A meta-analysis of previous falls and subsequent fracture risk in cohort studies.

The relationship between self-reported falls and fracture risk was estimated in an international meta-analysis of individual-level data from 46 prospective cohorts. Previous falls were associated with an increased fracture risk in women and men and should be considered as an additional risk factor in the FRAX® algorithm. INTRODUCTION: Previous falls are a well-documented risk factor for subsequent fracture but have not yet been incorporated into the FRAX algorithm. The aim of this study was to evaluate, in an international meta-analysis, the association between previous falls and subsequent fracture risk and its relation to sex, age, duration of follow-up, and bone mineral density (BMD). METHODS: The resource comprised 906,359 women and men (66.9% female) from 46 prospective cohorts. Previous falls were uniformly defined as any fall occurring during the previous year in 43 cohorts; the remaining three cohorts had a different question construct. The association between previous falls and fracture risk (any clinical fracture, osteoporotic fracture, major osteoporotic fracture, and hip fracture) was examined using an extension of the Poisson regression model in each cohort and each sex, followed by random-effects meta-analyses of the weighted beta coefficients. RESULTS: Falls in the past year were reported in 21.4% of individuals. During a follow-up of 9,102,207 person-years, 87,352 fractures occurred of which 19,509 were hip fractures. A previous fall was associated with a significantly increased risk of any clinical fracture both in women (hazard ratio (HR) 1.42, 95% confidence interval (CI) 1.33-1.51) and men (HR 1.53, 95% CI 1.41-1.67). The HRs were of similar magnitude for osteoporotic, major osteoporotic fracture, and hip fracture. Sex significantly modified the association between previous fall and fracture risk, with predictive values being higher in men than in women (e.g., for major osteoporotic fracture, HR 1.53 (95% CI 1.27-1.84) in men vs. HR 1.32 (95% CI 1.20-1.45) in women, P for interaction = 0.013). The HRs associated with previous falls decreased with age in women and with duration of follow-up in men and women for most fracture outcomes. There was no evidence of an interaction between falls and BMD for fracture risk. Subsequent risk for a major osteoporotic fracture increased with each additional previous fall in women and men. CONCLUSIONS: A previous self-reported fall confers an increased risk of fracture that is largely independent of BMD. Previous falls should be considered as an additional risk factor in future iterations of FRAX to improve fracture risk prediction.

Association of a Polygenic Risk Score With Osteoporosis in People Living With HIV: The Swiss HIV Cohort Study.

BACKGROUND: Bone mineral density (BMD) loss may be accelerated in people with HIV (PLWH). It is unknown whether a polygenic risk score (PRS) is associated with low BMD in PLWH. METHODS: Swiss HIV Cohort Study participants of self-reported European descent underwent ≥2 per-protocol dual x-ray absorptiometry (DXA) measurements ≥2 years apart (2011-2020). Univariable and multivariable odds ratios (ORs) for DXA-defined osteoporosis were based on traditional and HIV-related risk factors and a genome-wide PRS built from 9413 single-nucleotide polymorphisms associated with low BMD in the general population. Controls were free from osteoporosis/osteopenia on all DXA measurements. RESULTS: We included 438 participants: 149 with osteoporosis and 289 controls (median age, 53 years; 82% male, 95% with suppressed HIV RNA). Participants with unfavorable osteoporosis PRS (top vs bottom quintile) had univariable and multivariable-adjusted osteoporosis ORs of 4.76 (95% CI, 2.34-9.67) and 4.13 (1.86-9.18), respectively. For comparison, hepatitis C seropositivity, 5-year tenofovir disoproxil fumarate exposure, and parent history of hip fracture yielded univariable osteoporosis ORs of 2.26 (1.37-3.74), 1.84 (1.40-2.43), and 1.54 (0.82-2.9). CONCLUSIONS: In PLWH in Switzerland, osteoporosis was independently associated with a BMD-associated PRS after adjustment for established risk factors, including exposure to tenofovir disoproxil fumarate.

Heel quantitative ultrasound (QUS) predicts incident fractures independently of trabecular bone score (TBS), bone mineral density (BMD), and FRAX: the OsteoLaus Study.

This study aimed to better define the role of heel-QUS in fracture prediction. Our results showed that heel-QUS predicts fracture independently of FRAX, BMD, and TBS. This corroborates its use as a case finding/pre-screening tool in osteoporosis management. INTRODUCTION: Quantitative ultrasound (QUS) characterizes bone tissue based on the speed of sound (SOS) and broadband ultrasound attenuation (BUA). Heel-QUS predicts osteoporotic fractures independently of clinical risk factors (CRFs) and bone mineral density (BMD). We aimed to investigate whether (1) heel-QUS parameters predict major osteoporotic fractures (MOF) independently of the trabecular bone score (TBS) and (2) the change of heel-QUS parameters over 2.5 years is associated with fracture risk. METHODS: One thousand three hundred forty-five postmenopausal women from the OsteoLaus cohort were followed up for 7 years. Heel-QUS (SOS, BUA, and stiffness index (SI)), DXA (BMD and TBS), and MOF were assessed every 2.5 years. Pearson's correlation and multivariable regression analyses were used to determine associations between QUS and DXA parameters and fracture incidence. RESULTS: During a mean follow-up of 6.7 years, 200 MOF were recorded. Fractured women were older, more treated with anti-osteoporosis medication; had lower QUS, BMD, and TBS; higher FRAX-CRF risk; and more prevalent fractures. TBS was significantly correlated with SOS (0.409) and SI (0.472). A decrease of one SD in SI, BUA or SOS increased the MOF risk by (OR(95%CI)) 1.43 (1.18-1.75), 1.19 (0.99-1.43), and 1.52 (1.26-1.84), respectively, after adjustment for FRAX-CRF, treatment, BMD, and TBS. We found no association between the change of QUS parameters in 2.5 years and incident MOF. CONCLUSION: Heel-QUS predicts fracture independently of FRAX, BMD, and TBS. Thus, QUS represents an important case finding/pre-screening tool in osteoporosis management. The change in QUS over time was not associated with future fractures, making it inappropriate for patient monitoring.

