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1.
Nutritional Supplements and Skeletal Health.
Tabatabai, LS, Sellmeyer, DE
Current osteoporosis reports. 2021;(1):23-33
Abstract
PURPOSE OF REVIEW Nutrition influences skeletal health throughout the lifespan, from the impact of maternal intakes during development, through the development of peak bone mass, to the rate of bone loss during aging. However, there are limited data available on the effects of nutritional supplements on bone density, let alone fracture risk. This review will assess the current literature, focusing on human studies, and emphasizing nutrients where bone density or fracture data are available. RECENT FINDINGS Calcium and vitamin D supplements, in combination, reduce fracture risk, particularly in populations with low intakes. Extensive recent analyses have supported the safety of these interventions at recommended intakes. There is growing evidence that specific isoflavones may improve bone density although fracture data are lacking. Multiple other nutrient supplements may benefit skeletal health, but data are limited. The effect size of nutrient interventions are relatively small, requiring large sample sizes for trials with bone outcomes, may be difficult to blind, and the impact of supplementation may depend on baseline intake. However, nutrition is the only intervention that can be implemented life long and on a population wide basis. Further investigation is needed into the potential benefits of nutritional supplements to determine in which settings supplements may add benefit in addition to dietary intakes.
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Fracture Patterns in Type 1 and Type 2 Diabetes Mellitus: A Narrative Review of Recent Literature.
Van Hulten, V, Rasmussen, N, Driessen, JHM, Burden, AM, Kvist, A, van den Bergh, JP
Current osteoporosis reports. 2021;(6):644-655
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Abstract
PURPOSE OF REVIEW In this narrative review, we have summarized the literature on fracture risk in T1DM and T2DM with a special focus on fracture site, time patterns, glucose-lowering drugs, and micro- and macrovascular complications. RECENT FINDINGS T1DM and T2DM were associated with an overall increased fracture risk, with preferent locations at the hip, vertebrae, humerus, and ankle in T1DM and at the hip, vertebrae, and likely humerus, distal forearm, and foot in T2DM. Fracture risk was higher with longer diabetes duration and the presence of micro- and macrovascular complications. In T2DM, fracture risk was higher with use of insulin, sulfonylurea, and thiazolidinediones and lower with metformin use. The increased fracture risk in T1DM and T2DM concerns specific fracture sites, and is higher in subjects with longer diabetes duration, vascular complications, and in T2DM with the use of specific glucose-lowering medication.
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Therapies for Preventing Bone Loss with Glucocorticoid Treatment.
Agarwal, A, Adachi, JD
Current osteoporosis reports. 2021;(1):34-39
Abstract
PURPOSE OF REVIEW We aim to critically review recent recommendations regarding preventative strategies for glucocorticoid-induced osteoporosis and provide a summary of key evidence regarding available interventions. RECENT FINDINGS Lifestyle optimization remains the hallmark of bone health preservation. Early initiation of anti-osteoporotic agents in the setting of glucocorticoid exposure is essential, guided by appropriate risk stratification. Recommendations for calcium and vitamin D intake optimization are well-supported across all risk strata. Bisphosphonates are the mainstay of pharmacological therapy. Newer agents such as denosumab and teriparatide have demonstrated comparative benefit in terms of incident fracture risk reduction and bone mineral density preservation, with comparable adverse events. With due consideration to cost, resource availability, and patient values and preferences, these agents may warrant use as the first-line agents in this setting. Glucocorticoid-induced osteoporosis remains preventable and warrants early and targeted evidence-based therapy.
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Dual-energy CT in musculoskeletal trauma.
