Science, Scripture, and Sexuality: The US United Methodist Church at Crossroads.

During the past 50 years, medical and behavioral scientists have made great progress in understanding the variables which influence the development of sexual orientation, identity, and consequent behavior. In most instances, homosexuality is influenced by hormonal, genetic, and immunologic variables during fetal development, and the effects cannot usually be altered without consequence. The recent struggle within The United Methodist Church in the USA reflects the difficulty that society in general has with accepting homosexuality as part of the spectrum of sexuality. Hopefully, understanding the factors influencing sexual orientation will aid in reducing prejudice and eventually bring an end to the pain endured by the LGBTQ community, and the conflict within The United Methodist Church, a prototype of the struggle.

The Role of Sex and Gender in Transgender Bone and Other Musculoskeletal Health.

ABSTRACT: Musculoskeletal changes occur with gender-affirming hormonal therapy (GAHT) and gender-affirming surgery (GAS) used in the care of transgender adolescents and adults. Survey results have shown that orthopaedic surgeons desire to care for transgender individuals but express concern over a knowledge deficit. This article reviews the physiology and pathophysiology that may occur with GAHT and GAS. Transgender women have lower bone mineral density (BMD) prior to GAHT than cisgender men. Limited fracture data would suggest that transgender women >50 years of age have fracture rates similar to those of cisgender women. Transgender men have normal BMD prior to GAHT and are not at an increased risk for fracture compared with cisgender women. The use of puberty-blocking medications in the care of transgender youth does result in a decline in BMD, which returns to baseline with GAHT, but the effect of delaying puberty on maximal BMD and the lifetime fracture risk are unknown. At present, dual x-ray absorptiometry (DXA) is used to measure BMD and assess fracture risk. Attention should be paid to using the appropriate reference group in the interpretation of DXA for transgender individuals. Promote musculoskeletal health by ensuring appropriate calcium, vitamin D, weight-bearing activity, and a healthy lifestyle. Adherence to GAHT needs to be encouraged to avoid bone loss. Data with regard to therapy for osteoporosis in transgender patients have been lacking, but, at present, use of available therapies is expected to be effective. Information with regard to differences in other musculoskeletal health issues such as joint injuries has been lacking in transgender individuals.

Which Drug Next? Sequential Therapy for Osteoporosis.

The proliferation of drugs with unique modes of action for treating osteoporosis has been most welcome. Fear of complications, even though rare, associated with long-term bisphosphonates (BPs) changed prescribing patterns. The BPs are stored in bone for years. Drugs not stored in bone; for example, abaloparatide, teriparatide, denosumab, and romosozumab have expanded our armamentarium for treating osteoporosis but have brought new challenges. Bone accrued during treatment with the last 3 drugs, and perhaps abaloparatide, is lost rapidly after their withdrawal due to rebound increase in bone resorption. Treatment with these drugs must be followed by administration of an antiresorptive agent. The article by Kendler et al. (1) in this issue of JCEM reports alendronate preserves bone accrued during administration of denosumab.

Osteoporosis associated with excess glucocorticoids.

Excess glucocorticoids, whether endogenous or exogenous, can cause osteoporosis and fractures. Even low doses of oral glucocorticoids and mild endogenous hypercortisolism may be associated with bone loss. Patients treated with glucocorticoids, however, often are not evaluated and treated for this problem. Patients on chronic glucocorticoids or initiating these drugs should have their bone density measured and appropriate laboratory studies. They should be treated with adequate calcium and vitamin D, and antiresorptive therapy (particularly bisphosphonates) should be considered.

Physician differences in managing postmenopausal osteoporosis: results from the POSSIBLE US™ treatment registry study.

