老年骨质疏松性胸腰椎骨折术后再骨折的影响因素

目的探讨老年骨质疏松性胸腰椎骨折术后再骨折的影响因素。方法回顾性分析接受经皮穿刺椎体成形术(PVP)的141例老年骨质疏松性胸腰椎骨折患者的临床资料,依据其术后是否发生再骨折分为再骨折组(22例)和非再骨折组(119例)。记录一般资料,分析可能导致老年骨质疏松性胸腰椎骨折术后再骨折的影响因素。结果两组性别、骨折病史占比及骨水泥量比较,差异无统计学意义(P0.05);再骨折组年龄(≥75岁)、骨水泥渗漏、椎体侧凸畸形、骨密度(-2.5 S)、Cobb角恢复至正常(85%)占比均明显高于非再骨折组,差异有统计学意义(P0.05);Logistic回归分析发现,年龄(≥75岁)、骨水泥渗漏、椎体侧凸畸形、骨密度(-2.5 S)、Cobb角恢复至正常(85%)均是导致老年骨质疏松性胸腰椎骨折术后再骨折的影响因素(OR1,P0.05)。结论临床可通过控制危险因素指导老年骨质疏松性胸腰椎骨折患者术后早期活动,并积极给予抗骨质疏松治疗等方式降低术后再骨折发生风险。     

慢性肝病患者骨质疏松的研究进展

骨质疏松是慢性肝病的重要并发症,患者可发生脊椎压缩性骨折、桡骨及股骨骨折等,是致残、致死的重要原因. 1 诊断 1994年世界卫生组织对骨质疏松的定义是"以骨量减少、骨组织微结构退化为特征,以致骨的脆性和骨折易感性增加的全身性骨病".骨质疏松的诊断主要应用双能X线吸收法(dual-energy x-ray absorptiometry,DXA)测量腰椎、股骨颈等部位的骨密度(BMD),诊断标准为髋骨和(或)脊柱BMD较年轻成人的均值下降2.5个标准差或以上,下降1个标准差以上但未达到2.5个标准差者为骨量减少.     

骨质疏松性骨折的流行病学研究进展

骨质疏松可以定义为"以低骨量和骨组织的微结构损伤为特征,并最终导致骨脆性增加及容易发生骨折的一种全身性骨疾病".由于脆性骨折是骨质疏松造成的主要公共健康危害,因此诊断指标应该是那些可以预测骨折的指标.     

骨小梁分数在风湿病并发骨质疏松管理中的应用价值

骨质疏松症是以骨强度下降、骨折风险增加为特征的骨骼疾病。风湿病是继发性骨质疏松症的常见原因之一,可显著增加患者罹患骨质疏松、脆性骨折的风险,导致疾病致残及致死率升高。风湿病患者并发骨质疏松的风险预测、早期诊断、早期干预和治疗监测均具有重要意义。目前诊断骨质疏松的金标准是骨密度值(BMD),但BMD仅反映骨量变化,不能显示骨微结构等骨质量信息。骨小梁分数(TBS)是一种基于双能X线吸收测定法(DXA)图像的新型骨微结构无创评估手段。研究表明,TBS可用于原发性及各种继发性骨质疏松症的骨质量评估,并能作为BMD和骨折风险预测工具FRAX的辅助指标,提高骨折风险预测能力。本文就TBS在风湿病并发骨质疏松领域的相关研究进行综述,提示TBS在骨质疏松识别、骨折风险评估、药物疗效监测等方面的潜在应用价值。     

老年人骨质疏松性骨折风险评估及其与脊柱曲度的关系

目的评估老年人骨质疏松性骨折风险,并探讨其与脊柱曲度之间的关系。方法于2016年1月至2017年6月对北京市海淀医院1 213例老年人进行调查评估。通过双光能X线骨密度仪,采用骨折风险测评工具(FRAX)评估10年内主要骨质疏松性骨折(包括前臂、肩部、脊椎骨折等)概率和髋部骨折概率。采用脊柱电子测量仪测量直立位的躯干倾斜角、脊柱椎间夹角、脊柱曲度。最后对老年人骨质疏松性骨折风险进行评估并分析其与脊柱曲度的关系。结果≥80岁组发生髋部骨折概率≥3%的检出率高于60～79岁组(P0.05),女性发生髋部骨折概率≥3%的检出率显著高于男性(P0.05);骨量正常组、骨量减少组、骨质疏松组发生髋部骨折概率≥3%的检出率整体比较以及两两互相比较,差异均有统计学意义(P0.05)。主要骨质疏松性骨折风险概率、髋部骨折风险概率与T7、T8夹角及躯干前倾角呈正相关(P0.05)。主要骨质疏松性骨折风险概率、髋部骨折风险概率与直立胸椎曲度及直立腰椎曲度呈正相关(P0.05)。结论老年人骨质疏松性骨折风险不但与年龄、性别、骨量有关系,而且与脊柱曲度具有相关性,能够反映骨质疏松性骨折风险的高低。     