Wong, AJN, Wong, M, Kutschera, P, Lau, KK
Clinical radiology. 2021;(1):38-49
Abstract
Dual-energy computed tomography (DECT) combines the advantages of conventional CT with the ability to detect bone marrow oedema (BMO), which was previously limited to magnetic resonance imaging (MRI). By analysing DECT virtual non-calcium (VNCa) maps, radiologists can improve the detection of subtle and occult fractures and approximate the acuity/healing of fractures of indeterminate age. This review highlights the role of DECT in the assessment of musculoskeletal trauma, particularly among elderly, post-menopausal women and those at risk for osteoporosis. DECT is especially useful in investigating trabecular bone predominant regions (e.g., vertebral bodies, pelvis, hip, and long bone metaphyses) for stress (i.e., fatigue or insufficiency) and fragility fractures. CT is often performed first due to its increased availability, especially in the emergency setting, shorter imaging duration, and possible patient contraindications to magnetic resonance imaging (MRI). By enabling BMO detection, DECT may have a role in triaging patients for definitive MRI assessment. Understanding the role of anatomical, pathological, and patient factors in image interpretation can improve radiologist adoption of DECT, increase diagnostic confidence, and improve patient management.
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Modifiable lifestyle and environmental factors associated with onset of psoriatic arthritis in patients with psoriasis: A systematic review and meta-analysis of observational studies.
Xie, W, Huang, H, Deng, X, Gao, D, Zhang, Z
Journal of the American Academy of Dermatology. 2021;(3):701-711
Abstract
BACKGROUND Psoriatic arthritis (PsA) is a progressive joint disease associated with psoriasis. OBJECTIVES To investigate the association of modifiable lifestyle and environmental factors with PsA risk among people with psoriasis. METHODS We conducted a systematic search of PubMed, Embase, and Cochrane Library through May 2, 2020, for observational studies reporting lifestyle or environmental factors for PsA onset in patients with psoriasis. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were combined using a random-effects model. RESULTS We included 16 studies comprising 322,967 individuals. Obesity and being overweight were associated with an increased PsA risk in patients with psoriasis (OR, 1.75 [95% CI, 1.42-2.16] and OR, 1.50 [95% CI, 1.08-2.09], respectively), with an increase of approximately 6% for each kg/m2 rise in body mass index (OR, 1.06; 95% CI, 1.03-1.10). The presence of PsA was associated with a history of physical trauma (OR, 1.33; 95% CI, 1.16-1.54) or fracture (OR, 1.46; 95% CI, 1.22-1.74). No significant associations were observed regarding alcohol consumption (OR, 0.99; 95% CI, 0.88-1.13), smoking (OR, 0.89; 95% CI, 0.75-1.06), female hormonal exposure (OR, 1.45; 95% CI, 0.95-2.20), and psychologically traumatic events. LIMITATIONS Inherent limitations in the included observational studies. CONCLUSIONS Several lifestyle and environmental factors are associated with PsA onset among patients with psoriasis. These findings indicate that such risk may be modified with lifestyle changes or avoidance of physical trauma in people with psoriasis.
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Long-term effects of folic acid and vitamin-B12 supplementation on fracture risk and cardiovascular disease: Extended follow-up of the B-PROOF trial.
Oliai Araghi, S, Kiefte-de Jong, JC, van Dijk, SC, Swart, KMA, Ploegmakers, KJ, Zillikens, MC, van Schoor, NM, de Groot, LCPGM, Lips, P, Stricker, BH, et al
Clinical nutrition (Edinburgh, Scotland). 2021;(3):1199-1206
Abstract
BACKGROUND & AIMS In the initial B-proof, we found inconsistent results of B vitamin supplementation. However, the debate regarding the effects of B vitamins on age-related diseases continues. Therefore, our aim was to investigate the long-term effects (5-7 years follow-up) of an intervention with folic acid and vitamin-B12 supplementation on fracture and cardiovascular disease risk. METHODS Extended follow-up of the B-PROOF trial, a multi-center, double-blind randomized placebo-controlled trial designed to assess the effect of 2-3 years daily supplementation with folic acid (400 μg) and vitamin-B12 (500 μg) versus placebo (n = 2,919). Primary outcome was verified self-reported fracture incidence and secondary outcomes were self-reported cardiovascular endpoints, which were collected through a follow-up questionnaires Proportional hazard analyses was used for the effect of the intervention on risk of fracture(s) and logistic regression for the effect of the intervention on risk of cardiovascular disease. RESULTS A total of 1,298 individuals (44.5%) participated in the second follow-up round with median of 54 months [51-58], (n = 662 and n = 636, treatment versus placebo group). Median age at baseline was 71.0 years [68.0-76.0] for both groups. No effect was observed of the intervention on osteoporotic fracture or any fracture risk after a follow-up (HR: 0.99, 95% CI: 0.62-1.59 and HR: 0.77; 95% CI: 0.50-1.19, respectively), nor on cardiovascular or cerebrovascular disease risk (OR: 1.05; 95%CI: 0.80-1.44 and OR: 0.85; 95%CI: 0.50-1.45, respectively). Potential interaction by baseline homocysteine concentration was observed for osteoporotic- and any fracture (p = 0.10 and 0.06 respectively), which indicated a significantly lower risk of any fracture in the treatment group with higher total homocysteine concentrations (>15.1 μmol/l). No age-dependent effects were present. CONCLUSIONS This study supports and extends previous null-findings of the B-PROOF trial and shows that supplementation of folic acid and vitamin-B12 has no effect on fracture risk, nor on cardiovascular disease in older individuals over a longer follow-up period. However, B-vitamin supplementation may be beneficial in reducing fractures in individuals with high total homocysteine concentrations, a finding which needs to be replicated.
