Mild prevalent and incident vertebral fractures are risk factors for new fractures

Summary This prospective four-year study indicates that post-menopausal osteoporotic women with mild prevalent and incident vertebral fractures have an increased risk of incident fractures. Introduction Mild vertebral fractures are under diagnosed as there is disagreement about their clinical significance. Our aim was to assess the risk of subsequent fractures induced by both prevalent and incident mild vertebral fractures in osteoporotic post-menopausal women. Patients and methods Three thousand three hundred and fifty-eight patients, aged 74 ± 6 years, with post-menopausal osteoporosis included in the placebo groups of two clinical trials of strontium ranelate were followed for 4 years. A Cox regression model adjusted on age, body mass index and bone mineral density was used to calculate the relative risk (RR) of fracture in subjects with only mild fractures as compared to patients without fracture, and to patients with at least one grade ≥ 2 fracture. These calculations were made for prevalent and then incident fractures. Results The RR of vertebral fracture in 4 years was 1.8 (1.3–2.4) p < 0.001, and 2.7 (2.3–3.3) p < 0.001 for patients having only mild vertebral fractures and at least one grade ≥ 2 fracture at baseline respectively. The RR of vertebral fracture in the 3rd and 4th years of follow-up was 1.7 (1.1–2.6) p = 0.01, and 1.9 (1.3–2.6) p < 0.001 for patients having during the first 2 years incident mild fractures only, and for patients having at least one grade ≥ 2 incident fracture respectively. The RR of non-vertebral fracture in 4 years was 1.3 (0.9–1.9) p = 0.15 and 1.7 (1.4–2.1) p < 0.001 for patients having only mild or at least one grade ≥ 2 vertebral fracture at baseline respectively. For patients aged more than 70 years, these RR were 1.45 (0.99–2.11) (p = 0.06), and 1.72 (1.36–2.18) p < 0.001 respectively. The RR of non-vertebral fracture in the 3rd and 4th years was 1.68 (1.36–2.09) p < 0.001 for patients having at least one grade ≥ 2 incident fracture during the 2 first years of follow-up. Conclusion Mild vertebral fractures are a risk factor for subsequent vertebral and non-vertebral fracture in postmenopausal women with osteoporosis; 1 out of 4 patients with an incident mild vertebral fracture in 2 years will fracture again within the 2 next years.     

Baseline BMD and Bone Loss at Distal Radius Measured by Peripheral Quantitative Computed Tomography in Peri- and Postmenopausal Hong Kong Chinese Women

The current study was designed to investigate the rate of bone loss in distal radius and its association with baseline volumetric bone mineral density (BMD) and years since menopause (YSM) in peri- and postmenopausal women using precise and multislice peripheral quantitative computed tomography (pQCT; Densiscan 2000). Two hundred and five healthy Hong Kong Chinese perimenopausal (n = 26) and postmenopausal (n = 179) women within 10 years of the onset of menopause were recruited. Anthropometric parameters and menstrual status were also measured. The linear regression model derived from the baseline volumetric BMD revealed a significant and slightly better correlation with YSM than age, with a YSM-related annual decline of 2.56%, 1.82% and 0.65% in trabecular BMD (tBMD), integral BMD (iBMD) and cortical BMD (cBMD), respectively. Follow-up measurements after a time interval of 12 months showed that the rate of bone loss was higher than the annual decline in BMD calculated from the baseline BMD, with decreases of 2.89%, 2.16% 0.91% in tBMD, iBMD and cBMD, respectively. Baseline BMD was associated with age or YSM (r ranges from −0.283 to −0.502; p<0.001 in all cases), but no relationship was found between annual rate of bone loss and age or YSM. The rate of bone loss did not correlate with baseline volumetric BMD values or YSM after dividing the subjects into fast bone losers (with annual tBMD loss ≥3%), normal bone losers (with annual tBMD loss ≥ 1% but <3%) or slow bone losers (with annual tBMD loss <1%). The rate of bone loss was greater in both trabecular and cortical bone of postmenopausal women within the first 3 menopausal years but was only significant in the iBMD as compared with perimenopausal and postmenopausal women over 7 years after onset of menopause. The percentage distribution of slow and fast bone losers was not found to be associated with YSM. As a total of only 4 fracture cases were documented, the study could not provide conclusive information on whether perimenopausal and early postmenopausal baseline volumetric BMD or rate of bone loss determines the development of osteoporosis or fracture occurrence. Received: 12 November 2001 / Accepted: 18 July 2002     

