Adolescent Bone Advantages 3 Years After Resistance Training Trial.

PURPOSE: We assessed maintenance of skeletal advantages 3 years after completion of a 2-year, school-based, controlled exercise trial in adolescent girls. METHOD: Middle-school girls participated in a resistance training program embedded in physical education classes. Effort groups (low-effort group [LO] and high-effort group [HI]) were identified; the control group (CON) participated in standard physical education at a separate school. Baseline and follow-up (FU) assessments at 6, 18, and 54 (FU3) months included densitometry, anthropometry, and questionnaires assessing physical maturity and nonintervention organized physical activity. Linear mixed effects models were fit to evaluate bone outcomes across all FU time points for CON versus LO/HI. RESULTS: Sixty-eight girls (23 CON/25 HI/20 LO) were 11.6 (0.3) years at baseline. Bone parameters did not differ at baseline, except femoral neck bone mineral density (LO < HI/CON, P < .05). Forty-seven participants provided FU3 assessment: 17 CON/16 HI/14 LO. After adjusting for height, gynecologic age, baseline bone, and organized physical activity, bone gains across all time points were greater for HI versus CON for legs bone mineral content, femoral neck bone mineral content/bone mineral density, and third lumbar vertebra bone mineral content/bone mineral density (P ≤ .05). At FU3, bone values were greater for HI versus CON at subhead, legs, femoral neck, and third lumbar vertebra (P < .03). CONCLUSION: Adolescent girls who exerted high effort in a school-based resistance training program demonstrated significant skeletal benefits 3 years after program completion.

Osteoporosis Care Gap After Hip Fracture - Worse With Low Healthcare Access and Quality.

Despite the burden of osteoporosis-related fractures and availability of effective treatment, a substantial osteoporosis care gap persists. We evaluated this gap following fragility hip fracture, testing the hypothesis that patients who live in areas with low health care access or quality are less likely to undergo evaluation or treatment following hip fragility fracture. This retrospective analysis quantified osteoporosis evaluation and treatment just prior and for 12 mo following fragility hip fracture at an academic medical center in the upper Midwest. Initiation of pharmacologic therapy, Vitamin D screening and dual energy X-ray absorptiometry (DXA) scanning were measured. Each patient was assigned a value for 3 metrics of regional healthcare access and quality: (1) population per PCP ratio, (2) percent un-insured <65 yrs old, and (3) preventable hospitalization >65 yrs old. Generalized estimating equations, with county as a random effect, were used to assess the association of patient characteristics and/or heath care metrics with osteoporosis treatment at the time of admission and/or osteoporosis evaluation and treatment during hospitalization and post-discharge. A total of 585 patients were 80.7 ± 8.4 yrs of age at the time of hip fragility fracture; 68% were women. In 12 mo post-fracture, 17% underwent vitamin D screening, 12% received a DXA scan and 17% began a new bone anti-resorptive medication. Only in-hospital Vitamin D screening was more common in patients from counties with low healthcare access; all other pre- and post-fracture care was more common for patients with greater healthcare access and quality. Overall rates of initiating pharmacologic treatment and/or obtaining a Vitamin D screen or DXA scan following hip fragility fracture were very low and were worse in patients from counties with low access and quality of healthcare. These results remind the practitioner to diagnose and treat osteoporosis following hip fracture and suggests a role for targeting high-risk groups.

Can imaging studies be omitted in patients with sporadic primary hyperparathyroidism?

BACKGROUND: The cost-effectiveness of routine preoperative imaging for patients undergoing parathyroidectomy is controversial. The purpose of this study is to evaluate whether omission of routine preoperative imaging would affect efficiency or safety of parathyroidectomy. METHODS: We implemented a no-imaging protocol for patients with primary hyperparathyroidism and no prior neck surgery. If the patient did not have preoperative parathyroid imaging before evaluation by a surgeon, no radiologic studies were ordered, and the patient was scheduled for parathyroidectomy. We used propensity matching to address differences between the imaging and no-imaging groups. RESULTS: From 2000 to 2015, 83 patients underwent parathyroidectomy without imaging compared to 1245 patients with preoperative imaging. We successfully matched 64 patients with no preoperative imaging to equivalent patients who had imaging prior to surgery. Median age was 60 y, and 84% were women. There was no significant difference in operative time between patients with and without preoperative imaging (84 min for both groups, P < 0.32). Intraoperative parathyroid hormone levels dropped by at least 50% in all patients without preoperative imaging and in 98% of patients with imaging (P < 0.24). Neither group had recurrences 6 mo after surgery. Overall complication rates in the no-imaging (5%) and the imaging group (11%) were also similar (P < 0.18). CONCLUSIONS: Parathyroid surgery without preoperative imaging is safe, effective, and offers equivalent outcomes compared to an approach based on routine preoperative imaging. Experienced surgeons can consider omitting preoperative imaging in patients without a history of neck surgery as this may reduce overall treatment costs.

