Simulated Osteopenia Impairs Metaphyseal Bone Ingrowth of Metal Implants in an Animal Model

Abstract Background and Purpose: Cementless total joint replacement in osteopenic bone is suspected to deteriorate long-term survival of implants because results in dental implantology research indicate that bone ingrowth of dental implants in osteoporotic bone is impaired. The present investigation was designed to determine whether osteopenic bone stock, experimentally created in ovariectomized rats, influences the active bone-implant integration process. Material and Methods: 40 Sprague-Dawley rats were randomly assigned to two treatment groups; one group underwent ovariectomy, the other sham ovariectomy. Successful development of osteopenia was assessed by bone mineral density measurement of the lumbar vertebra L5 before implant surgery and before sacrifice. An uncoated and a hydroxyapatite-coated titanium implant were surgically inserted into the medullary canal of each femur. After 28 days specimens were prepared for histomorphometry to determine the osseointegrated implant surface. Results: The results showed a successful development of experimentally induced osteopenia in ovariectomized rats. For hydroxyapatite-coated implants the histomorphometry revealed a mean osseointegrated implant surface of 54.5% in the sham group versus 23.7% in the ovariectomy group. There was no significant difference for uncoated titanium implants. Conclusion: The present study in rats clearly demonstrates that osteopenic bone loss induced by ovariectomy impairs bone-implant ingrowth of hydroxyapatite-coated implants in the metaphysis of the femur. This is a potential risk for deterioration of long-term outcome of cementless metal implants in osteopenic bone. In consequence, the quality of bone stock has to be taken into account while making a decision for cemented or cementless joint replacements.     

Scurvy in pediatric age group – A disease often forgotten?

Scurvy is caused by prolonged severe dietary deficiency of vitamin C. Being rare as compared to other nutritional deficiencies, it is seldom suspected and this frequently leads to delayed recognition of this disorder. Children with abnormal dietary habits, mental illness or physical disabilities are prone to develop this disease. The disease spectrum of scurvy is quite varied and includes dermatological, dental, bone and systemic manifestations. Subperiosteal hematoma, ring epiphysis, metaphyseal white line and rarefaction zone along with epiphyseal slips are common radiological findings. High index of suspicion, detailed history and bilateral limb radiographs aids physician in diagnosing this eternal masquerader. We searched Pubmed for recent literature (2009–2014) with search terms “scurvy” “vitamin C deficiency” “ascorbic acid deficiency” “scurvy and children” “scurvy and pediatric age group”. There were a total of 36 articles relevant to pediatric scurvy in children (7 reviews and 29 case reports) which were retrieved. The review briefly recapitulates the role of vitamin C, the various disease manifestations and the treatment of scurvy to create awareness of the disease which still is reported from our country, although sporadically. The recent advances related to scurvy and its management in pediatric age group are also incorporated.     

Emerging views about "osteoporosis", bone health,strength, fragility,and their determinants

 Recent articles by Drs. Lanyon, Raisz, Seeman, and Skerry summarized some emerging views about the causes and nature of some effects of mechanical loading on bones and “osteoporosis”, the causes of fractures in that condition, and the causes of increased bone fragility and age-related bone loss. This article would supplement theirs with further evidence and ideas. This includes a definition of bone health that suggests currently popular classifications of “osteoporosis” and “osteopenia” could fail to distinguish healthy differences from normal averages from true bone diseases. This definition also suggests a classification of osteoporotic fractures that could question some current methods and uses of noninvasive absorptiometry. This article emphasizes concepts and generalities, and leaves resolution of any devils in the details to other places, times, and people. Received: March 29, 2002 / Accepted: May 28, 2002 Offprint requests to: H.M. Frost     

A review of the association between osteoporosis and alveolar ridge augmentation.