骨折风险评估工具(FRAX~)对绝经后低骨量女性骨折的预测价值

目的评估骨折风险评估工具(FRAX)对绝经后低骨量女性骨折的预测价值。方法收集绝经后低骨量上海女性769人,记录所有受试者年龄、身高、体重、脆性骨折史、父母脆性骨折史、口服激素史、类风湿关节炎史、吸烟史、饮酒史,腰椎1-4(L1-4)和左侧股骨颈骨密度(bone mineral density,BMD)。应用骨折风险评估工具(FRAX)中国模式计算受试个体的10年骨折概率,筛选达到骨质疏松性骨折高危患者诊断标准的个体。按年龄将受试者分为50~59岁组,60~69岁组,70~79岁组和80~90岁组,分析不同年龄组10年髋部骨折概率和10年主要骨质疏松性骨折概率。结果受试者中无人达到骨质疏松性骨折高危患者诊断标准。10年髋部骨折概率为0.40±0.26(范围:0~2.2);10年主要骨质疏松性骨折概率为2.27±0.62(范围:1.0~4.9)。10年髋部骨折概率随着年龄增长而升高,各年龄组间差异有统计学意义(P0.01)。10年主要骨质疏松性骨折概率在50至70岁期间,并随年龄增长而升高,随后随年龄增长逐渐下降,各年龄组差异有统计学意义(P0.01)。结论 FRAX中国模式运算结果低估了绝经后低骨量上海女性10年骨折概率,尤其是70岁以后10年主要骨质疏松性骨折概率;应进一步探讨FRAX中国模式对绝经后低骨量女性骨折的预测价值。     

腰椎QCT与DXA对老年骨质疏松的诊断差异

目的研究腰椎定量CT(quantitative computed tomography,QCT)和双能X线吸收检测仪(dual-energy X-ray absorptiometry,DXA)检测骨密度(bone mineral density,BMD)诊断老年人群骨质疏松效能的差异。方法收集北京积水潭医院同时接受腰椎DXA、髋部DXA和腰椎QCT检查、年龄60岁的老年患者614例。DXA诊断骨质疏松采用世界卫生组织(World Health Organization,WHO)推荐的标准:T值≤-2.5 SD为骨质疏松,-2.5 SDT-1.0 SD为低骨量,≥-1.0 SD为正常。QCT采用美国放射学院(American College of Radiology,ACR)的诊断标准,腰椎BMD80 mg/cm~3为骨质疏松,120 mg/cm3为正常,80 mg/cm~3≤BMD≤120 mg/cm~3为低骨量。当两种方法诊断骨质疏松只有一个分类差别时,称为小差异;当一种方法诊断为骨质疏松而另一种方法诊断为骨量正常时,这种差异称为大差异。比较DXA和QCT诊断骨质疏松的结果差异。结果在614例平均年龄(76.3±26.0)岁的老年人群中,DXA和QCT诊断骨质疏松的大差异、小差异和诊断一致率分别为5.9%、46.9%和47.2%。DXA(腰椎正位、髋部)和腰椎QCT对骨质疏松的检出率差异有统计学意义(χ~2=177.96,P0.01)。结论利用腰椎QCT测量BMD对老年人群骨质疏松的诊断具有重要价值。     

骨折风险预测简易工具对住院2型糖尿病患者骨折风险的预测及临床意义

目的探讨骨折风险预测简易工具(FRAX)预测住院低骨量2型糖尿病(T2DM)患者发生骨质疏松性骨折的风险。方法采用随机选择175例住院T2DM患者作为T2DM组,同期门诊非T2DM患者108例作为对照组。受试者均采用双能X线骨密度测量仪(DXA)检测腰椎(L1-4)及左侧股骨(股骨颈、大转子、wards三角)的骨密度(BMD),记录每例患者日常生活中可能影响骨代谢的危险因素,根据体重指数(BMI)和股骨颈BMD,用FRAX计算10年主要骨质疏松性骨折发生概率(临床性脊椎、髋骨、前臂和肱骨骨折)和10年髋部骨折发生概率。结果 T2DM组BMD与对照组相比无明显下降(P0.05),但发生骨质疏松性骨折的风险却明显增高(P0.05);根据BMI计算10年全部主要骨质疏松性骨折(BBMO)发生概率和10年髋部骨折(BBHF)发生概率、根据股骨颈骨密度计算10年全部主要骨质疏松性骨折(BMO)发生概率和10年髋部骨折(BHF)发生概率之间呈显著正相关(P0.001);年龄、绝经年限、BMI、吸烟、补充钙与维生素D、以往骨折史、骨质疏松病史、父母髋部骨折史、糖尿病病史等与发生骨质疏松性骨折的风险密切相关(均P0.05)。结论 T2DM患者较对照组更易发生骨质疏松性骨折,并与多种危险因素密切相关;常规补充适量钙剂和维生素D、进行体育运动、控制血糖等可预防和减少骨质疏松性骨折。     