Metacarpal Radiogrammetry by Computed Radiography in Postmenopausal Women with Colles' Fracture and Vertebral Crush Fracture Syndrome

Based on the hypothesis that the underlying osteoporotic mechanism of Colles' fracture in postmenopausal women is similar to that of other osteoporotic fractures, that is, cortical bone resorption as opposed to cancellous bone resorption, the rate of corticoendosteal bone loss was compared in 40 normal postmenopausal women [average age 68.4 ± 7.1 years; 20 ± 4 years since menopause (YSM)], in 35 postmenopausal women with Colles' fracture (age 69.4 ± 7.5 years, 22 ± 8 YSM), in 35 normal postmenopausal women with vertebral crush fracture (age 69.4 ± 7.5 years, 22 ± 8 YSM, and in 35 normal premenopausal women (age 36.1 ± 7.9 years). Radiogrammetry by digital radiography of the second metacarpal was used to measure external (ED) and internal (ID) diameter, cortical thickness (CCT), cortical area (CA), and the ratio of cortical area to total area (CA/TA). The ID values of the groups of postmenopausal women were subtracted from the ID value of the premenopausal women and the result was divided by YSM to obtain the rate of corticoendosteal resorption/year (ΔC), CA resorption year (ΔCA) and CA/TA resorption/year (ΔCA/TA). ID, ΔC, ΔCA, and ΔCA/TA all were larger in the postmenopausal women with Colles' and vertebral crush fractures than in the normal postmenopausal women (ANOVA: all P < 0.0001). ID, CCT, ΔC, CA, ΔCA, and ΔCA/TA did not differ between the two groups of postmenopausal women with fractures. ΔC was 87% greater in postmenopausal women with vertebral crush fracture and 116% greater in women with Colles' fracture than in normal postmenopausal women. These results indicate that the loss of cortical bone is an important factor in Colles' fracture in postmenopausal women. Received: 10 October 1996 / Accepted: 15 October 1997     

Echogenic Carotid Artery Plaques are Associated with Vertebral Fractures in Postmenopausal Women with Low Bone Mass

Although low bone mass has been associated with atherosclerosis even after adjustment for age, little is known about the association between vertebral fractures and calcified atherosclerotic plaques. Our objective was to investigate whether osteoporotic vertebral fractures are independently related to the prevalence of atherosclerotic carotid plaques in postmenopausal women with low bone mass. We enrolled 195 postmenopausal women with osteopenia or osteoporosis. Bone mineral density and the presence of vertebral fractures were assessed. Intima media thickness and atherosclerotic plaques of the carotid artery were assessed using ultrasonography. Of the 195 subjects in the study, 84 had no plaques and 111 had at least one. The percentage of women with vertebral fractures was significantly higher in subjects with echogenic carotid plaques than in those without (27% vs. 11%, respectively; P < 0.05). However, there was no difference in the prevalence of vertebral fractures between women with echolucent plaques and those without (10.9% vs. 10.7%, respectively; P = nonsignificant). By logistic regression analysis with multivariate adjustment, age (P < 0.01), dyslipidemia (P < 0.05), and the presence of vertebral fracture (P < 0.05) were independent risk factors for echogenic carotid plaques. Osteoporotic vertebral fractures are associated with an increased risk of echogenic atherosclerotic plaques in postmenopausal women with low bone mass. It appears that the high association of echogenic atherosclerotic plaques and vertebral fractures could partially explain why osteoporotic vertebral fractures are linked to increased mortality.     

