Abstract: OBJECTIVES: Association between vitamin D deficiency and excess of vitamin A as a potential risk factor of osteoporosis and fracture has been evaluated. DESIGN AND METHODS: 232 healthy postmenopausal women were studied. Serum parameters were analyzed by standard methods and fat-soluble vitamins by an own HPLC method. QUS measurement of the calcaneal bone was carried out by Sahara. RESULTS: 124 patients were considered non-osteoporotic and 101 (44.9%) were osteoporotic. The prevalence of high serum levels of retinol was 36.4% and vitamin D deficiency was 70.1%. 60.4% of women with vitamin D deficiency have high serum levels of retinol. In the whole population, the increased risk of osteoporosis was up to three times higher for the highest retinol quintile, as compared with the lowest retinol quintile. Whereas in women with vitamin D deficiency the risk of osteoporosis increased was up 5 times higher than women in the lowest quintile of retinol. CONCLUSIONS: Our results show that high retinol levels together with vitamin D deficiency are hitherto an overlooked risk factor for osteoporosis.
Abstract: Background: An association between cardiovascular disease and osteoporosis has been described. A number of drugs often used in patients with coronary heart disease as thiazides, statins and beta-bockers have shown controversial effects on bone. Objectives: 1) To study the possible association between coronary heart disease (CHD) and bone mass density (BMD), quantitative ultrasound measurements (QUS) and the prevalence of fragility and vertebral fractures. 2) To study the possible influence of a number of drugs: statins, thiazides and beta-blockers, on BMD and fractures. Methods. Case-control study performed on 74 postmenopausal women who had recently suffered a CHD, and 111 age-matched controls. BMD was measured by Dual-X-Ray Absorptiometry (DXA) at the lumbar spine and the proximal femur. Quantitative Ultrasounds (QUS) were also performed at the heel. Vertebral fractures were diagnosed by lateral, thoracic and lumbar X-Rays. The occurrence of non-vertebral fractures was determined through an examination of medical records. Results: Patients with CHD showed higher values of BMI. They had a higher prevalence of arterial hypertension and hyperlipidemia and consequently a higher consumption of beta-blockers and statins, but not of thiazides, and had lower alcohol consumption. Patients with CHD had higher BMD values, measured by DXA at the proximal femur, than controls, but there were no differences in DXA values at the lumbar spine or QUS at the heel between the two groups. The prevalence of all fragility factures was slighty higher in patients with CHD but not to significant levels. The prevalence of vertebral fractures was similar in the two groups. In a logistic analysis to identify factors associated with all fractures, beta-blockers were positively associated with fragility fractures, and DXA at the femoral neck was inversely associated with fragility fractures. Conclusions: Postmenopausal women with CHD have higher values of BMD at the proximal femur but, in spite of this, they show a slight, but non-significant increase in the prevalence of fragility fracture. Beta-blockers are independently associated with fragility fractures, but thiazides or statins are not.
Abstract: Osteonecrosis of the jaw associated to biphosphonate use is more common in cancer patients with bone metastases, that are using intravenous diphosphonates. When these drugs are used orally the risk of the complication is lower. We report 3 diabetic women aged 69, 76 and 82 years, receiving alendronate 70 mg every one week. The unveiling event was the extraction of several teeth without the use of antibiotics. All had bone pain, purulent discharge, loss of bone and halitosis. All improved five months after discontinuing alendronate.