OBJECTIVE: Because of increasing life expectancy and popularity of dental implants, surgeons face a larger number of osteoporotic patients who require bone augmentation. Relationship between low bone density/osteoporosis and bone graft success is still not clear. The purpose of this article is to review and summarize the literature regarding the success of alveolar bone augmentation in osteoporosis. STUDY DESIGN: The study design includes a literature review of relevant preclinical and clinical articles that address the association between osteoporosis and alveolar bone augmentation. RESULTS: Increased rate of complications such as resorption of bone graft, non-integration of bone graft, delayed healing time, and implant failure in augmented bone especially in the maxilla may be associated with compromised bone health. CONCLUSIONS: Despite the decreased success rate, osteoporosis is not an absolute contraindication for bone augmentation and dental implant placement. The modifiable risk factors for osteoporosis should be eliminated before surgery.     

“Ride-on” technique and other simple and logical solutions to counter most common complications of silicone implants in augmentation rhinoplasty

Augmentation rhinoplasty can be carried out using a wide range of materials including autologous bone and/or cartilage as well as alloplasts. Use of biologic bone and cartilage grafts results in lower infection rates, but they are associated with long-term resorption and donor-site morbidity. Alloplastic materials, in particular silicone, have been associated in literature with extrusion, necrosis of the tip, mobility and deviation or displacement of the implant, immobile nasal tip and infection. However, they have the advantages of being readily available and easy to reshape with no requirement for harvesting autografts.

Aim:

To overcome these problems associated with silicone implants for which the authors have devised a novel technique, the “rideon technique”.

Materials and Methods:

The present study was carried out on 11 patients over a period of 4 years. The authors have devised a simple technique to fix the silicone implant and retain it in place. Restricting the implant to only dorsum avoided common complications related to the silicone implant.

Results:

The authors have used this technique in 11 patients with encouraging results. Follow-up ranged from 12 months to 36 months during which patients were assessed for implant mobility, implant extrusion and tip necrosis. There was no incidence of above mentioned complications in these patients.

Conclusion:

The “rideon technique” provides excellent stability to silicone implants and restricting the implant only to dorsum not only eliminates chances of tip necrosis and thus implant extrusion but also maintains natural shape, feel and mobility of the tip.KEY WORDS: Alloplasts, autografts, rhinoplasty, silicone implants     

Clinical and panoramic predictors of femur bone mineral density

Dentists are a potentially valuable resource for initial patient screening for signs of osteoporosis, as individuals with osteoporosis have altered architecture of the inferior border of the mandible as seen on panoramic radiographs. Our aim was to evaluate the efficacy of combining clinical and dental panoramic radiographic risk factors for identifying individuals with low femoral bone mass. Bone mineral density was measured at the femoral neck and classified as normal, osteopenic or osteoporotic using WHO criteria in 227 Japanese postmenopausal women (33–84 years). Panoramic radiographs were made of all subjects. Mandibular cortical shape and width was determined and trabecular features were measured in each ramus. Mean subject age, height, and weight were significantly different in the three bone-density groups (P<0.0001). A classification and regression trees (CART) analysis using just clinical risk factors identified 136 (87%) of the 157 individuals with femoral osteopenia or osteoporosis. Mean mandible cortical width (P<0.0001), cortical index (P<0.0001) and trabecular features (P=0.02) were also significantly different in the three bone density groups. A CART analysis considering only radiographic features found 130 (83%) of the 157 individuals with femoral osteopenia or osteoporosis, although none of the subjects with osteoporosis was correctly identified. A CART analysis using both clinical and radiographic features found that the most useful risk factors were thickness of inferior border of the mandible and age. This algorithm identified 130 (83%) of the 157 individuals with femoral osteopenia or osteoporosis. The results of this study suggest that 1) clinical information is as useful as panoramic radiographic information for identifying subjects having low bone mass, and 2) dentists have sufficient clinical and radiographic information to play a useful role in screening for individuals with osteoporosis.     

Barbie Doll Forehead: CAD Design from Silicon Block

The forehead is an important determinant of masculine or feminine look of the face. There are many methods described to achieve forehead augmentation for a more feminine face, and they include fillers, autologous fat grafting, silicone implant or methyl methacrylate. We present a case of a “Barbie doll forehead,” which is an interesting trend in Asian countries. Availability of silicone implants of various sizes are not uniform and currently unavailable in India. Alternatively, we devised carved silicone block using computer-aided design (CAD). We also discuss the various methods described for forehead augmentation with their advantages and disadvantages.     