High weight or body mass index increase the risk of vertebral fractures in postmenopausal osteoporotic women

In the general population, low body weight and body mass index (BMI) are significant risk factors for any fracture, but the specific association between body weight, BMI, and prevalence of vertebral fractures in osteoporotic women is not fully recognized. Hence, the association between body weight, BMI, and prevalent vertebral fractures was investigated in 362 women with never-treated postmenopausal osteoporosis. All participants underwent measurement of BMI, bone mineral density (BMD), and semiquantitative assessment of vertebral fractures. Thirty percent of participants had ≥1 vertebral fracture. Body weight and BMI were associated with L1–L4 BMD (R = 0.29, P < 0.001 and R = 0.17, P = 0.009, respectively). In logistic regression analysis, BMI was positively associated with the presence of vertebral fractures independent of age and other traditional risk factors for fractures. Including weight and height instead of BMI in the multivariate model, showed weight as a positive and significant covariate of the presence of vertebral fractures (OR = 1.045; P = 0.016; 95% CI 1.008–1.084). BMI was associated with the number of vertebral fractures (rho = 0.18; P = 0.001), this association being confirmed also in the multivariate analysis (β =  0.14; P = 0.03) after correction for smoking, early menopause, family history of fragility fractures and BMD. In conclusion, among postmenopausal women with osteoporosis, body weight and BMI are associated with a higher likelihood of having a vertebral fracture, irrespective of the positive association between weight and BMD.     

Increase in Vertebral Fracture Risk in Postmenopausal Women Using Omeprazole

Proton pump inhibitors are taken by millions of patients for prevention and treatment of gastroesophageal diseases. Case-control studies have suggested that use of omeprazole is associated with an increased risk of hip fractures. The aim of this prospective study was to assess the risk of vertebral fractures in postmenopausal women using omeprazole. We studied 1,211 postmenopausal women enrolled in the Osteoporosis and Ultrasound Study from the general population. Information on omeprazole and other risk factors for fractures including prevalent fractures and bone mineral density was obtained at baseline. Vertebral fractures were assessed on X-rays obtained at baseline and at the end of the 6-year follow-up and analyzed centrally. At baseline, 5% of this population was using omeprazole. Age-adjusted rates for vertebral fractures were 1.89 and 0.60 for 100 person-years for omeprazole users and nonusers, respectively (P = 0.009). In the multivariate analysis, omeprazole use was a significant and independent predictor of vertebral fractures (RR = 3.50, 95% CI 1.14–8.44). The other predictors were age higher than 65 years (RR = 2.34, 95% CI 1.02–5.34), prevalent vertebral fractures (RR = 3.62, 95% CI 1.63–8.08), and lumbar spine T score ≤ −2.5 (RR = 2.38, 95% CI 1.03–5.49). Omeprazole use is associated with an increased risk of vertebral fractures in postmenopausal women. Further studies are required to determine the mechanism of the association between the underlying gastric disease, omeprazole use, and risk of osteoporotic fractures.     

Cortical Bone Resorption in Osteoporosis

A study was made of 110 women: 35 healthy premenopausal, 40 healthy postmenopausal, and 35 women diagnosed as having postmenopausal osteoporosis. The postmenopausal women had similar ages and years since menopause (YSM). In all of the women, total bone mass was evaluated by dual-energy X-ray absorptiometry and metacarpal morphometry was evaluated by radiogrammetry on the second metacarpal of the nondominant hand, performed by computed radiography. An external metacarpal diameter of ≥7.4 mm was required as proof of having developed an adequate peak bone mass. The endosteal diameter, which is indicative of bone resorption in both groups of postmenopausal women, obtained in the postmenopausal groups was subtracted from the endosteal diameter obtained in the premenopausal group and the resulting figure was divided by the years since menopause to calculate the rate of cortical bone resorption/year for each group. The endosteal diameters values differed in the three groups studied (P < 0.0001): 3.2 ± 0.7 mm in the healthy premenopausal women; 3.9 ± 0.6 mm in the healthy postmenopausal women; and 4.7 ± 0.5 mm in the osteoporotic postmenopausal women. The rate of cortical bone resorption was 0.068 ± 0.002 mm/YSM (years since menopause) in the osteoporotic postmenopausal women and 0.033 ± 0.003 mm/YSM in the healthy postmenopausal women (P < 0.0001). These figures reflect the importance of bone resorption, as opposed to deficient bone formation, as a cause of osteoporosis. Received: 27 January 1995 / Accepted: 21 August 1996     

Factors predicting osteoporosis treatment initiation in a regionally based cohort