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Effects of Anti-Diabetic Drugs on Fracture Risk: A Systematic Review and Network Meta-Analysis.
Zhang, YS, Zheng, YD, Yuan, Y, Chen, SC, Xie, BC
Frontiers in endocrinology. 2021;:735824
Abstract
PURPOSE Available data on the effects of anti-diabetic drugs on fracture risk are contradictory. Therefore, our study aimed to analyze all available data on the effects of anti-diabetic drugs on fracture risk in type 2 diabetes mellitus (T2DM) patients. METHODS Embase, Medline, ClinicalTrials.gov, and Cochrane CENTRAL were searched for relevant trials. All data analyses were performed with STATA (12.0) and R language (3.6.0). Risk ratio (RR) with its 95% confidence interval (CI) was calculated by combining data for the fracture effects of anti-diabetic drugs, including sodium-glucose co-transporter 2 (SGLT2) inhibitors, dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, meglitinides, α-glucosidase inhibitors, thiazolidinediones, biguanides, insulin, and sulfonylureas. RESULTS One hundred seventeen eligible randomized controlled trials (RCTs) with 221,364 participants were included in this study. Compared with placebo, trelagliptin (RR 3.51; 1.58-13.70) increased the risk of fracture, whereas albiglutide (RR 0.29; 0.04-0.93) and voglibose (RR 0.03; 0-0.11) decreased the risk of fracture. Other medications were comparable in terms of their effects on fracture risk, and no statistical significance was observed. In terms of fractures, voglibose (0.01%) may be the safest option, and trelagliptin (13.64%) may be the worst. Sensitivity analysis results were consistent with those of the main analysis. No statistically significant differences were observed in the regression coefficients of age (1.03; 0.32-2.1), follow-up duration (0.79; 0.27-1.64), and sex distribution (0.63; 0.15-1.56). CONCLUSIONS We found varied results on the association between the use of anti-diabetic drugs and fracture risk. Specifically, trelagliptin raised the risk of fracture, whereas voglibose and albiglutide showed benefit with statistical difference. Other drugs were comparable in terms of their effects on fracture risk. Some drugs (omarigliptin, sitagliptin, vildagliptin, saxagliptin, empagliflozin, ertugliflozin, rosiglitazone, pioglitazone, and nateglinide) may increase the risk of fracture, while others (such as dulaglutide, exenatide, liraglutide, semaglutide, lixisenatide, linagliptin, alogliptin, canagliflozin, dapagliflozin, glipizide, gliclazide, glibenclamide, glimepiride, metformin, and insulin) may show benefits. The risk of fracture was independent of age, sex distribution, and the duration of exposure to anti-diabetic drugs. When developing individualized treatment strategies, the clinical efficacy of anti-diabetic drugs must be weighed against their benefits and risks brought about by individual differences of patients. SYSTEMATIC REVIEW REGISTRATION This Systematic Review was prospectively registered on the PROSPERO (https://www.crd.york.ac.uk/PROSPERO/, registration number CRD42020189464).
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The Impact of Vitamin D Levels in Foot and Ankle Surgery.