骨折风险评估工具(FRAX(R) )对绝经后低骨量女性骨折的预测价值

目的 评估骨折风险评估工具(FRAX(R) )对绝经后低骨量女性骨折的预测价值.方法 收集绝经后低骨量上海女性769人,记录所有受试者年龄、身高、体重、脆性骨折史、父母脆性骨折史、口服激素史、类风湿关节炎史、吸烟史、饮酒史,腰椎1-4(L1-4)和左侧股骨颈骨密度(bone mineral density,BMD).应用骨折风险评估工具(FRAX(R))中国模式计算受试个体的10年骨折概率,筛选达到骨质疏松性骨折高危患者诊断标准的个体.按年龄将受试者分为50～59岁组,60～69岁组,70~79岁组和80~90岁组,分析不同年龄组10年髋部骨折概率和10年主要骨质疏松性骨折概率.结果受试者中无人达到骨质疏松性骨折高危患者诊断标准.10年髋部骨折概率为0.40±0.26(范围:0～2.2);10年主要骨质疏松性骨折概率为2.27±0.62(范围:1.0～4.9).10年髋部骨折概率随着年龄增长而升高,各年龄组间差异有统计学意义(P＜0.01).10年主要骨质疏松性骨折概率在50至70岁期间,并随年龄增长而升高,随后随年龄增长逐渐下降,各年龄组差异有统计学意义(P＜0.01).结论 FRAX(R)中国模式运算结果低估了绝经后低骨量上海女性10年骨折概率,尤其是70岁以后10年主要骨质疏松性骨折概率;应进一步探讨FRAX(R)中国模式对绝经后低骨量女性骨折的预测价值.     

骨质疏松药物治疗进展

骨质疏松(OP)是一种以低骨量、骨组织的微结构破坏为特征导致骨骼脆性增加和易骨折的全身性疾病.1994年WHO制定了以骨密度测量为基础的诊断骨质疏松的标准骨密度值低于或等于正常年轻人2.5个标准差即可诊断为骨质疏松,有过一次或多次骨折经历的都肯定有严重的骨质疏松.随着全球人口的老龄化,OP在全世界常见病、多发病中的地位逐渐上升至第7位,患病人数超过2亿,我国已达9000万.     

Diagnosis with bone mass

In diagnostic criteria of osteoporosis proposed by WHO, the severe osteoporosis is defined as a patient with a value for BMD or BMC more than 2.5SD below the young adult mean value in the presence of one or more fragility fractures. When severe fragility fracture occurs from the second to forth lumbar vertebra, the lumbar BMD could be over-estimated. On the other hand, when the lumbar BMD is markedly low, the demarcation of bone contour is incomplete, and the precision of the BMD measurement decreases. Thus, in the severe osteoporosis it is necessary to be careful in the diagnosis with bone mass using DXA.     

Osteoporosis: the evolution of a diagnosis

The global trend towards increased longevity has resulted in ageing populations and a rise in diseases or conditions that primarily affect older persons. One such condition is osteoporosis (fragile or porous bones), which causes an increased fracture risk. Vertebral and hip fractures lead to increased morbidity and mortality and result in enormous healthcare costs. Here, we review the evolution of the diagnosis of osteoporosis. In an attempt to separate patients with normal bones from those with osteoporosis and to define the osteoporosis diagnosis, multiple factors and characteristics have been considered. These include pathology and histology of the disease, the endocrine regulation of bone metabolism, bone mineral density (BMD), fracture type or trauma severity, risk models for fracture prediction, and thresholds for pharmacological intervention. The femoral neck BMD ?2.5 SDs cut‐off for the diagnosis of osteoporosis is arbitrarily chosen, and there is no evidence to support the notion that fracture location (except vertebral fractures) or severity is useful to discriminate osteoporotic from normal bones. Fracture risk models (including factors unrelated to bone) dissociate bone strength from the diagnosis, and treatment thresholds are often based on health‐economic considerations rather than bone properties. Vertebral fractures are a primary feature of osteoporosis, characterized by decreased bone mass, strength and quality, and a high risk of another such fracture that can be considerably reduced by treatment. We believe that the 2001 definition of osteoporosis by the National Institutes of Health Consensus Development Panel on Osteoporosis is still valid and useful: ‘Osteoporosis is defined as a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture’.     