Abstract: This study assesses the possible association between poverty and osteoporosis and/or fragility fractures in a population of postmenopausal women. We found that postmenopausal women with low socioeconomic status had lower values of BMD at the lumbar spine, a higher prevalence of densitometric osteoporosis, and a higher prevalence of total and vertebral fractures. INTRODUCTION: Some lifestyles are related to the presence of osteoporosis and/or fragility fractures, whereas poverty is related to some lifestyles. Because of this, we studied the possible association of poverty with osteoporosis and fractures. METHODS: This was an observational, cross-sectional study performed in the Canary Islands, Spain. Participants consisted of a total of 1,139 ambulatory postmenopausal women aged 50 years or older with no previous osteoporosis diagnosis and who were enrolled in some epidemiological studies. The prevalence of fractures (vertebral and non-vertebral) and the prevalence of osteoporosis (T-score <-2.5 either at the lumbar spine or the femoral neck). A previously validated questionnaire elicited the most important risk factors for osteoporosis: socioeconomic status, defined by the annual income was also assessed by a personal interview. A dorso-lateral X-ray of the spine was performed, and bone mineral density (BMD) was measured by DXA in the lumbar spine (L2-L4) and proximal femur. RESULTS: Compared to women with a medium and high socioeconomic status (n = 665), those who were classified into poverty (annual family income lower than 6,346.80 Euros, in a one-member family, n = 474), were older and heavier and had lower height, lower prevalence of tobacco and alcohol consumption, lower use of HRT and higher use of thiazides. After correcting for age and body mass index (BMI), women in poverty had lower spine BMD values than women with a medium and high socioeconomic status (0.840 g/cm(2) vs. 0.867 g/cm(2), p = 0.005), but there were no statistical differences in femoral neck BMD between groups. The prevalence of osteoporosis was also higher in women in poverty [40.6% vs. 35.6%, (OR 1.35, CI 95%: 1.03; 1.76)] after adjusting by age and BMI. Moreover, 37.8% of women in poverty had a history of at least one fragility fracture compared to 27.7% of women not in poverty (OR: 1.45, CI 95%: 1.11; 1.90). The prevalence of vertebral fractures was also higher in women in poverty 24.7% vs. 13.4%, (OR 2.01, CI 95%: 1.44; 2.81). CONCLUSIONS: Postmenopausal women with low socioeconomic status had lower values of BMD at the lumbar spine, and a higher prevalence of densitometric osteoporosis, and a higher prevalence of total and vertebral fractures. Because of this, apart from the well known risk factors for osteoporosis, poverty should be taken into account as a possible risk factor for both osteoporosis and fragility fractures, in order to establish sanitary strategies to protect unfavoured postmenopausal women.
Abstract: BACKGROUND AND AIMS: Type 2 diabetes mellitus (DM) has a high prevalence in aging obese postmenopausal women. It is not clear whether or not diabetes produces an increase in bone mineral density or an increase in fracture rates. OBJECTIVE: The main objective of this study was to investigate whether type 2 DM produces a higher prevalence of vertebral, hip and non-vertebral fractures in obese postmenopausal Caucasian women. A secondary objective was to study the influence of DM in quantitative ultrasound measurements of the heel (QUS) and bone mineral density (BMD) measured by dual X-ray absorptiometry (DXA), in both lumbar spine (L2-L4) and proximal femur. METHOD: This study was a prospective cohort of 111 patients with type 2 DM and 91 control individuals (CTR) over age 65 and obese, recruited from 16 centers in Spain. MAIN OUTCOME MEASURES: Lateral dorsal and lumbar X-rays were performed to assess vertebral fractures. Hip and non-vertebral fractures were noted from medical records, written reports or Xray studies. QUS measurements were made of the calcaneus and BMD measurements of the lumbar spine (L2-L4) and proximal femur. RESULTS: Patients had higher BMD in the lumbar spine (L2-L4) than controls (0.979 g/cm2 vs 0.927 g/cm2, p=0.035), but we found no statistically significant differences in the proximal femur. QUS measurements showed similar values in both groups: BUA (69.3 dB/Mhz vs 66.7 dB/Mhz, p=0.291), SOS (1537 m/sg vs 1532 m/sg, p=0.249) and QUI (87.5 vs 83.7, p=0.153). No statistically significant differences were found in any case. There was no association between vertebral, hip and non-vertebral fractures and DM. The crude odds ratio, without adjusting was 1.045 (CI 95% 0.531 ; 2.059), and the adjusted odds ratio was 0.927 (CI 95% 0.461 ; 1.863). CONCLUSIONS: In obese postmenopausal Caucasian women, type 2 DM produces an increase in BMD of the lumbar spine without changes in BMD of the proximal femur or in QUS measurements of the heel. The prevalence of vertebral, hip and non-vertebral fractures did not increase in type 2 DM.