Spinal cord involvement in Lewy body-related α-synucleinopathies

Context: Lewy body (LB)-related α-synucleinopathy (LBAS) is the neuropathological hallmark of several neurodegenerative diseases such as Parkinson disease (PD), but it is also found in neurologically asymptomatic subjects. An abnormal accumulation of α-synuclein has been reported also in the spinal cord, but extent and significance of the spinal cord involvement are still poorly defined.Objective: We aimed to review the studies addressing the spinal cord involvement of LBAS in healthy subjects and in patients with PD or other neurodegenerative diseases.Methods: A MEDLINE search was performed using following terms: “spinal cord”, “ α-synucleinopathy”, “α-synuclein”, “Lewy body”, “Parkinson’s disease”, “multiple system atrophy”, “neurodegenerative disorder”.Results: LBAS in the spinal cord is associated with that of the medullary reticular formation and locus ceruleus in the brainstem but not with that in the olfactory bulb and amygdala. The intermediolateral columns of the thoracic and sacral cord are the most frequently and severely affected region of the spinal cord. LBAS occurs in centrally projecting spinal cord neurons integrating pain, in particular from lower body periphery. It also involves the sacral parasympathetic nucleus innervating the smooth muscles of the bladder and distal colon and the Onuf’s nucleus innervating the striated sphincters. The spinal cord lesions may thus play a crucial role in the genesis of frequent non-motor symptoms such as pain, urinary symptoms, bowel dysfunction, autonomic failure including orthostatic hypotension and sexual disturbances. Moreover, these may also contribute to the motor symptoms, since α-synuclein inclusions have been observed in the pyramidal tracts of patients with PD and multiple system atrophy.Conclusion: Recognition of this peculiar spinal cord pathology may help in the management of the related symptoms in subjects affected by α-synucleinopathies.     

Revision rate after short-stem total hip arthroplasty: A systematic review of 49 clinical studies

Background and purpose

The aim of short-stem total hip arthroplasty is to preserve proximal bone stock for future revisions, to improve biomechanical reconstruction, and to make minimally invasive approaches easier. It is therefore being increasingly considered to be a sound alternative to conventional total hip arthroplasty, especially for young and active patients. However, it is still unknown whether survival rates of short-stem hips match current standards. We made a systematic summary of reported overall survival after short-stem total hip arthroplasty.

Materials and methods

We conducted a systematic review of English, French, German, and Dutch literature. 2 assessors independently identified clinical studies on short-stem hip arthroplasty. After recalculating reported revision rates, we determined whether each implant had a projected revision rate of 10% or less at 10 years of follow-up or a revision rate per 100 observed component years of 1 or less. Stems were classified as “collum”, “partial collum”, or “trochanter-sparing”.

Results and Interpretation

We found 49 studies, or 51 cohorts, involving 19 different stems. There was a large increase in recent publications. The majority of studies included had a follow-up of less than 5 years. We found a large number of observational studies on “partial collum” and “trochanter-sparing” stems, demonstrating adequate survival rates at medium-term follow-up. Clinical evidence from “collum stem” studies was limited to a small number of studies with a medium-term follow-up period. These studies did not show a satisfactory overall survival rate.In recent years, there has been an increase in uncemented total hip arthroplasty in young and more active patients (Adelani et al. 2013). The diaphyseal or metadiaphyseal anchorage features of uncemented stems may, however, cause proximal stress shielding. Concern about potential metaphyseal bone loss during future revision—especially in younger patients—has led to the quest for a more bone-preserving implant. Short-stemmed implants were introduced with the aim of preserving proximal bone stock for future revisions by preventing stress shielding through metaphysical bone loading. Furthermore, by following the anatomic curvature of the femoral neck, short stems may restore biomechanical proportions better than conventional stems, and tissue-sparing minimally invasive approaches may be easier with small curved stems.Current total hip arthroplasty stems can be roughly divided into the following anchoring principles (Gulow et al. 2007): (1) Resurfacing endoprostheses anchoring on the epiphysis; (2) Collum endoprostheses solely anchoring on the metaphysis; (3) Short collum preserving stems anchoring on the metaphysis with short anchorage on the diaphysis; and (4) Conventional stems anchoring on the metaphysis with a long diaphyseal anchorage.Collum endoprostheses and short stems may be combined with conventional cups and bearings, in contrast to resurfacing designs. They are increasingly being considered to be a sound alternative, especially for young and active patients. However, it is still unknown whether survival rates of short hip stems are comparable with conventional uncemented stems. With a growing number of short-stem implants being introduced to the market, we wanted to summarize in a systematic way the reported overall survival after short-stem total hip arthroplasty and to compare the survival with the current benchmark level for conventional total hip arthroplasty.     