Epidemiology of osteoporosis

The epidemiology of osteoporosis is reviewed in this article. Attempts were made to answer the following questions: How should osteoporosis be defined? How can risk factors and bone mineral density (BMD) measurements be applied to diagnose osteoporosis? How do the rates for osteoporotic fractures vary by country, sex, age and time? What are the costs for osteoporosis in terms of direct and indirect cost, morbidity and mortality? According to the WHO criteria, osteoporosis can be defined as a BMD of 2.5 standard deviations or more below the young normal mean. BMD measurements are predictive of fracture risks. Hip fracture is by far the most costly of osteoporotic fractures, and the rates are highest in Caucasians, intermediate in Asians and lowest in Blacks. Risk factors could be used to assist in the decision to measure BMD.     

Diagnosis of osteoporosis and assessment of fracture risk

The diagnosis of osteoporosis centres on the assessment of bone mineral density (BMD). Osteoporosis is defined as a BMD 2.5 SD or more below the average value for premenopausal women (T score < -2.5 SD). Severe osteoporosis denotes osteoporosis in the presence of one or more fragility fractures. The same absolute value for BMD used in women can be used in men. The recommended site for diagnosis is the proximal femur with dual energy X-ray absorptiometry (DXA). Other sites and validated techniques, however, can be used for fracture prediction. Although hip fracture prediction with BMD alone is at least as good as blood pressure readings to predict stroke, the predictive value of BMD can be enhanced by use of other factors, such as biochemical indices of bone resorption and clinical risk factors. Clinical risk factors that contribute to fracture risk independently of BMD include age, previous fragility fracture, premature menopause, a family history of hip fracture, and the use of oral corticosteroids. In the absence of validated population screening strategies, a case finding strategy is recommended based on the finding of risk factors. Treatment should be considered in individuals subsequently shown to have a high fracture risk. Because of the many techniques available for fracture risk assessment, the 10-year probability of fracture is the desirable measurement to determine intervention thresholds. Many treatments can be provided cost-effectively to men and women if hip fracture probability over 10 years ranges from 2% to 10% dependent on age.     

Mapping translational research into individualized prognosis of fracture risk

The assessment of fracture risk has until now been based on the measurement of bone mineral density (BMD) and/or a prior fracture. Individuals with BMD T‐scores < –2.5 (e.g. osteoporosis) or with prior fractures are indicated for treatment. However, recent data have suggested that 55% of women and 74% of men who sustained a fracture did not have osteoporosis. Therefore, the current strategy reduces a small number of fractures in the general population, and new thinking is required for that majority of individuals whose BMD measurements are at or near (both sides) the current threshold of osteoporosis. An individual's absolute risk of fracture can be estimated from the individual risk profile, which includes age, BMD, weight or body mass index, prior fracture, comorbidities, corticosteroid use, lifestyle factors, and falls. Therefore, risk assessment must simultaneously consider all risk factors to which the individual is exposed. A number of prognostic models and predictive nomograms have been developed to estimate an individual's absolute risk of fracture, but they have not been externally validated. Nevertheless, these prognostic models can be effective tools for individualizing short‐term and long‐term risks of fracture, which can help patient counseling and selecting appropriate patients for intervention to maximize the benefit of fracture reduction in the general population.     

The impact of oral corticosteroid use on bone mineral density and vertebral fracture

The use of oral corticosteroids is associated with an increased risk of fracture, but there is limited information on the relationship between corticosteroid dose, bone mineral density (BMD), and fracture. We examined this relationship in a community population (more than 50 years) taking oral corticosteroids for chronic lung disease. Details of corticosteroid use and lifestyle were obtained by questionnaire, general practice records, and patient interview. BMD was assessed at the lumbar spine and femur and vertebral fracture by morphometric X-ray absorptiometry. Of the 117 patients who participated (median age, 69), 48% were female. Fifty-eight percent had osteoporosis (a T score of less than -2.5), and 61% had a vertebral fracture. The presence of vertebral fracture was related to BMD at the femoral neck, with an odds ratio of 1.6 for a 1 SD reduction in BMD. The cumulative prednisolone dose ranged from 3.4 to 175 g and was strongly associated with vertebral fracture, with the odds ratio between the highest and lowest dose quartiles being 4.4 (95% confidence interval, 1.04, 18.8). The difference in femoral neck BMD between the same dose quartiles was only modest, however (0.5 SD; 95% confidence interval, 0.09, 0.94). In patients taking long-term oral corticosteroids for chronic lung disease, the relationship between vertebral fracture risk and BMD is similar to that seen in other populations. Cumulative prednisolone dose is strongly related to fracture risk, and this effect is independent of its more modest impact on BMD.     

