Volume 5 · Number 1 · March 2013
- Checklist for prevention of new hip fractures [7-14]
- Effects of calcium and vitamin D, with and without lactulose, in bone mineral density on postmenopausal women with osteopenia: Pilot randomized controlled trial [15-23]
- PINP in patients with hepatic insufficiency: Comparison of two methods of measurement and association with different biochemical parameters [24-29]
- Epidemiology of hip fracture in Gran Canaria over the five year period of 2007-2011 [30-35]
- Increased bone modelling as a presentation of Graves’ disease [36-38]
- Zebra lines: Radiological repercussions of the action of bisphosphonates on the immature skeleton [39-41]
Spain has one of the highest hospital costs relating to hip fracture, at 9,936 euros for an admission related to this pathology1. To these economic-health costs we must add those arising in the patient’s environment and, above all, the non-quantitative costs arising from the changes in lifestyle and the loss of productivity which fragility fractures produce, both for the patient, as well as for their families, and for society as a whole. These are difficult to quantify, pending the results of the ICUROS and PROA2 studies, which have estimating these costs as their objectives.
If we take into account the high number of hip fractures treated annually, 720 cases annually for every 100,000 people over 60 years of age, it is not difficult to understand the serious public health problem this represents. However, the true problem is not the financial costs, but in the personal cost which results, and which is translated into raised levels of morbimortality.
Hip fracture, the outcome of loss of femoral resistance, and in many cases, of a fall, is the most serious example of the complications of osteoporosis. Its treatment should be based on resolving the functional problem, improving the nutritional and metabolic state of the injured person, on avoiding new falls and trying to recuperate and reinforce the bone structure.
If these actions are not carried out diligently the clinical and life prognosis will become more serious.
Introduction: Hip fracture is the worst complication of osteoporosis and especially affects postmenopausal women in the developed world. Previous studies have shown low rates of initiating osteoporosis treatment during hip fracture hospitalization.
Objective: To probe the effectiveness of the so-called hip fracture checklist in increasing the rate of the initiation of osteoporosis treatment compared with the previous two years.
Methods: Rates of initiating treatment among a population of one hundred postmenopausal women over 60 years of age surgically treated after suffering a hip fracture. Comparison of rates of prescription in our hospital before and after initiating the current study.
Results: In 2006, 1.66% of the patients were discharged from hospital with a new treatment for osteoporosis. In 2007, the rate was 6.9%. The age of our patients was 80.4 years. All of them were diagnosed during hospitalization with either osteoporosis (61.9%) or osteopenia (38.1%), but only 13% of them were previously diagnosed with osteoporosis, 10% of them were taking calcium and vitamin D, and 2% bisphosphonates. At the time of discharge, we prescribed calcium and vitamin D to all the patients (100%), and bisphosphonates (oral or parenteral) to the 94.6% of them.
Conclusions: The results show a significant increase in rates of antiosteoporotic drugs prescription compared with the previous two years. The implementation of the hip fracture checklist clearly increases the likelihood of starting osteoporosis treatment post hip fragility fracture.
Effects of calcium and vitamin D, with and without lactulose, in bone mineral density on postmenopausal women with osteopenia: Pilot randomized controlled trial
We report the results of a randomized, double-blind, double-dummy, multicenter, parallel group pilot study, the objective of which was to assess whether the addition of lactulose to vitamin D and calcium supplementation for 12 months contributed to bone mineral density (BMD) maintenance in postmenopausal women with osteopenia (T-score –1 to –2.5 SD). Women in the lactulose group (n=19) received lactulose 15 mL/day (equivalent to 10.05 g), vitamin D3 400 IU/day and calcium carbonate 500 mg/day, and women (n=22) in the placebo group were administered lactulose placebo, vitamin D3 400 IU/day and calcium carbonate 1,000 mg/day. The baseline daily calcium intake was similar in both study groups. The primary endpoint was the BMD in the lumbar spine at the final visit. A generalized liner model was used to assess final versus baseline differences in BMD in both study groups. Differences in least-square means of BMD between lactulose and placebo were not statistically significant both in the per-protocol data set (–0.012, 95% CI –0.031 to 0.007, P=0.224) and in the intention-to-treat population (–0.005, 95% CI –0.025 to 0.016, P=651). As we have not found differences within the two study groups, the addition of lactulose to 500 mg of calcium carbonate associated with vitamin D supplementation could have similar effects on lumbar BMD as 1.000 mg of calcium carbonate. These findings may indicate that lactulose may improve calcium absorption in postmenopausal women. A long follow-up study with a greater number of subjects would be necessary to confirm these preliminary observations.