Mixing of components from different manufacturers in total hip arthroplasty: prevalence and comparative outcomes: A study of over 90,000 cases of mixed components in the National Joint Registry for England and Wales

Background and purpose — There have recently been highly publicized examples of suboptimal outcomes with some newer implant designs used for total hip replacement. This has led to calls for tighter regulation. However, surgeons do not always adhere to the regulations already in place and often use implants from different manufacturers together to replace a hip, which is against the recommendations of the Medicines and Healthcare Products Regulatory Agency (MHRA) and the directions of the manufacturers.Patients and methods — We used data from the National Joint Registry of England and Wales (NJR) to investigate this practice.Results — Mixing of components was common, and we identified over 90,000 cases recorded between 2003 and 2013. In the majority of these cases (48,156), stems and heads from one manufacturer were mixed with polyethylene cemented cups from another manufacturer. When using a cemented stem and a polyethylene cup, mixing of stems from one manufacturer with cups from another was associated with a lower revision rate. At 8 years, the cumulative percentage of revisions was 1.9% (95% CI: 1.7–2.1) in the mixed group as compared to 2.4% (2.3–2.5) in the matched group (p = 0.001). Mixing of heads from one manufacturer with stems from another was associated with a higher revision rate (p < 0.001). In hip replacements with ceramic-on-ceramic or metal-on-metal bearings, mixing of stems, heads, and cups from different manufacturers was associated with similar revision rates (p > 0.05).Interpretation — Mixing of components from different manufacturers is a common practice, despite the fact that it goes against regulatory guidance. However, it is not associated with increased revision rates unless heads and stems from different manufacturers are used together.Total hip replacement (THR) has become the standard treatment for end-stage arthritis of the hip, and it is used in a significant proportion of patients with a subcapital fracture of the femoral neck.The majority of manufacturers stipulate in their “instructions for use” that surgeons should use all the components from the same manufacturer, otherwise the surgeons will be working “off label”. However, many surgeons in the UK have matched a femoral component from one manufacturer with an acetabular component from another manufacturer. The surgeons who do this are encouraged by the excellent results that can be achieved following this practice—results that are at least comparable to those obtained when mixing and matching has not been performed. This group of excellent results has usually involved a metal or ceramic head on a polyethylene acetabular component. For example, the NJR 10th Annual Report recorded that between 2003 and 2011 over 6,000 Exeter V40 stems (manufactured by Stryker) were implanted with Elite plus polyethylene cups (manufactured by DePuy), with excellent implant survivorship. In 2013, 11,496 out of 78,479 hip replacements undertaken in England, Wales, and Northern Ireland were “mixed”, i.e. components from different manufacturers were used together. In all, 820 different combinations of stems and cups were used, out of which 487 different combinations were mixed.Recently, the practice of mixing and matching has again come under close scrutiny with the use of large-head “metal-on-metal” devices (LHMOM), where both the femoral head and the acetabular components are made of metal (Telegraph 2014). It is known that LHMOM is associated with a high implant failure rate (Smith et al. 2012), and not only has the bearing surface come under scrutiny but also the “taper junction” where the tapered trunnion of the neck of the femoral implant engages the modular femoral head (Nassif et al. 2014). It has been shown that poorly fitting femoral heads will lead to increased fretting and wear at the taper junction, which has been suggested as a cause for early failure of LHMOM implants (Donaldson et al. 2014, Bolland et al. 2011). It is logical to assume that when components that are made by different manufacturers—with different tolerances and designs—are used together, the fretting will be worse.We investigated the practice of “mixing and matching” of components from different manufacturers in total hip replacement in England and Wales using data from the National Joint Registry. Our hypothesis was that the mixing and matching of components from different manufacturers in primary THR would lead to higher implant revision rates.     

