Recommendations for bone mineral density reporting in Canada: a shift to absolute fracture risk assessment.

In June 2005, new Canadian recommendations for bone mineral density (BMD) reporting in postmenopausal women and older men were published by Osteoporosis Canada (formerly the Osteoporosis Society of Canada) and the Canadian Association of Radiologists. The recommendations were developed by a multidisciplinary working group that included the Canadian Panel of the International Society for Clinical Densitometry and were reviewed and endorsed by multiple stakeholders. Previous Canadian osteoporosis guidelines advised intervention based on an individual's World Health Organization category (normal, osteopenia, or osteoporosis) as a marker of relative fracture risk. In the new approach, an individual's 10-yr absolute fracture risk, rather than BMD alone, is used for fracture risk categorization. Absolute fracture risk is determined using not only BMD results, but also age, sex, fragility fracture history, and glucocorticoid use. A procedure is presented for estimating absolute 10-yr fracture risk in untreated individuals, leading to assigning an individual to 1 of 3 absolute fracture risk categories: low risk (<10% 10-yr fracture risk), moderate risk (10-20%), and high risk (>20%). We propose that an individual's absolute fracture risk category should be the basis for deciding on treatment and frequency of BMD monitoring.     

Recognizing and reporting vertebral fractures: reducing the risk of future osteoporotic fractures.

OBJECTIVE: Given the increasing evidence that vertebral fractures are underdiagnosed and not acted on, Osteoporosis Canada and the Canadian Association of Radiologists initiated a project to develop and publish a set of recommendations to promote and facilitate the diagnosis and reporting of vertebral fractures. OPTIONS: The identification of spinal fractures is not uniform. More than 65% of vertebral fractures cause no symptoms. It is also apparent that vertebral fractures are inadequately recognized when the opportunity for diagnosis arises fortuitously. It is to patients' benefit that radiologists report vertebral fractures evident on a chest or other radiograph, no matter how incidental to the immediate clinical indication for the examination. OUTCOMES: The present recommendations can help to close the gap in care in recognizing and treating vertebral fractures, to prevent future fractures and thus reduce the burden of osteoporosis-related morbidity and mortality, as well as fracture-related costs to the health care system. EVIDENCE: Several studies indicate that a gap exists in regard to the diagnosis of vertebral fractures and the clinical response following such diagnosis. All recommendations presented here are based on consensus. VALUES: These recommendations were developed by a multidisciplinary working group under the auspices of the Scientific Advisory Council of Osteoporosis Canada and the Canadian Association of Radiologists. BENEFITS, HARM, AND COSTS: Prevalent vertebral fractures have important clinical implications in terms of future fracture risk. Recognizing and reporting fractures incidental to radiologic examinations done for other reasons has the potential to reduce health care costs by initiating further steps in osteoporosis diagnosis and appropriate therapy. RECOMMENDATIONS: Physicians should be aware of the importance of vertebral fracture diagnosis in assessing future osteoporotic fracture risk. Vertebral fractures incidental to radiologic examinations done for other reasons should be identified and reported. Vertebral fractures should be assessed from lateral spinal or chest radiographs according to the semiquantitative method of Genant and colleagues. Grade II and Grade III fractures as classified by this method should be given the greatest emphasis. Semiquantitative fracture recognition should include the recognition of changes such as loss of vertebral end-plate parallelism, cortical interruptions, and quantitative changes in the anterior, midbody, and posterior heights of vertebral bodies. When spine radiographs are performed to assess the presence of vertebral fractures, anteroposterior examinations may assist in the initial evaluation. The standard follow-up need only consist of single lateral views of the thoracic and lumbar spine that include T4 to L4 vertebrae. The radiographic technique described in this paper, or a technique of comparable efficacy, should be used. Dual X-ray absorptiometry examinations that include lateral spinal morphological assessments (vertebral fracture assessment) may contribute to fracture recognition. Educational material about the clinical importance of vertebral fracture recognition as a potential indicator of future osteoporotic fracture risk with its associated morbidity and mortality should be directed to all physicians. VALIDATION: Recommendations were based on consensus opinion.     

Glycemic responses to foods: possible differences between insulin-dependent and noninsulin-dependent diabetics

The effect on the blood glucose response of varying the amount (25 or 50 g) and type (bread or beans) of carbohydrate (CH2O) in test meals and of adding fat and protein was examined in a group of insulin dependent and noninsulin dependent diabetic volunteers. With noninsulin-dependent diabetics, the blood glucose area after a half bread portion was 48% that of the full bread meal (p less than 0.001). White pea beans (50 g CH2O) gave a blood glucose response of 41 +/- 5% (p less than 0.001) that of bread (50 g CH2O). A combined meal of bread (25 g CH2O) and beans (25 g CH2O) gave a blood glucose response of 60 +/- 8% of the full bread meal (p less than 0.005) and similar to that expected. Addition to bread of butter and skim milk cheese either singly or in combination had little effect on the glycemic response although a reduced rise was seen after addition of fat and protein as peanut butter. Insulin-dependent diabetics tended to respond similarly to noninsulin-dependent diabetics but their greater variability indicates that other factors in addition to the nature of the food may also be major determinants of their glycemic responses to foods.     