Role of cervical ultrasound in detecting thyroid pathology in primary hyperparathyroidism.

BACKGROUND: Minimally invasive parathyroidectomy for primary hyperparathyroidism is made possible with accurate preoperative imaging. In addition to the detection of parathyroid adenomas, cervical ultrasound also provides concomitant assessment of the thyroid gland, and many surgeons believe that it is essential. However, the incidental identification of thyroid nodules may then subject patients to further workup and potentially invasive thyroid procedures. We sought to determine the long-term consequence of omitting preoperative ultrasound on the development of thyroid pathology and cancer. METHODS: At our institution, 222 patients with primary hyperparathyroidism underwent parathyroidectomy without preoperative cervical ultrasound from 1990-2001. Thyroid pathology discovered by follow-up after parathyroidectomy, subsequent biopsy, and surgical interventions were analyzed. RESULTS: Of the 222 patients who underwent parathyroidectomy, the mean age was 55 ± 1 y and 149 were female (67%). In the course of their follow-up after parathyroidectomy, 13 patients (6%) received a cervical ultrasound, and seven of 13 (3%) underwent fine needle aspiration of a thyroid nodule. Only one of seven (0.4% of all patients) was ultimately diagnosed with thyroid cancer. Four additional patients were discovered to have thyroid malignancies as a result of intraoperative decision making. All five patients are currently alive with an average follow-up time of 14.9 ± 1.6 y. No patients in this series had an unnecessary thyroid intervention. CONCLUSIONS: In patients who underwent parathyroidectomy without a preoperative ultrasound, only a small number (0.4%) were subsequently diagnosed with thyroid cancer. Furthermore, omission of ultrasound during the localization of parathyroid glands does not have a negative impact on the diagnosis of thyroid pathology as all patients who had thyroid cancer had good outcomes, and in fact, may prevent unnecessary thyroid interventions. Therefore, the use of cervical ultrasound for parathyroid localization should be considered optional rather than essential.

A 2-yr, School-Based Resistance Exercise Pilot Program Increases Bone Accrual in Adolescent Girls.

PURPOSE: The current analysis evaluates cumulative benefits after year two (Y2) of a school-based resistance training intervention. METHODS: Adolescent girls were enrolled and measured at the beginning of 6th grade (baseline, BL) and again at 1st follow-up (FU1: Y1 end) and 2nd follow-up (FU2: Y2 end). School gym classes met alternate school days. Site 1 had standard gym classes (CON). Site 2 gym classes included 8-12 minutes of resistance training (INT); INT girls were categorized based on observed participation effort and time (LO, HI). Measurements included: 1) height and weight; 2) questionnaires to assess extracurricular exercise and diet (calcium, vitamin D); 3) dual-energy X-ray absorptiometry (DXA, Lunar Prodigy). Whole body less head (SUB) scans yielded bone mineral content (BMC) and body composition. Lumbar spine (L1-L4) and femoral neck (FN) scans yielded BMC and areal bone mineral density (BMD); radius scans yielded ultradistal and 1/3 BMD. ANCOVA compared group means for percent gains from BL to FU2, accounting for biological maturity, BL height, height change, inter-scan interval, organized activity, calcium and vitamin D. RESULTS: In 62 girls (21 CON, 41 INT), intention to treat analyses detected INT vs. CON advantages for L1-L4 BMC and BMD (4.1%, 5.6%: p<0.05). HI effort participants (n=19) demonstrated advantages for BMC and BMD at L1-L4 and FN (5.7% to 8.2%, p<0.01) vs. CON. CONCLUSIONS: Over two school years, this resistance intervention yielded lumbar spine advantages; enthusiastic participation (HI) yielded lumbar spine and femoral neck advantages. Further work is warranted to evaluate benefit persistence after intervention cessation.