BACKGROUND: Osteoporosis is a disease that often goes undetected until a fracture occurs. Previous reports indicate that disease diagnosis and care of patients with osteoporosis may vary within the medical community. OBJECTIVE: Using data from the POSSIBLE US™ registry (October 2004-December 2009), we evaluated patterns of care for a group of primary care (i.e. first-contact) physicians who frequently prescribe osteoporosis medications to determine whether variations existed in the characteristics of their postmenopausal patients; physician approaches to diagnosis; treatment choices and monitoring; and patient-reported medication use. METHODS: POSSIBLE US™ was a large prospective registry of postmenopausal women receiving osteoporosis treatment. We analysed data from 42 family practice physicians (FPPs), 50 internal medicine specialists (IMs).[internists, physicians], 41 gynaecologists (GYNs) and the 4917 patients they enrolled in the POSSIBLE US™ registry between October 2004 and January 2007. Women who had been postmenopausal for at least 1 year and who were newly initiating osteoporosis therapy, switching or augmenting therapy or continuing on a stable therapy regimen were investigated. Therapies included bisphosphonates, full-length or peptide derivative of parathyroid hormone, calcitonin, oral or transdermal postmenopausal estrogen, selective estrogen receptor modulators (SERMs), calcium and/or vitamin D supplements (alone or in combination with other therapies), or any combination of these agents. Data on physician characteristics were collected on an initial qualification questionnaire. Physicians reported data for enrolled patients at study entry and were also asked to provide relevant data obtained at clinic visits throughout the follow-up period. Patient-reported data were collected using questionnaires mailed out semi-annually throughout the follow-up period. Patient-reported and physician-reported data were assessed using ANOVA models and chi-squared (χ2) or Cochran-Mantel-Haenszel tests to evaluate differences across physician types. Multivariate logistic regression models examined the odds of patients having an osteoporosis diagnosis, being prescribed specific agents and receiving an additional dual energy x-ray absorptiometry (DXA) scan after the initial diagnostic scan. Cox proportional hazards regression models were used to determine whether the risk of patient-reported treatment discontinuation during 12 months of follow-up differed by physician characteristics. RESULTS: Although low-bone density diagnoses were not required, physicians reported DXA as the method of diagnosis in 84% of patients. The majority of patients were prescribed bisphosphonates (55%); the next most frequently prescribed treatment was calcium/vitamin D only (19%). Women treated by GYNs were younger; had fewer co-morbidities, higher T-scores and fewer prior fractures; were 30% less likely to carry a diagnosis of osteoporosis; and were more likely to be treated with SERMs or hormone replacement therapy (HRT) than women treated by IMs or FPPs. Patients cared for by physicians with >30 years of experience were 20% less likely to carry a diagnosis of osteoporosis, had greater odds of receiving either HRT or calcium/vitamin D only and had a higher risk of treatment discontinuation. Overall, there was less laboratory testing to assess secondary causes of osteoporosis in this cohort than might have been expected, given the high incidence of secondary osteoporosis generally in women of similar age. CONCLUSIONS: This study documents potentially important variations in osteoporosis care, even among physicians who frequently prescribe osteoporosis medications.

Can dermal thickness measured by ultrasound biomicroscopy assist in determining osteoporosis risk?

BACKGROUND AND PURPOSE: A study was undertaken to evaluate the relationship between dermal thickness and bone density. Ninety-eight female subjects were recruited from a population of patients attending a university hospital osteoporosis clinic. The subject population ranged in age from 30 to 88 years with a mean age of 60. The weight range was from 91 to 274 pounds, mean 142 pounds. METHODS: Dermal thickness measurements were taken at the right forearm using a Longport high resolution 20 MHz ultrasound scanner. Bone density measurements were taken using a GE Lunar Prodigy DXA scanner at both hips. RESULTS: Statistical analysis using the intraclass correlation coefficient (ICC) of the skin measurements showed that the dermal measurement technique was highly reliable (CI=0.87, 0.92). Linear regression was used to examine the value of dermal thickness as a predictor of bone density. The correlation coefficient between dermal thickness and hip T score was statistically significant in the positive direction (corr.=0.304, P=0.001). We further investigated the relationship between dermal thickness and T scores using penalized splines. CONCLUSION: This analysis indicated that the strongest association with bone density occurred between 1.0 and 1.5 mm of dermal thickness. In those subjects identified as having osteoporosis dermal thickness measure of > or =1.04 corresponds to 4% of the subjects having osteoporosis. If dermal thickness is <1.04 then 23% have osteoporosis.

Effect of hospitalist consultation on treatment of osteoporosis in hip fracture patients.

The objective of this study was to determine if hospitalist consultation during admission for hip fracture results in improved treatment for osteoporosis. This was a retrospective chart review, carried out in a university-based academic hospital. Administrative discharge data was used to identify patients discharged between 1 September 1999 and 1 September 2001, discharged with the diagnosis of hip fracture. Eighty-two patient charts were reviewed after exclusion for traumatic and pathologic fractures. Treatment for osteoporosis consisted of medications recommended by the National Osteoporosis Foundation (NOF), including calcium (+/-vitamin D), estrogen, raloxifene, calcitonin, alendronate and risedronate. Osteoporosis treatment improvement was defined as the addition of a medication for osteoporosis that strengthened treatment. Twenty-nine percent of patients in our study received treatment for osteoporosis at the time of discharge from the hospitalization for hip fracture. While 20% received calcium, only 7% received a bisphosphonate. Twelve percent received improvement in osteoporosis treatment from admission to discharge. Those that received hospitalist consultation did not have a significant improvement in osteoporosis treatment (P=0.314), but had significantly more co-morbid illnesses and were significantly older than those receiving no consultation (P<0.05). Identification of osteoporosis as a medical problem was significantly associated with osteoporosis treatment (P<0.05). Potential barriers to hospitalist consultation's effect on osteoporosis treatment included patient age and co-morbidities. Further research is needed to identify and overcome barriers to effective osteoporosis treatment in patients with fractures.