Abstract: Osteoporosis is a very common disease, which affects aged elderly people. Fractures are the main clinical manifestation of osteoporosis, being the more frequent fractures, vertebral fractures, distal forearm fractures and proximal femur fractures. The main objective in the treatment of osteoporosis is to avoid or to reduce new fractures. To obtain this, an integral approach should be done, including non-pharmacological measures, as a well balanced diet, the practising of regular exercise, avoiding or suppressing toxic habits (excess of alcohol and tobacco), and when indicated, patients should take a drug. There are several drugs available whose reduce the risk of fracture, all of them evaluated under the "Evidence-Based Medicine" criteria. Not all the drugs reduce the risk of all fracture. Thus, there are drugs that reduce only the risk of vertebral fractures, drugs that reduce the risk of non-vertebral fractures and finally, drugs that reduce the risk of hip fracture. All the studies performed on osteoporosis, the drugs have been always prescribed together with a supplement of calcium and Vitamin D. So, the correct prescription of a treatment for osteoporosis should include general measurements, the chosen drug and a supplement of calcium and Vitamin D.
Abstract: BACKGROUND: Obesity has become a major public health problem in all western countries, and its prevalence is increasing. This condition is associated with a higher prevalence of diabetes mellitus, hypertension, and coronary heart disease; furthermore, obesity is a risk factor for mortality. OBJECTIVE: To study the association of some prevalent diseases (diabetes mellitus, thyroid disease, obesity, hypertension, inflammatory rheumatic disease, urolithiasis), the distribution of some lifestyle factors (tobacco, alcohol and caffeine consumption and physical activity during leisure time) and the prevalence of poverty in a population of postmenopausal women in the Canary Islands with obesity class II or III (BMI>35). METHOD: A personal interview was performed in all patients. A questionnaire was administered to assess their lifestyles and current medication use. The women's medical records were reviewed to confirm the existence of certain diseases. A complete physical examination was performed in all patients. Weight and height were measured with the patient dressed in light clothing. Blood samples were obtained with the patient in a fasting state for subsequent analysis. Poverty was defined according to the criteria of the Spanish National Institute of Statistics. RESULTS: Women with obesity class II or III were older (56.8+/-11 vs 53.9+/-11.6 years, p=0.02), shorter (153.7+/-6.3 vs 156.9+/-36.1 cm, p=0.001), heavier (89.6+/-9.3 vs 66.6+/-10.4 kg, p=0.001) and had a greater body surface than controls (1.73+/-0.13 vs 1.54+/-0.13 m2, p=0.001). Alcohol and tobacco consumption were lower in obese women than in controls. Obese women drank more coffee and took less physical activity during leisure time than controls. The prevalence of hypertension -36% vs 17.9%, p=0.001, odds ratio [OR] [95% confidence interval (IC)]=2.57 (1.56-4.24)-, diabetes mellitus -24.4% vs 11.3%, p=0.001, OR=2.52 (1.47-1.05)-and hypothyroidism -14.3% vs 8%, p=0.04; OR=1.91 (0.99-3.68)-was higher in obese women than in controls. More than half lived in rural areas and were below the poverty threshold. CONCLUSIONS: More than half of postmenopausal women with obesity class II or III were below the poverty threshold and lived in a rural area. In these women there was a lower consumption of alcohol and tobacco, lesser physical activity during leisure time, and a higher prevalence of diabetes mellitus, hypertension and hypothyroidism than in control postmenopausal women.