Interpretation of antibodies reacting solely with human retroviral core proteins in western equatorial Africa

Out of 4176 sera from asymptomatic adults originating from Chad, equatorial Guinea and Gabon tested for HIV-1 antibodies, 146 (3.5%) were positive by an enzyme immunoassay (EIA). By Western blot (WB), 20 (0.5%) were positive, i.e. with antibodies to the core and the envelope proteins, 96 (2.3%) were indeterminate, i.e. with antibodies to the viral core proteins only and 30 (0.7%) were negative. On testing for HIV-2 by WB, two of the 96 indeterminate sera had antibodies to the HIV-2 envelope glycoproteins. Two complementary tests were used: a radioimmunoprecipitation assay (RIPA) and a HIV EIA recombinant assay (ENVACOR) to check 53 of these indeterminate sera. Forty-one were positive for the p25 protein in RIPA, of which 34 were negative in ENVACOR; six were positive for core proteins only and one was positive for envelope and core proteins using this assay. Twelve of the 53 indeterminate sera were negative in RIPA, of which 11 were negative and one positive for core proteins in ENVACOR. Thus, 42 of these sera remained indeterminate even after the two additional tests which did not allow a distinction between retroviral infection or non-specific reactions. We were able to isolate an unusual HIV-1 virus from lymphocyte cultures of two subjects presenting antibodies directed only against the core proteins.     

Comparison of long-term outcome between anti-Jo1- and anti-PL7/PL12 positive patients with antisynthetase syndrome

The aims of the present study were to: compare the characteristics between antisynthetase syndrome (ASS) patients with anti-Jo1 antibody and those with anti-PL7/PL12 antibody. The medical records of 95 consecutive patients with ASS were reviewed. Seventy-five of these patients had anti-Jo1 antibody; the other patients had anti-PL7 (n=15) or anti-PL12 (n=5) antibody. At ASS diagnosis, the prevalence of myalgia (p=0.007) and muscle weakness (p=0.02) was significantly lower in the group of anti-PL7/PL12-positive patients than in those with anti-Jo1 antibody; median value of CK (p=0.00003) was also lower in anti-PL7/PL12 patients. Anti-Jo1 positive patients developed more rarely myositis resolution (21.3% vs. 46.2%); in addition, the overall recurrence rate of myositis was higher in anti-Jo1 positive patients than in patients with anti-PL7/PL12 antibody (65.9% vs. 19.4%). Anti-Jo1-positive patients, compared with those with anti-PL7/PL12 antibody, more often experienced: joint involvement (63.3%vs. 40%) and cancer (13.3% vs. 5%). By contrast, anti-PL7/PL12 positive patients, compared with those with anti-Jo1 antibody, more commonly exhibited: ILD (90% vs. 68%); in anti-PL7/PL12 positive patients, ILD was more often symptomatic at diagnosis, and led more rarely to resolution of lung manifestations (5.6% vs. 29.4%). Finally, the group of anti-PL7/PL12 positive patients more commonly experienced gastrointestinal manifestations related to ASS (p=0.02). Taken together, although anti-Jo1 positive patients with ASS share some features with those with anti-PL7/PL12 antibody, they exhibit many differences regarding clinical phenotype and long-term outcome. Our study underscores that the presence of anti-Jo1 antibody results in more severe myositis, joint impairment and increased risk of cancer. On the other hand, the presence of anti-PL7/PL12 antibody is markedly associated with: early and severe ILD, and gastrointestinal complications. Thus, our study interestingly indicates that the finding for anti-Jo1 and anti-PL7/PL12 antibodies impacts both the long-term outcome and prognosis of patients with ASS.     

Fragility fractures and the osteoporosis care gap in women: the Canadian Multicentre Osteoporosis Study

Summary

Canadian women over 50?years old were studied over a 10-year period to see if those who sustained a fracture (caused by minimal trauma) were receiving the recommended osteoporosis therapy. We found that approximately half of these women were not being treated, indicating a significant care gap in osteoporosis treatment.

Introduction

Prevalent fragility fracture strongly predicts future fracture. Previous studies have indicated that women with fragility fractures are not receiving the indicated treatment. We aimed to describe post fracture care in Canadian women using a large, population-based prospective cohort that began in 1995?C1997.

Methods

We followed 5,566 women over 50?years of age from across Canada over a period of 10?years in the Canadian Multicentre Osteoporosis Study. Information on medication use and incident clinical fragility fractures was obtained during a yearly questionnaire or interview and fractures were confirmed by radiographic/medical reports.

Results

Over the 10-year study period, 42?C56% of women with yearly incident clinical fragility fractures were not treated with an osteoporosis medication. During year?1 of the study, 22% of the women who had experienced a fragility fracture were on treatment with a bisphosphonate and 26% were on hormone therapy (HT). We were not able to differentiate HT use for menopause symptoms vs osteoporosis. Use of bisphosphonate therapy increased over time; odds ratio (OR) for use at year?10 compared to use at year?1 was 3.65 (95% confidence interval (CI) 1.83?C7.26). In contrast, HT use declined, with an OR of 0.07 (95%CI 0.02?C0.24) at year?10 compared to year?1 of the study.

Conclusion

In a large population-based cohort study, we found a therapeutic care gap in women with osteoporosis and fragility fractures. Although bisphosphonate therapy usage improved over time, a substantial gap remains.