How Should We Grade Lumbar Disc Herniation and Nerve Root Compression? A Systematic Review

Background

MRI is the gold standard for evaluating the relationship of disc material to soft tissue and neural structures. However, terminologies used to describe lumbar disc herniation and nerve root compression have always been a source of confusion. A clear understanding of lumbar disc terminology among clinicians, radiologists, and researchers is vital for patient care and future research.

Questions/purposes

Through a systematic review of the literature, the purpose of this article is to describe lumbar disc terminology and comment on the reliability of various nomenclature systems and their application to clinical practice.

Methods

PubMed was used for our literature search using the following MeSH headings: “Magnetic Resonance Imaging and Intervertebral Disc Displacement” and “Lumbar Vertebrae” and terms “nomenclature” or “grading” or “classification”. Ten papers evaluating lumbar disc herniation/nerve root compression using different grading criteria and providing information regarding intraobserver and interobserver agreement were identified.

Results

To date, the Combined Task Force (CTF) and van Rijn classification systems are the most reliable methods for describing lumbar disc herniation and nerve root compression, respectively. van Rijn dichotomized nerve roots from “definitely no root compression, possibly no root compression, indeterminate root compression, possible root compression, and definite root compression” into no root compression (first three categories) and root compression (last two categories). The CTF classification defines lumbar discs as normal, focal protrusion, broad-based protrusion, or extrusion. The CTF classification system excludes “disc bulges,” which is a source of confusion and disagreement among many practitioners. This potentially accounts for its improved reliability compared with other proposed nomenclature systems.

Conclusions

The main issue in the management of patients with lumbar disc disease and nerve root compression is correlation of imaging findings with clinical presentation and symptomatology to guide treatment and intervention. Although it appears that the most commonly supported nomenclatures have strong interobserver reliability, the classification term “disc bulges” is a source of confusion and disagreement among many practitioners. Additional research should focus on the clinical application of the various nomenclatures.

Electronic supplementary material

The online version of this article (doi:10.1007/s11999-014-3674-y) contains supplementary material, which is available to authorized users.     

Longitudinal Alveolar Bone Loss in Postmenopausal Osteoporotic/Osteopenic Women

The purpose of this 2-year longitudinal clinical study was to investigate alveolar (oral) bone height and density changes in osteoporotic/osteopenic women compared with women with normal lumbar spine bone mineral density (BMD). Thirty-eight postmenopausal women completed this study; 21 women had normal BMD of the lumbar spine, while 17 women had osteoporosis or osteopenia of the lumbar spine at baseline. All subjects had a history of periodontitis and participated in 3- to 4-month periodontal maintenance programs. No subjects were current smokers. All patients were within 5 years of menopause at the start of the study. Four vertical bitewing radiographs of posterior sextants were taken at baseline and 2-year visits. Radiographs were examined using computer-assisted densitometric image analysis (CADIA) for changes in bone density at the crestal and subcrestal regions of interproximal bone. Changes in alveolar bone height were also measured. Radiographic data were analyzed by the t-test for two independent samples. Osteoporotic/osteopenic women exhibited a higher frequency of alveolar bone height loss (p<0.05) and crestal (p<0.025) and subcrestal (p<0.03) density loss relative to women with normal BMD. Estrogen deficiency was associated with increased frequency of alveolar bone crestal density loss in the osteoporotic/osteopenic women and in the overall study population (p<0.05). These data suggest that osteoporosis/osteopenia and estrogen deficiency are risk factors for alveolar bone density loss in postmenopausal women with a history of periodontitis. Received: 9 April 1998 / Accepted: 18 August 1998     

Site-Specific Variation in the Classification of Osteoporosis, and the Diagnostic Reclassification Using the Lowest Individual Lumbar Vertebra T-score Compared with the L1–L4 Mean, in Early Postmenopausal Women