Giakoumis, M
Clinics in podiatric medicine and surgery. 2020;(2):305-315
Abstract
Hypovitaminosis D has been established as a global health problem. As an important regulator of skeletal health homeostasis throughout one's life, optimal levels are presumed. Debate, however, still exists surrounding the definition of normal vitamin D levels and what affect hypovitaminosis D has on fracture prevention, fracture healing, and successful arthrodesis. A literature search failed to show any level 1 studies examining hypovitaminosis D and union rates in foot and/or ankle arthrodesis procedures. Several retrospective studies do point to some sort of association between nonunion and hypovitaminosis D. Because of lack of high-level studies, a potential study design is proposed.
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Color-coded virtual non-calcium dual-energy CT for the depiction of bone marrow edema in patients with acute knee trauma: a multireader diagnostic accuracy study.
Booz, C, Nöske, J, Lenga, L, Martin, SS, Yel, I, Eichler, K, Gruber-Rouh, T, Huizinga, N, Albrecht, MH, Vogl, TJ, et al
European radiology. 2020;(1):141-150
Abstract
OBJECTIVES To evaluate the diagnostic accuracy of dual-energy computed tomography (CT) virtual non-calcium (VNCa) reconstructions for the depiction of traumatic knee bone marrow edema. METHODS Fifty-seven patients (mean age, 50 years; range, 20-82 years) with acute knee trauma further divided into 30 women and 27 men, who had undergone third-generation dual-source dual-energy CT and 3-T magnetic resonance imaging (MRI) within 7 days between January 2017 and May 2018, were retrospectively analyzed. Six radiologists, blinded to clinical and MRI information, independently analyzed conventional grayscale dual-energy CT series for fractures; after 8 weeks, readers evaluated color-coded VNCa reconstructions for the presence of bone marrow edema in six femoral and six tibial regions. Quantitative analysis of CT numbers on VNCa reconstructions was performed by a seventh radiologist. Two additional radiologists, blinded to clinical and CT information, analyzed MRI series in consensus to define the reference standard. Sensitivity, specificity, and the area under the curve (AUC) were the primary metrics of diagnostic accuracy. RESULTS MRI revealed 197 areas with bone marrow edema (91/342 femoral, 106/342 tibial). In the qualitative analysis, VNCa showed high overall sensitivity (1108/1182 [94%]) and specificity (2789/2922 [95%]) for depicting bone marrow edema. The AUC was 0.96 (femur) and 0.97 (tibia). A cutoff value of - 51 Hounsfield units (HU) provided high sensitivity (102/106 [96%]) and specificity (229/236 [97%]) for differentiating tibial bone marrow edema. CONCLUSIONS In both quantitative and qualitative analyses, dual-energy CT VNCa reconstructions yielded excellent diagnostic accuracy for depicting traumatic knee bone marrow edema compared with MRI. KEY POINTS • Dual-energy CT (DECT) virtual non-calcium (VNCa) reconstructions are highly accurate in depicting bone marrow edema of the femur and tibia. • Diagnostic confidence, image noise, and image quality were rated as equivalent in VNCa reconstructions and MRI (magnetic resonance imaging) series. • VNCa images may serve as an alternative imaging approach to MRI.
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Deep learning in fracture detection: a narrative review.
Kalmet, PHS, Sanduleanu, S, Primakov, S, Wu, G, Jochems, A, Refaee, T, Ibrahim, A, Hulst, LV, Lambin, P, Poeze, M
Acta orthopaedica. 2020;(2):215-220
Abstract
Artificial intelligence (AI) is a general term that implies the use of a computer to model intelligent behavior with minimal human intervention. AI, particularly deep learning, has recently made substantial strides in perception tasks allowing machines to better represent and interpret complex data. Deep learning is a subset of AI represented by the combination of artificial neuron layers. In the last years, deep learning has gained great momentum. In the field of orthopaedics and traumatology, some studies have been done using deep learning to detect fractures in radiographs. Deep learning studies to detect and classify fractures on computed tomography (CT) scans are even more limited. In this narrative review, we provide a brief overview of deep learning technology: we (1) describe the ways in which deep learning until now has been applied to fracture detection on radiographs and CT examinations; (2) discuss what value deep learning offers to this field; and finally (3) comment on future directions of this technology.