Abstract: BACKGROUND: Daily doses higher than 7.5 mg/daily of prednisone or equivalents confer a great risk of vertebral and hip fractures with a clear dose dependence of fracture risk. Information regarding the utility in assessing trabecular bone mineral density by quantitative computer tomography (QCT) in these patients, either in the Canaries or in Spain, is lacking. Moreover, in this setting, the importance of secondary hyperparathyroidism is still controversial. DESIGN, PATIENTS AND METHODS: Cross-sectional observational study performed on 1177 consecutive Canary postmenopausal women who attended our Bone Metabolic Unit. The Patient Group was composed of 88 postmenopausal women who were taking oral corticosteroids in dose higher than 7.5 mg/day of prednisone or equivalent for more than 6 months (OG group). The Control Group included 838 postmenopausal women who did not take steroids. A complete validated questionnaire for osteoporosis risk assessment and a complete physical examination were performed. A lateral X-ray of the spine was performed on every woman. Bone mineral density (BMD) was measured at the lumbar spine (LS) by dual X-ray Absorptiometry (DXA) and QCT and at the femoral neck by DXA. Fasting serum and 24 hour urine was collected and biochemical markers of bone remodelling were studied. RESULTS: Both groups were comparable in general characteristics and calcium intake. The OG group showed lower values of BMD estimated both by DXA and QCT (p<0.05). LS BMD was closely correlated by using both methods (r=0.636, p<0.001). The OG group showed lower values of osteocalcin (p=0.023) and TRAP (p=0.026) without significant differences in PTH. Patients in OG group had a higher prevalence of vertebral fractures than controls (13.3% vs 8.6%; crude values: p=0.049, OR: 1.63 (0.99-2.67); age adjusted: p=0.003, OR 2.29 (1.33-9.93)). CONCLUSIONS: In postmenopausal Canarian women, chronic glucocorticoid therapy is associated with low bone mineral density, measured either by DXA or QCT, with evidence of low turnover and high prevalence of fractures without significant changes in PTH. DXA and QCT provide similar information in the assessment of this high risk population.
Abstract: Our objective has been to elaborate an updated Clinical Guide of the Spanish Society of Internal Medicine (SEMI) for the prevention and treatment of glucocorticoids-induced osteoporosis (GIO), identifying and measuring the grade of evidence that supports the given recommendations. For this, we reviewed studies performed on pathophysiology, diagnosis, prevention and treatment of GIO and after analyzing them we elaborated the present recommendations. This was done after a pre-specified and reproducible process that included an accepted model for the evaluation, and the reference of the evidence that supported it. Once the Scientific Committee elaborated the draft of the Clinical Guide, it was reviewed by all the members of the Working Group on Osteoporosis of the SEMI, and by an External Committee who included experts of many different specialities. Pathophysiology of GIO is complex and yet unknown. Bone effects of glucocorticoids are determined by multiple factors although accumulated doses seems to be the most important one. The best method to diagnose GIO is Dual X-Ray Absorptiometry (DXA), although WHO criteria defined for the diagnosis of postmenopausal osteoporosis are not applicable in GIO. The presence of a T-score lower than -1.5 Tscore indicates the necessity of treatment in any patient who receives or is going to receive more than 3 months treatment with glucocorticoids at a dose higher than 2.5 mg/day (in postmenopausal women) and 5 mg/day (in premenopausal women and men). DXA is also useful to follow up the patients, who can be done annually. Treatment must be prescribed to any patient who is receiving glucocorticoids or is going to receive them at doses higher than 7.5 mg/day for more than 3 months and 5 mg/day if the patient is a postmenopausal woman or has suffered from previous fragility fractures. Risedronate and alendronate are the drugs of election, always together with calcium and vitamin D supplements and general measurements usually prescribed in the treatment of osteoporosis. In very ill patients, parathyroid hormone can be used. The treatment for GIO should be maintained while glucocorticoid therapy is used.
Abstract: BACKGROUND: Fractures are the clinical complication of osteoporosis. There are no previous studies that describe the prevalence of vertebral fractures (VF) in patients admitted into a hospital due to a hip fracture (HF). OBJECTIVE: To study the prevalence of vertebral fractures in elderly women in the moment of their admission to the hospital due to a hip fracture. METHOD: This is a cooperative, multicentric, case-control study, performed in 21 different hospitals of Spain by the Working Group on Osteoporosis of the Spanish Society of Internal Medicine. A total of 143 elderly women with hip fractures comprised the case group. The control group consists of 138 elderly women admitted into other wards of the hospital due to other diseases with no relationship with osteoporosis. A questionnaire was administered and a lateral thoracic and lumbar X-ray was performed to assess vertebral fractures applying Genant's criteria. RESULTS: The mean age of the patients with HF was 79.8 +/- 6.9 years and the mean age of the controls was 77.7 +/- 8.9 years. Patients suffering from HF had less weight than controls (BMI: 25.9 +/- 4.4 g/m2 vs 27.7 +/- 5.2 kg/m2, p = 0.002). Prevalence of VF was 62.6% in patients with HF, and 50% in controls (p = 0.039). CONCLUSIONS: Elderly women admitted to a hospital due to hip fracture have a very high prevalence of previously undiagnosed VF. Indeed, elderly women admitted into the hospital because of other diseases also have a high prevalence of VF. These facts must be taken into account due to the morbidity and mortality of VF, that increases the HF morbidity and mortality.