Summary  Osteoporosis treatment initiation was assessed during the year after baseline BMD testing in 8,689 previously untreated women. Treatment initiation increased progressively as BMD T-scores decreased, but there was a gradient response rather than step increases at conventional T-score intervention thresholds. Introduction  Bone mineral density (BMD) testing is used to identify those at high fracture risk and guide osteoporosis treatment (OTx) initiation. Clinical guidelines have used the World Health Organization T-score diagnostic cutoffs as thresholds for treatment intervention. Our objective was to assess whether OTx initiation tracks these T-score cutoffs. Methods  Eight thousand six hundred and eighty-nine women age ≥50 years who had not been dispensed any OTx medication in the year prior to baseline BMD were identified from a regionally based database in the Province of Manitoba, Canada, and OTx initiation rates were analyzed. Results  Forty-four percent of women were dispensed OTx in the year after BMD. OTx initiation increased progressively as BMD T-scores decreased (8.2% normal, 41.0% osteopenic, 78.5% osteoporotic, p-for-trend < 0.0001). There was a gradient response to OTx initiation, rather than step increases at conventional T-score intervention thresholds. BMD was strongly associated with OTx (p < 0.0001) while age, weight, and fracture in the last year were not. Conclusions  Physicians rely heavily on BMD T-score to decide on OTx initiation. Although guidelines suggest using clinical risk factors to guide decision making, we did not see evidence of this. More explicit methods of reporting fracture risk may help physicians select patients who are likely to derive the largest benefit from OTx.     

Increases in Hip and Spine Bone Mineral Density are Predictive for Vertebral Antifracture Efficacy with Ibandronate

The relationship between bisphosphonate-induced bone mineral density (BMD) gains and antifracture efficacy remains to be fully elucidated. Data from two antifracture studies were analyzed. Postmenopausal osteoporotic women received oral (2.5 mg daily, 20 mg intermittent) or intravenous (0.5 mg, 1 mg quarterly) ibandronate. Outcome measures included moving averages plots and logistic regression analyses of the relationship between BMD change and vertebral fracture rate. In moving averages plots, ibandronate-induced BMD gains were consistently associated with decreased fracture rates. In the oral study, total-hip BMD increases at years 2 and 3 and lumbar spine BMD increases at year 3 were associated with 3-year vertebral fracture rate (relative risk reduction [RRR] at year 3 for 1% change from baseline: hip, 7.9% [95% CI 2.1–13.5%, P = 0.0084]; lumbar spine, 4.7% [−0.1% to 9.3%, P = 0.0565]). In the intravenous study, total-hip BMD increases at years 1, 2, and 3 and lumbar spine BMD increases at years 2 and 3 were significantly associated with vertebral fracture rate (RRR at year 3 for 1% change from baseline: hip, 11.6% [7.0–16.0%, P < 0.0001]; lumbar spine, 6.9% [2.9–10.6%, P = 0.0008]). In a pooled analysis, changes in total-hip and lumbar spine BMD were associated with 3-year vertebral fracture risk reduction and explained a substantial proportion of the antifracture effect (23–37% at 2 and 3 years). This analysis suggests that ibandronate-induced BMD gain in postmenopausal osteoporotic women is associated with vertebral fracture risk reduction.     

A simple method for determining the probability a new vertebral fracture is present in postmenopausal women with osteoporosis

The vertebral fracture status of women with osteoporosis has strong prognostic implications that may influence clinical decisions. We developed a simple method for estimating the probability that a new vertebral fracture has occurred in postmenopausal women with osteoporosis. Data was from the placebo groups of the Fracture Prevention Trial (median observation =21 months) and the MORE Trial at 2 years. A logistic regression analysis identified prior vertebral fracture (yes/no), new or worsening back pain (yes/no), and height loss (≥2 cm, yes/no) as significant predictors for the presence of a new vertebral fracture. The actual probability of a new vertebral fracture in patients without these predictors, over the median observation period of 23 months, was 2.1%. Presence of back pain increased this probability fourfold; prior vertebral fracture increased this probability threefold, and height loss ≥2 cm increased this probability threefold. The predicted probabilities of a new vertebral fracture being present for each subgroup representing each of the eight possible combinations of back pain, prior vertebral fracture, and height loss were highly correlated with both the multivariate logistic regression-derived probabilities (r=0.98, p <0.001) and with the actual probabilities (r=0.99, p <0.001). The validity of this simple method was confirmed in patients from the MORE trial at both 2 years and 3 years, and in the Fracture Prevention Trial alone. This simple method provides clinicians with an estimate of the probability that a new vertebral fracture has occurred in postmenopausal women with osteoporosis.     