绝经后妇女脊椎压缩性骨折与骨密度的关系

目的探讨绝经后妇女脊椎压缩性骨折与骨密度（BMD）的关系。方法为病例一对照研究，入选250例有脊椎压缩性骨折的绝经后妇女，另有250名无脊椎压缩性骨折的绝经后妇女作为对照组。两组均有胸腰椎正侧位X线摄片，并应用双能X线吸收仪检测腰椎1～4和左股骨近端各部位BMD。结果脊椎压缩性骨折组身高、体重、腰椎2～4和股骨近端各部位BMD值均显著低于对照组（均P〈0．01）。腰椎2～4BMD是发生脊柱骨折的预报因子（r=-0．416，P〈0．01）。身高和全髋部BMD与骨折次数和骨折椎体数目呈负相关（均P〈0．01）。按股骨颈和全髋部BMD值，骨折组骨质疏松检出率各为50．8％和50．4％；另外剔除在腰椎2～4发生椎体骨折53例，按腰椎2～4BMD检出骨质疏松占64．5％。同时，腰椎2～4、股骨颈或全髋部BMD值低于-2．5s者发生脊柱压缩性骨折的风险分别是BMD正常者的4．76、2．36和3．52倍。结论腰椎呈低骨量是发生脊椎压缩性骨折的重要危险因素。身高的下降和全髋部低BMD值是骨折发生次数和受累椎体数目的危险因子；对绝经后妇女在重视BMD测量的同时，应重视脊柱X线正侧位检查。     

Electronic medical record reminder improves osteoporosis management after a fracture: a randomized, controlled trial

OBJECTIVES: Osteoporosis treatment rates after a fracture are low. This study evaluated methods to increase guideline-recommended osteoporosis care postfracture. DESIGN: Participants were randomly assigned to usual care or one of two interventions. Analysis of primary outcomes used electronic data and linear regression. SETTING: A Pacific Northwest nonprofit health maintenance organization. PARTICIPANTS: Female patients aged 50 to 89 who suffered a fracture in 1999 and had not received bone mineral density (BMD) measurement or medication for osteoporosis (n=311) and their primary care providers (n=159). INTERVENTION: Patient-specific clinical guideline advice to the primary care provider delivered by electronic medical record (EMR) message or electronic reminder to the provider plus an educational letter mailed to the patient. MEASUREMENTS: BMD measurement and osteoporosis medication. RESULTS: At 6 months, provider reminder resulted in 51.5% of patients receiving BMD measurement or osteoporosis medication, provider reminder plus patient education resulted in 43.1%, and usual care resulted in 5.9% (P<.001). The effect of provider advice combined with patient education was not significantly different from provider advice alone (P=.88). Patients aged 60 to 69 were 18% (95% confidence interval=3-34) more likely to receive BMD measurement or an osteoporosis medication than those aged 80 to 89. CONCLUSION: Patient-specific postfracture advice to the provider through an EMR message significantly increased BMD measurement and osteoporosis medication. As EMRs become more widespread, this intervention could improve osteoporosis management for many postfracture patients. Future research should identify barriers to and facilitators of care for older, high-risk patients.     

Hip fracture in women without osteoporosis

The proportion of fractures that occur in women without osteoporosis has not been fully described, and the characteristics of nonosteoporotic women who fracture are not well understood. We measured total hip bone mineral density (BMD) and baseline characteristics including physical activity, falls, and strength for 8065 women aged 65 yr or older participating in the Study of Osteoporotic Fractures and then followed these women for hip fracture for up to 5 yr after BMD measurement. Among all participants, 17% had osteoporosis (total hip BMD T-score < or = -2.5). Of the 243 women with incident hip fracture, 54% were not osteoporotic at start of follow-up. Nonosteoporotic women who fractured were less likely than osteoporotic women with fracture to have baseline characteristics associated with frailty. Nevertheless, among nonosteoporotic participants, several characteristics increased fracture risk, including advancing age, lack of exercise in the last year, reduced visual contrast sensitivity, falls in the last year, prevalent vertebral fracture, and lower total hip BMD. These findings call attention to the many older women who suffer hip fracture but do not have particularly low antecedent BMD measures and help begin to identify risk factors associated with higher bone density levels.