Abstract: BACKGROUND AND AIMS: An association between the polymorphism for transcription factor Sp1 in the gene COL1A1 and low bone density (BMD) and osteoporotic fractures has been described but not confirmed for all races and ages. The aim of this preliminary work was to ascertain whether this association is present in women from the Canary Islands. METHODS: Polymerase chain reaction RFLP was used to determine COL1A1 polymorphism Sp1 in 199 consecutive outpatient post-menopausal Caucasian women from the Canary Islands, aged 50-70 years. BMD was measured at lumbar spine and hip by DXA and at third lumbar vertebrae by QCT. Prevalent vertebral fractures were recorded on standard lateral X-ray film. Non-vertebral osteoporotic fractures were registered by medical record and self-reported history. Biochemical markers (serum osteocalcin, tartrate-resistant acid phosphatase), blood calcium and phosphate were also assessed. RESULTS: Distribution genotypes were 113 (50.8%) GG homozygotes, 73 (36.7%) Ss heterozygotes and 7 (3.5%) TT homozygotes. All patients with osteoporotic fractures carried the GG allele more frequently than TT homozygotic women. The odds ratio was 3.01 (95% CI 1.6-5.7) for prevalent vertebral fractures (n=62) and 2.33 (95% CI 1.2-4.4) for all osteoporotic fractures (n=65) for the T-carrying allele vs TT homozygotic women. There was no difference in BMD measured by DXA or QCT, nor in bone markers, blood calcium or phosphate. CONCLUSIONS: This preliminary study confirmed that the presence of at least one copy of the T allele is associated with osteoporotic fractures, but not with low BMD, in women from the Canary Islands.
Abstract: Current treatments available for osteoporosis until recently were active by inhibiting osteoclast activity and, thus, reducing bone remodelling. Intact PTH (PTH 1-84) and its analog, teriparatida (human recombinant PTH 1-34), are a new class of anabolic treatment of osteoporosis. It has been described a positive effect on bone microarchitecture and a reduction of the risk of new fractures due to a bone-forming mechanism.PTH must be considered as an useful alternative in the treatment of severe osteoporosis, both in men and women, in patients with several osteoporosis-related fractures or with a very low bone mineral density (T-score below -3.5) an a high risk for fracture. Other potential uses are glucocorticoid-induced and other secondary osteoporosis. The use of PTH is not recommended for more than 18 months for teriparatida and 24 months for PTH 1-84.
Abstract: Osteoporosis is the most prevalent metabolic bone disease and fractures are its clinical complication. We have nowadays some drugs that reduce the incidence of new fractures: Bisphosphonates. Nevertheless, treatment must be taken properly in the long run to reduce the incidence of new fractures and a few months alter starting the treatment, a great number of patients stop it because of different reasons. The introduction of new bisphosphonates that can be taken weekly or even better monthly, has improved notably the adherence and compliance to osteoporosis treatment.
Abstract: BACKGROUND: It is a matter of controversy whether or not Colles' fracture is an osteoporotic fracture. Indeed, the usefulness of quantitative ultrasound in distinguishing Colles' fracture from normal fractures is also unclear. METHODS: A cross-sectional case-control study was done on 469 postmenopausal Spanish women, 121 with Colles' fracture and 348 controls. Assessment of risk factors for osteoporosis and measurement of calcaneus quantitative ultrasound were carried out using a Sahara, Hologic device. RESULTS: Patients with Colles' fracture had BUA, SOS, and QUI values that were similar to those of controls, and no statistically significant differences were found. We estimated ROC curves for SOS and a score based on a linear combination of height and SOS (SH-Score). The areas under both curves were 0.56 and 0.61, respectively, which was statistically significant. To obtain 5% false-negative and 10% false-positive figures, the T-score cut-off for SOS was -2.45 and -0.045, respectively. Of these, only 9.2% were classified as high risk and 11% as low risk with 79.8% undetermined. CONCLUSIONS: Patients with Colles' fracture had BUA, SOS, and QUI values that were similar to those of controls. Nevertheless, ROC curves calculated by a combination of height and SOS showed that quantitative calcaneus ultrasound may be a useful tool for identifying postmenopausal women with Colles' fracture. These results indicate that measuring bone mineral density with ultrasound only captures limited aspects of the pathophysiology of Colles' fractures.