In this study we report first the concordance and variation in diagnostic osteoporosis classification using multiple skeletal site measurements compared with the lumbar spine only; and secondly, at the lumbar spine, the variation and diagnostic osteoporosis reclassification using the lowest individual vertebra T-score compared with the L1–L4 mean T-score. One hundred and fifty early postmenopausal women were evaluated as part of the recruitment for a multicenter osteoporosis prevention study. Bone mineral density (BMD) was restricted such that no more than 10% of the subjects had a lumbar spine BMD below 0.8 g/cm². Forty-seven per cent of the subjects were classified as having low bone mass (T-score ≤−1.0) at the lumbar spine, 63% at the mid-forearm, 39% at the distal forearm and 50% at the hip (p<0.05). The greatest proportion of subjects were categorized as osteoporotic at the lumbar spine, followed by the forearm and then the hip. Correlation between sites ranged from 0.57 to 0.60 (p<0.01). Eighty-one percent of the subjects had a significant difference between their highest and lowest individual lumbar vertebra T-score (defined as a difference outside the 90% confidence interval coefficient of variation T-score value). Using the lowest individual lumbar T-score, recategorized 33% of the subjects classified as osteopenic (based on the mean L1–L4 T-score) as osteoporotic, and 23% of those classified as normal as osteopenic (p<0.05). Of all four vertebrae, L2 had the highest T-score in 37.7% of the subjects (mean −0.3) and L4 the lowest in 61% (mean −1.5) (mean difference 1.2 units, 95% CI 0.7 to 1.7). The classification of osteoporosis varies according to skeletal site, with pronounced differences in the early menopausal population. T-scores are useful for characterizing subjects with the highest risk of osteoporosis but BMD and fracture risk must be recognized in a continuum. Individual T-scores of the lumbar vertebrae show wide variation in the absence of degenerative spinal disease or vertebral collapse and the use of the lowest, significantly different, individual lumbar vertebra T-score reclassified over half of the subjects in this study. This poses a great therapeutic dilemma in clinical practice, particularly if these fractures are at higher risk of future collapse. Received: 9 November 1999 / Accepted: 27 April 2000     

Retrograde intramedullary nailing for the treatment of femoral medial condyle fracture nonunion

An unicondylar fracture of the femur is uncommon and of the medial condyle more so. Open reduction and internal fixation of these fractures is most commonly performed with screws or plate and screws. Secure bone fixation is compromised by osteoporosis in elderly patients; additional measures may be required. We report the case of an elderly osteoporotic patient with a medial condyle fracture nonunion treated successfully through retrograde intramedullary nailing. A 78-year-old osteoporotic woman suffered medial condyle fracture of the femur 9 months before visiting our hospital. She had been treated conservatively, and the fracture demonstrated a complete nonunion with gross instability. The edge fragments appeared sclerotic, and the nonunion site was accompanied by a bony defect. Although fixation by a plate and screw is the standard method for the treatment of such fracture, we judged that stability would be difficult to achieve with this method due to the accompanying bony defect and osteoporosis. Thus, we performed open reduction and fixation by retrograde intramedullary nailing with the use of “condyle screw and nut” system, followed by bone grafting. Bony union was successfully obtained. The stability and range of motion of the knee were recovered, and the patient regained the ability to walk. We suggest the unique application of retrograde intramedullary nailing with condyle screw and nut for the treatment of specific, complex cases of femoral medial condyle fracture.     

A bisphosphonate-coating improves the fixation of metal implants in human bone. A randomized trial of dental implants

Many surgical procedures use metal implants in bone. The clinical results depend on the strength of the bone holding these implants. Our objective was to show that a drug released from the implant surface can improve parameters reflecting the quality or amount of this bone. Sixteen patients received paired dental titanium implants in the maxilla, in a randomized, double-blinded fashion. One implant in each pair was coated with a thin fibrinogen layer containing 2 bisphosphonates. The other implant was untreated. Fixation was evaluated by measurement of resonance frequency (implant stability quotient; ISQ) serving as a proxy for stiffness of the implant-bone construct. Increase in ISQ at 6months of follow-up was the primary variable. None of the patients had any complications. The resonance frequency increased 6.9 ISQ units more for the coated implants (p=0.0001; Cohen's d=1.3). The average difference in increase in ISQ, and the effect size, suggested a clinically relevant improvement. X-ray showed less bone resorption at the margin of the implant both at 2months (p=0.012) and at 6months (p=0.012). In conclusion, a thin, bisphosphonate-eluting fibrinogen coating might improve the fixation of metal implants in human bone. This might lead to new possibilities for orthopedic surgery in osteoporotic bone and for dental implants.     