Reference values for vertebral shape in young Chinese women: implication for assessment of vertebral deformity

The race- and sex-specific reference values for vertebral shape are important to determine the prevalence of osteoporotic vertebral fracture. However, these reference values are absent in Chinese women. In the present study, the anterior, middle and posterior heights and the ratios of these heights were measured from 14 vertebral bodies (T4–L5) in 60 premenopausal Chinese women (aged 19–25 years). Cutoff values were set as standard deviations (3 and 3.5 SD) and percentages (15 and 20%) below the means of vertebral height (VH) ratios to define vertebral deformities. The number of subjects with a VH ratio lower than −15% cutoff were significantly more than those with a VH ratio lower than −3 SD cutoff (p < 0.05), but this difference did not occur when a −20% cutoff was selected. A few VH ratios were distributed below −20% and −3 SD cutoffs, and none was below −3.5 SD. The vertebral shape defined by VH ratios was different between Chinese and European women. We conclude that 3.5 SD below the reference mean is an ideal cutoff value for the definition of prevalent vertebral fractures in Chinese women, and reference data should be obtained from young premenopausal women.     

Biochemical markers for bone turnover predict risk of vertebral fractures in postmenopausal women over 10 years: the Japanese Population-based Osteoporosis (JPOS) Cohort Study

Summary

We evaluated how bone turnover might predict vertebral fracture risk in postmenopausal women over 10 years. After adjusting for age and femoral neck bone mineral density, high bone-specific alkaline phosphatase and total and free deoxypyridinoline at baseline predicted increased vertebral fracture risk in women with ≥ 5 years since menopause.

Introduction

The aim was to evaluate the ability of bone turnover markers (BTMs) in predicting vertebral fractures.

Methods

Participants in the 1996 baseline survey of the JPOS Cohort Study included 522 postmenopausal women, with no diseases or medications affecting bone metabolism. Vertebral fractures were ascertained in three follow-up surveys (1999, 2002, and 2006). Initial fracture events were diagnosed morphometrically. The Poisson regression model was applied to estimate the rate ratio (RR) of the following log-transformed BTM values at baseline: osteocalcin and bone-specific alkaline phosphatase (BAP) in serum and C-terminal cross-linked telopeptide of type I collagen, total deoxypyridinoline (tDPD), and free deoxypyridinoline (fDPD) in urine.

Results

Eighty-three fracture events were diagnosed over a median follow-up period of 10.0 years. RR per standard deviation (SD) (95 % confidence interval) for BAP was 4.38 (1.45, 13.21) among 65 subjects with years since menopause (YSM) < 5 years. RRs per SD (95 % confidence interval) for BAP, tDPD, and fDPD were 1.39 (1.12, 1.74), 1.32 (1.05, 1.67), and 1.40 (1.12, 1.76), respectively, after adjusting for age and femoral neck bone mineral density (FN BMD) among 457 subjects with YSM ≥ 5 years. Of the 451 women followed at least once until 2002, RRs per SD for BAP, tDPD, and fDPD adjusted for age and FN BMD over 6 years were not significantly different from those over 10 years.

Conclusion

BAP was associated with vertebral fracture risk among early postmenopausal women. BTMs can predict vertebral fractures independently of BMD among late postmenopausal women over a 10-year follow-up period.     