Abstract: Measurement of ultrasonographic parameters provides information concerning not only bone density but also bone architecture. We investigated the usefulness of ultrasonographic parameters and bone mineral density (BMD) to evaluate the probability of Colles' fracture. Two-hundred eighty-nine postmenopausal women (62.3 +/- 8.7 yr) with (n = 76) and without (n = 213) Colles' fracture were studied. BMD of lumbar spine and proximal femur was evaluated in all women by dual-energy X-ray absorptiometry (DXA) and speed of sound (SOS), broadband ultrasound attenuation (BUA), and stiffness in the calcaneus were measured by a Sahara ultrasonometer (Hologic). Patients suffering from Colles' fracture had lower values of BMD adjusted by height at the lumbar spine, L2-L4 (0.797 g/cm2 vs 0.860 g/cm2), femoral neck (0.685 g/cm2 vs 0.712 g/cm2 ), SOS (1518 m/sg vs 1525 m/sg), and stiffness (74.6 vs 77.7) (p < 0.05). Nevertheless, BUA values were similar in both groups. After stepwise logistic regression analysis, the area found under receiver operating characteristic (ROC) curves was 0.60 for L2L4 and 0.63 for a formula combining L2L4 and height. Our data suggest that patients suffering from Colles' fracture have lower values of BMD by DXA, SOS, and stiffness. However, the ability of these techniques to discriminate is low because the values for the area under ROC curve are 0.60 for L2-L4 and 0.63 for a formula derived of the combination of L2-L4 and height.
Abstract: The efficacy of alendronate in slowing the loss of bone mass, or even in increasing it, in osteoporotic patients and thus reducing the risk of new fractures has been described. Nevertheless, the way of taking this drug, together with its side effects, sometimes produces withdrawals. In this study, we analyzed if an alternative way of taking the alendronate improves the follow-up of the treatment and if it had the same effect on bone mineral metabolism than the traditional way of prescription. An open, intention-to-treat study, with follow-up of 2 yr was conducted. Eighty women suffering from postmenopausal osteoporosis were included in the study. They were classified in a random manner into two groups, each one of them received 10 mg/d alendronate, together with 1.2 g of calcium and 800 IU of Vitamin D3. Group I received the drug fasting, before breakfast, as usually prescribed and group II received the alendronate fasting, at noon, before lunch. Biochemical markers of bone remodeling were determined. Total alkaline phosphatase, osteocalcin, tartrate-resistant acid phosphatase, urine calcium/creatinine ratio, crosslinked N-telopeptides of type I collagen/creatinine ratio, serum calcium, and parathyroid hormone were also determined, and a lateral dorsolumbar radiography of the spine was performed. Bone mineral density was determined in the lumbar spine by dual-energy X-ray absorptiometry and quantitative computed tomography and by dual-energy X-ray absorptiometry in the proximal femur. Both groups showed an increase in bone mineral density in the lumbar spine and in the proximal femur, which was statistically significant after 1 yr of treatment in the range between 1.5% and 4.3%, depending on the anatomical localization where bone mineral density was measured. There was also an important decrease in the biochemical markers of bone remodeling, between 5.6% and 42.5%, depending on the biochemical marker; the decrease of amino-terminal telopetide during the first year was more important. The group that received alendronate in the morning reported a significantly higher number of withdrawals than the group that received the drug at noon. The alternative administration of 10 mg alendronate at noon had the same effect on bone mineral metabolism than its traditional administration in the morning, but the rate of withdrawals was significantly lower.