Osteoporosis and Related Risk Factors in Renal Transplant Recipients

Decreased bone mineral density is a common problem after kidney transplantation. Osteoporosis has a major role in morbidity in these patients. We evaluated the incidence of osteoporosis and determined risk factors in 77 patients aged 17 to 50 years who had undergone renal transplantation 6 months to 2 years previously. Bone mineral densitometry was performed using dual-energy x-ray absorptiometry. The incidence of osteoporosis was 26% (20 of 77 patients). Mean (SD) age of affected patients was 34.6 (8.7) years. The most common sites of osteoporosis were the hip (osteoporotic in 19 patients [24.7%] and osteopenic in 42 [54.5%]) and the spine (osteoporotic in 6 patients [7.8%] and osteopenic in 52 [67.5%]). There was a significant relationship between posttransplantation creatinine concentration and hip osteoporosis (P = .01). No relationship was observed between osteoporosis and age, sex, body mass index, duration of hemodialysis therapy, cumulative dosage of any drugs, or use of pulsed methylprednisolone therapy. A hip or spine z score of 1 or less had no relationship to the number of steroid pulse sessions but was significantly related to the total dosage of cyclosporine (P < .001), prednisolone (P < .001), and mycophenolate mofetil (P < .05). A hip z score of less than 1 was related to the posttransplantation period (P = .02). In conclusion, osteoporosis is a frequent complication that requires detection and treatment to reduce morbidity.     

Osteoporosis changes the amount of vertebral trabecular bone at risk of fracture but not the vertebral load distribution.

STUDY DESIGN: A finite-element study to investigate the amount of trabecular bone at risk of fracture and the distribution of load between trabecular core and cortical shell, for healthy, osteopenic, and osteoporotic vertebrae. OBJECTIVES: To determine differences between healthy, osteopenic, and osteoporotic vertebrae with regard to the risk of fracture and the load distribution. SUMMARY OF BACKGROUND DATA: The literature contains no reports on the effects of osteopenia and osteoporosis on load distribution in vertebral bodies, nor any reports on the amount of trabecular bone at risk of fracture. METHODS: Computed tomography data of vertebral bodies were used to construct patient-specific finite-element models. These models were then used in finite-element analyses to determine the physiologic stresses and strains in the vertebrae. RESULTS: For all three classes of vertebrae the contribution of the trabecular core to the total load transfer decreased from about 70% near the endplates to about 50% in the midtransverse region. The amount of trabecular bone that is at risk of fracture was about 1% for healthy vertebrae, about 3% for osteopenic vertebrae, and about 16% for osteoporotic vertebrae. CONCLUSIONS: Our finite-element models indicated that neither osteopenia nor osteoporosis had any effect on the contribution of the trabecular core to the total load placed on the vertebra. The trabecular core carried about half the load. Our finite-element models indicated that osteoporosis had a significant effect on the amount of trabecular bone at risk of fracture, which increased from about 1% in healthy vertebrae to about 16% for osteoporotic vertebrae.     