Increased Fracture Risk in Normocalcemic Postmenopausal Women with High Parathyroid Hormone Levels: A 16-Year Follow-Up Study

High PTH levels increase bone turnover and decrease bone mineral density (BMD). Low plasma 25-hydroxyvitamin D (25OHD) levels cause secondary hyperparathyroidism, but the relative contribution of low 25OHD and high PTH levels on risk of fracture is largely unknown. Within the cohort of women (n = 2,016) included in the Danish Osteoporosis Prevention Study (DOPS), we studied risk of fracture according to parathyroid status. Analyses were performed on effects of high PTH levels (i.e., in the upper tertile, ≥4.5 pmol/L) on risk of incident fractures at different 25OHD levels during 16 years of follow-up. Incident fractures were assessed using a nationwide hospital discharge register. In addition, effects of high PTH levels on BMD and vertebral fractures were assessed by DXA scans and spinal X-ray examination after 10 years of follow-up. High PTH levels were associated with a decreased body mass index, adjusted BMD, and an increased risk of any fracture (HR = 1.41, 95% CI 1.11–1.79) as well as an increased risk of osteoporotic fractures (HR = 1.59, 95% CI 1.20–2.10). Plasma 25OHD levels per se did not affect fracture risk, but high PTH levels were associated with an increased fracture risk only at 25OHD levels <50 nmol/L and 50–80 nmol/L. High PTH levels did not increase risk of fracture at 25OHD levels >80 nmol/L. In conclusion, PTH levels in the upper part or above the upper level of the reference interval increase risk of fracture in the presence of low vitamin D levels.     

Women with Cardiovascular Disease Have Increased Risk of Osteoporotic Fracture

This study investigated whether women with cardiovascular disease (CVD) would have an increased risk of fractures as osteoporosis and CVD share many common risk factors. From February 2006 to January 2007, 17,033 women aged ≥50 years (mean 71.8, range 50–106) were recruited by 1,248 primary care practitioners and interviewed by trained nurses. For each woman, 10-year probability of a future major osteoporotic fracture was estimated using the World Health Organization Fracture Risk Assessment Tool (FRAX). The study showed that the 10-year probability of a major osteoporotic fracture was higher for 6,219 CVD women compared to 10,814 non-CVD women after adjustment for age, BMI, current smoking, and alcohol use (adjusted geometric means 14.3 and 13.8%, respectively; P < 0.001). With regard to high risk of fracture (i.e., 10-year probability ≥ 20%), the adjusted odds ratio for CVD was 1.23 (95% CI 1.13–1.35, P < 0.001). However, compared to non-CVD women, CVD women were more likely to report a previous fracture, to have a secondary osteoporosis, and to use glucocorticoids. Among the 4,678 women who were classified as having a high fracture risk, current use rate of bone-related medications (i.e., any one of bisphosphonates, raloxifene, PTH, vitamin D, calcium, or hormone therapy) was 50.2% in the CVD group and 56.9% in the non-CVD group. Women with CVD were at increased risk of fracture partly due to bone-specific risk factors such as history of previous fracture, use of glucocorticoids, and secondary osteoporosis. This risk is not being treated appropriately by primary health physicians.     

Sister’s fracture history may be associated with perimenopausal bone fragility and modifies the predictability of fracture risk

Summary  The present study investigated the effects of first degree relatives’ fractures on fracture incidence after the menopause. Sister’s, but not other relatives’, wrist or hip fracture history was associated with increased risk of fragility fractures after the menopause. This suggests genetic predisposition to bone fragility among postmenopausal women. Objective  The aim of the present study was to investigate the association between first degree relatives’ fractures and perimenopausal bone fragility. Materials and methods  The study sample of 971 perimenopausal women was extracted from randomly selected Kuopio Osteoporosis Risk Factor and Prevention cohort and measured with dual X-ray absorptiometry in femoral neck (FN) in baseline (1989–1991), in 5 years (1994–97), and in 10 years (1999–2001). All low-trauma energy fractures during the 10-year follow-up were recorded based on self-reports and validated from medical records. First degree relatives’ history of life-time hip and wrist fractures (exact classification or trauma energy not specified) was questioned by postal inquiries. Results  There was a significant correlation between fathers’ vs. brothers’ and mothers’ vs. sisters’ fractures (p < 0.01 in Pearson bivariate correlations). Sister’s, but not mother’s, father’s, or brother’s wrist and hip fractures were associated with significantly lowered 10-year fragility fracture-free survival rate (HR = 0.56, p = 0.006). Sisters’ or other relatives’ fractures were not associated with FN bone loss rate or bone mineral density (BMD) in the follow-up measurements (p = NS in ANCOVA). The predictive power of BMD for fragility fractures differed according to sisters’ fracture history: Baseline FN T score predicted fracture-free survival only among women without sisters’ fracture history (HR 0.62, p < 0.001 vs. women with sisters’ fracture in Cox regression). Conclusions  In conclusion, sisters’ fracture history is associated with 10-year fracture-free survival in perimenopausal women but not with BMD or its changes. Predictability of fragility fracture risk with BMD may depend on sister’s fracture history. This may indirectly suggest genetic predisposition to bone fragility independently of BMD.     

