explored by real time quantitative PCR.
Results: No statistical differences in RANKL and OPG gene expression were found along the in vitro mineralization of hOBs. Interestingly, OPG transcriptional levels were markedly higher than RANKL levels. However, no differences in the transcriptional levels of RANKL and OPG were observed between both groups.
Conclusions: Overall, our data confirm that osteoblasts produce RANKL and OPG. However, our results suggest that the gene expression differences found in the osteoporotic and osteoarthritic bone tissue are not explained by the intrinsic characteristics of osteoblasts.

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Osteology images
Poster Communications
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