Women of Worth: the impact of a cash plus intervention to enhance attendance and reduce sexual health risks for young women in Cape Town,South Africa

IntroductionConditional cash transfers (CTs) augmented with other interventions are promising interventions for reducing HIV risk in adolescent girls and young women.MethodsA multi‐phase, quasi‐experimental study assessed the impact of a CT (ZAR300; $22) conditional on attending a skills building intervention, Women of Worth (WoW), designed to improve sexual and reproductive health (SRH) outcomes in Cape Town, South Africa from May 2017 to December 2019. The intervention entailed 12 sessions with encouragement to attend adolescent and youth‐friendly health services. Women aged 19–24 years were randomized 1:1 to receive the intervention with a CT (“cash + care” or C+C) or without a CT (“care”). The study included a pilot phase followed by a post‐modification phase with improved uptake and retention without changing programme content or CT. Self‐reported HIV prevalence and SRH/HIV vulnerability were assessed via a self‐administered questionnaire at baseline, after 11 sessions, and 6–30 months’ post‐intervention for a subset. Mixed effect logistic regression models were fitted to estimate within‐subject changes in outcomes.ResultsOf 5116 participants, 904 (452 participants per arm) were in the pilot and 4212 (2039 “care” participants and 2173 “C+C” participants) were in the post modified phase. There were 1867 (85.9%) and 135 (6,6%) participants in the “C+C” group and the “Care,” respectively, that were WoW completers (≥ 11 sessions/retention). During the pilot phase, 194 (42.9%) and 18 (4.0%) participants in “C+C” and the “care” groups were retained. Receiving a CT sustained participation nearly 60‐fold (OR 60.37; 95% CI: 17.32; 210.50, p <0.001). Three‐hundred and thirty women were followed for a median of 15.0 months [IQR: 13.3; 17.8] to assess the durability of impact. Self‐reported new employment status increased more than three‐fold (p <0.001) at WoW completion and was sustained to the longer time point. Intimate partner violence indicators were reduced immediately after WoW, but this was not durable.ConclusionsParticipants receiving CT had sustained participation in an SRH/HIV prevention skills building with improvement in employment and some SRH outcomes. Layered, “young woman centred” programmes to address HIV and SRH risk in young women may be enhanced with CT.     

Bone Mineral Density Referral for Dual-Energy X-Ray Absorptiometry Using Quantitative Ultrasound as a Prescreening Tool in Postmenopausal Women from the General Population: A Cost-Effectiveness Analysis

The aim of our study was to assess, from the perspective of the National Health Services in Spain, the cost-effectiveness of quantitative ultrasound (QUS) as a prescreen referral method for bone mineral density (BMD) assessment by dual-energy X-ray absorptiometry (DXA) in postmenopausal women of the general population. Using femoral neck DXA and heel QUS. We evaluated 267 consecutive postmenopausal women 65 years and older and attending primary care physician offices for any medical reason. Subjects were classified as osteoporotic or nonosteoporotic (normal or osteopenic) using the WHO definition for DXA. Effectiveness was assessed in terms of the sensitivity and specificity of the referral decisions based on the QUS measurement. Local costs were estimated from health services and actual resource used. Cost-effectiveness was evaluated in terms of the expected cost per true positive osteoporotic case detected. Baseline prevalence of osteoporosis evaluated by DXA was 55.8%. The sensitivity and specificity for the diagnosis of osteoporosis by QUS using the optimal cutoff thresholds for the estimated heel BMD T-score were 97% and 94%, respectively. The average cost per osteoporotic case detected based on DXA measurement alone was € 23.85. The average cost per osteoporotic case detected using QUS as a prescreen was €22.00. The incremental cost-effectiveness of DXA versus QUS was €114.00 per true positive case detected. Our results suggest that screening for osteoporosis with QUS while applying strict cufoff values in postmenopausal women of the general population is not substantially more cost-effective than DXA alone for the diagnosis of osteoporosis. However, the screening strategy with QUS may be an option in those circumstances where the diagnosis of osteoporosis is deficient because of the difficulty in accessing DXA equipment. ECOSAP DXA Substudy Group Investigators: Mercedes Abizanda and Arthur Cervera (Centro de Atención Primaria Gran Vía, Barcelona, Spain); Cristina Carbonell, Adoración Cama, and Carmen Olmos (Area Básica de Salud Vía Roma, Barcelona, Spain); Rosa M. Alcolea, Teresa Rama, and Elena Galindo (Area Básica de Salud Llefiá, Badalona, Barcelona, Spain); Angel Pérez–Romero (Department of Medical Research, Eli Lilly and Company, Madrid, Spain). This research was supported by an unrestricted grant of the Medical Research Department, Eli Lilly and Company, Spain.