Spinal deformity index (SDI) is a good predictor of incident vertebral fractures

Summary  The spinal deformity index is a convenient tool to quantify the number and the severity of prevalent vertebral fractures. It is a predictor of the risk of sustaining incident vertebral fracture. This quantification must be taken into account to improve management of patients. Introduction  Prevalent fractures are strong risk factors for subsequent fractures. Methods  The study subjects were women from the placebo groups of two studies of strontium ranelate in postmenopausal osteoporosis (N = 723 and 637 patients, respectively). Three lateral radiographs of the spine were obtained at baseline and annually over 3 years, according to standardized procedures. The semiquantitative visual assessment of each vertebra from T4 to L4 was performed by the same reader throughout the study. A spinal deformity index (SDI) was calculated by summing for each patient the grade of each vertebra from T4 to L4. Results  There was a linear relationship between baseline SDI and the 3-year incidence of vertebral fracture (adjusted R ² = 0.76). The 3-year incidence of vertebral fractures was different among the tertiles of baseline SDI: 17.3 ± 3.6%, 25.4 ± 2.6%, and 47.6 ± 3.1% from the lowest to the highest, respectively. There was no relationship between SDI and non-vertebral fractures incidence. Conclusion  SDI is a good predictor of incident vertebral fractures. Patients with highest SDI should receive highest priority to treatment.     

Six and Twelve Month Changes in Bone Turnover are Related to Reduction in Vertebral Fracture Risk During 3 Years of Raloxifene Treatment in Postmenopausal Osteoporosis

We studied the relationship between change in bone turnover and vertebral fracture risk during raloxifene therapy using 3-year data from the MORE trial, where 2622 of the 7705 randomized women had measurement of bone markers at baseline and after 6 and 12 months participation. Change in bone turnover was significantely related to future risk of vertebral fracture, also after adjusting for baseline vertebral fracture status and BMD. Thus, for a decrease of 9.3 mg/l in serum osteocalcin after 1 year’s raloxifene therapy, the odds ratio (OR) for a new vertebral fracture during 3 years was 0.69 (0.54–0.88), p= 0.003. Similarly, for a decrease of 5.91 mg/l in serum bone alkaline phosphatase, OR was 0.75 (0.62–0.92), p= 0.005. The change in BMD over 12 and 24 months was not related to fracture risk in any of the analyses. The strongest predictor for vertebral fracture was prevalent vertebral fracture – even during therapy. The predictive value of baseline BMD was in the same order of magnitude as bone turnover change during raloxifene treatment. In conclusion, the change in bone turnover is related to fracture risk during raloxifene therapy. In contrast the change in BMD is not related to fracture risk. The strongest predictor for vertebral fracture is prevalent vertebral fracture. Received: 2 January 2001 / Accepted: 30 May 2001     

High prevalence of fractures in Brazilian patients with inflammatory bowel disease: lack of association with bone mass density and quantitative ultrasound measurements

Summary To investigate the impact of inflammatory bowel disease (IBD) on bone status, a cross-sectional study was conducted including 102 Brazilian patients with ulcerative colitis or Crohn’s disease. Our results demonstrated the higher prevalence of low bone mass and fragility fractures in Brazilian patients compared with other populations with IBD. Introduction The prevalence of low bone mass and fractures in Brazilian patients with Crohn’s disease (CD) and ulcerative colitis (UC) was investigated. Methods Patients with CD or UC answered a questionnaire detailing clinical risk factors for fracture. Bone mineral density (BMD) and quantitative ultrasound (QUS) measurements were performed in all patients. Spine X-ray was performed to determine the prevalence of vertebral fractures. Non-vertebral fracture data were obtained from medical history. Results A total of 61 women and 41 men (mean age 41.2 years) were included. Fractures were observed in 40.8% and 33.3% of the UC and CD patients respectively. 31.9% and 7.2% of the patients had vertebral and non-vertebral fractures respectively. Weight and body mass index were higher in patients with fracture than in those without (p < 0.01), while other clinical variables did not differ significantly between groups. Densitometric osteoporosis was detected in 14.7% of the population. Osteoporosis was more prevalent among men than women (p = 0.014). CD patients had significantly lower BMD values than UC patients. BMD and QUS values were not associated with fractures. Conclusion We observed a high prevalence of vertebral fractures (37.1%) in a young Brazilian IBD population. BMD and QUS were not associated with fracture in these patients.     