PINP in patients with hepatic insufficiency: Comparison of two methods of measurement and association with different biochemical parameters
Introduction: N-terminal propeptide of type 1 collagen (PINP) is a marker for bone formation. Blood PINP is found in trimeric and monomeric forms. There are two automated methods for its determination. R-PINP (Roche Diagnostics) determines both forms (Total PINP). IDS-PINP (IDS iSYS N-Mid® Vitro) determines the trimeric part (Intact PINP).
Objective: To compare the two methods.
Material and method: 81 patients (64 men and 17 women, average age of 53 ± 8 years) with terminal hepatic insufficiency were recruited. Creatinine, PTH, 25-OH-vitamin D, beta-crosslaps (β-CTX), desoxypyridinoline (Dpyr), hepatic function and PINP with both methods, were measured. Bone mineral density (BMD) was measured (Hologic®, QDR 4500) in the lumbar spine and femoral neck. The comparison between the two methods was carried out using a Bland-Altman and Passing’Bablok analysis.
Results: R-PINP showed higher values than IDS-PINP (85.03 ± 56.67 vs. 55.22 ± 32.81 ng/mL, p<0,001). The correlation between the two methods was r= 0.81 (p<0.01) and the Passing-Bablok regression analysis Y = 0.570 [0.475-0.669] X + 7.724 [2.130-12.542].
Conclusion: There is a good correlation between the two methods in patients with hepatic insufficiency, although not proportional or interchangeable.
Background: Hip fracture is the most serious clinical complication of osteoporosis, due to its raised morbidity and mortality.
Method: We have studied the epidemiological and demographic characteristics of all the fragility fractures of the hip occurring in patients of &Ge; 50 years of age recorded in Gran Canaria during the 5 year period of 2007-2011 from the admission, coding, emergency and traumatology services of all the hospitals in Gran Canaria, in both the public and private healthcare sectors.
Results: A total of 2,222 hip fractures were recorded, of which 1,593 (71.7%) occurred in women and 629 (28.3%) in men. The female/male ratio was 2.53. The average age at which the fractures occurred was 79 ± 9.7 years. Over the 5 years, the total number of fractures (men and women) varied between 402 (in 2007) and 504 (in 2010). The number of fractures increased with age up to the 90s. The annual global incidence was 150 cases/100,000 inhabitants &Ge; 50 years: in women 205.4 cases with respect to the population of this sex and age, and in men, 89.1 with respect to the population of men &Ge; 50 years. During the winter months 29.7% of the total fractures occurred, 7.5% more than those happening during the summer months (22.2%).
Conclusions: During the period 2007-2011 the incidence of hip fracture in Gran Canaria remained more or less stable, in every year being greater in women than in men, and increasing with age up until the 90s. The greatest number of hip fractures occurred during the winter months, with similar numbers in spring, summer or autumn.
The adverse effects of hyperthyroidism on bone have been described for years. Thyroid hormones are necessary for growth, maturation, metabolism and bone remodelling. However, untreated thyrotoxicosis causes increased remodelling, osteopenia or osteoporosis and increased fracture risk. Since the introduction of antithyroid drugs and radioiodine, hyperthyroid bone disease is less common. Here we present a rare case of an asymptomatic patient with thyrotoxicosis making its debut as increased bone remodelling.
The bisphosphonates are used in the treatment of osteogenesis imperfecta, with a reduction in fractures in these patients observed with their use. However, the use of these drugs on the immature skeleton in these patients results in the formation of some radiologically visible hyperdense linear bands called zebra lines. We present the case of a patient with osteogenesis perfecta who started treatment with bisphosphonates at 10 years of age and after 2 years already showed these radiological images.
The principals of classical mechanics are applied to the study of the resistance of materials to fracture when subject to a certain load. Bone has been, for a long time, the object of study in the field of mechanics in order to understand and resolve problems of fracture associated with deficient mechanical behaviour which may exist due to factors such as age or certain pathologies. The great quantity of specific vocabulary used in biomechanics, derived as it is from the terminology of mechanical engineering, makes it very difficult, on occasion, for researchers specialising in bone and mineral metabolism to interpret information available in the literature on the resistance of bone. The objective of this work is to describe as briefly and concisely as possible the main concepts and fundamental principles used in biomechanics, focused on their application to bone tissue. In addition, the main mechanical trials carried out on whole bones or on samples of trabecular or cortical bone are reviewed.
Several data support the concept that skeletal homeostasis, repair and adaptation to daily life depend on mechanically-induced signals that promote appropriate responses of bone cells. This review considers the cells that are responsive to mechanical signals within the bone environment, and the molecular mechanisms involved in mechanotransduction, the process by which cells convert mechanical stimuli in biochemical signals and subsequently modify biological activity. Understanding the cellular and molecular mechanisms underlying bone responses to mechanical loads will positively impact current knowledge on basic bone biology and pathophysiology and will likely contribute to the development of new interventions to improve bone strength.