Association of Carotid Intima-media Thickness and Cardiovascular Risk Factors in Women Pre- and Post-bariatric Surgery

Background  Obesity is associated with cardiovascular risk factors (CVRFs), such as hypertension, hypertriglyceridemia, and low levels of high-density cholesterol (HDL-C). In obese patients with a body mass index (BMI) of ≥40 kg/m² or 35–40 kg/m² associated with CVRFs, weight loss may be achieved more effectively by bariatric surgery on reducing several CVRFs. Carotid intima-media thickness (C-IMT) is an indicator of early atherosclerosis, and may be correlated with CVRFs. Our objective was to correlate C-IMT with CVRFs before (baseline data) and after surgery, and to observe whether weight loss is followed by a regression of C-IMT. Methods  Eighteen women who had undergone bariatric surgery participated in this study. Assessments were carried out on the baseline date, and 3, 6, and 12 months after surgery. Some of the CVRFs analyzed were: total cholesterol (TC) levels, HDL-C, triglycerides to HDL-C ratio (TG/HDL-C) and fasting plasma glucose. C-IMT was measured by B-mode ultrasound. Results  A positive correlation was found between C-IMT and age and triglyceride level (p = 0.002 and p = 0.02, respectively). Six months after surgery, we found a significant reduction in C-IMT (p < 0.05), which was significantly correlated with TG level and systolic pressure (p < 0.05). Conclusion  The weight loss achieved with bariatric surgery resulted in regression of C-IMT. This regression could be observed 6 months following surgery, with an additional benefit at 12 months. Also, this finding was correlated with a reduction in triglyceride levels and systolic blood pressure.     

Effects of alfacalcidol alone or in combination with elcatonin on incidence of osteoporotic vertebral fractures in postmenopausal women with spondylosis

Osteoporosis and spondylosis often occur simultaneously. However, there are no previous reports about the effects of osteoporosis medication on incidence of vertebral fractures in people with spondylosis. In this study, we conducted a retrospective investigation of the effects of alfacalcidol alone or in combination with elcatonin on incidence of osteoporotic vertebral fractures in women with spondylosis. The present subjects were 101 postmenopausal women with osteoporosis aged >60 years, divided into three groups: D group (n = 45), treated for >5 years with alfacalcidol; D+ECT group (n = 26), treated for >5 years with alfacalcidol plus elcatonin; control group (n = 30), who received no medications for >5 years. Over the 5-year treatment period, bone mineral density (BMD) of the lumbar spine and proximal femur did not significantly change in the D and D+ECT groups, but they significantly decreased in the control group (P < 0.05). The number of incident vertebral fractures per patient was significantly higher in the control group (2.9) than in the D group (1.2) and D+ECT group (1.5) (P < 0.01). There was no significant difference in BMD or incident vertebral fractures between the D and D+ECT groups. In all three groups, the number of incident vertebral fractures positively correlated with the number of prevalent vertebral fractures (0.303 ≤ r ≤ 0.434), and negatively correlated with baseline BMD (−0.703 ≤ r ≤ −0.326) and the osteophyte score representing the degree of spondylosis (−0.769 ≤ r ≤ −0.365). Further multiple regression analysis revealed that the medication (D or D+ECT, P < 0.001) and the osteophyte score (P < 0.001) were the most significant contributors for the number of incident vertebral fractures. In conclusion, elcatonin had no additive effects on BMD or prevention of vertebral fractures in postmenopausal women receiving alfacalcidol. Presence of spondylosis (indicated by a high osteophyte score) appears to have an effect on prevention of vertebral fractures.