Update on the clinical use of trabecular bone score (TBS) in the management of osteoporosis: results of an expert group meeting organized by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO), and the International Osteoporosis Foundation (IOF) under the auspices of WHO Collaborating Center for Epidemiology of Musculoskeletal Health and Aging.

PURPOSE: Trabecular bone score (TBS) is a grey-level textural measurement acquired from dual-energy X-ray absorptiometry lumbar spine images and is a validated index of bone microarchitecture. In 2015, a Working Group of the European Society on Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) published a review of the TBS literature, concluding that TBS predicts hip and major osteoporotic fracture, at least partly independent of bone mineral density (BMD) and clinical risk factors. It was also concluded that TBS is potentially amenable to change as a result of pharmacological therapy. Further evidence on the utility of TBS has since accumulated in both primary and secondary osteoporosis, and the introduction of FRAX and BMD T-score adjustment for TBS has accelerated adoption. This position paper therefore presents a review of the updated scientific literature and provides expert consensus statements and corresponding operational guidelines for the use of TBS. METHODS: An Expert Working Group was convened by the ESCEO and a systematic review of the evidence undertaken, with defined search strategies for four key topics with respect to the potential use of TBS: (1) fracture prediction in men and women; (2) initiating and monitoring treatment in postmenopausal osteoporosis; (3) fracture prediction in secondary osteoporosis; and (4) treatment monitoring in secondary osteoporosis. Statements to guide the clinical use of TBS were derived from the review and graded by consensus using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach. RESULTS: A total of 96 articles were reviewed and included data on the use of TBS for fracture prediction in men and women, from over 20 countries. The updated evidence shows that TBS enhances fracture risk prediction in both primary and secondary osteoporosis, and can, when taken with BMD and clinical risk factors, inform treatment initiation and the choice of antiosteoporosis treatment. Evidence also indicates that TBS provides useful adjunctive information in monitoring treatment with long-term denosumab and anabolic agents. All expert consensus statements were voted as strongly recommended. CONCLUSION: The addition of TBS assessment to FRAX and/or BMD enhances fracture risk prediction in primary and secondary osteoporosis, adding useful information for treatment decision-making and monitoring. The expert consensus statements provided in this paper can be used to guide the integration of TBS in clinical practice for the assessment and management of osteoporosis. An example of an operational approach is provided in the appendix. This position paper presents an up-to-date review of the evidence base, synthesised through expert consensus statements, which informs the implementation of Trabecular Bone Score in clinical practice.

[Osteoporosis: what's new in 2022]. / Ostéoporose : ce qui a changé en 2022.

The year 2022 has seen numerous studies: questioning the usefulness of vitamin D, the effect of osteoporosis treatments on mortality, and the benefit of parathyroidectomy on fractures in primary hyperparathyroidism. The efficacy of romosozumab is diminished by the treatments prescribed before its introduction. Finally, and fortunately, promising new molecules are available in various countries for the treatment of rare bone diseases.

L'année 2022 a vu de nombreuses études questionner l'utilité de la vitamine D et s'intéresser à l'effet des traitements de l'ostéoporose sur la mortalité ou encore au bénéfice de la parathyroïdectomie sur les fractures lors d'hyperparathyroïdie primaire. L'efficacité du romosozumab est diminuée selon les traitements prescrits avant son introduction. Finalement, et heureusement, de nouvelles molécules prometteuses sont disponibles dans différents pays pour le traitement des maladies osseuses rares.

[Does artificial intelligence have a role in osteoporosis management?] / L'intelligence artificielle a-t-elle un rôle dans la prise en charge de l'ostéoporose ?

The individual and societal burden of osteoporosis is high and will continue to increase due to the demographic situation. Applications based on artificial intelligence models can provide concrete solutions at each step of the management of osteoporosis: screening, diagnostic, therapy management and prognostic assessment. The implementation of such models could assist clinicians in their workflow while improving overall patient care.

L'ostéoporose représente un fléau important, à l'échelle individuelle mais aussi sociétale. Avec le vieillissement de la population, le nombre de patients concernés augmente de manière considérable. Des applications basées sur des modèles d'intelligence artificielle nous apportent des solutions de plus en plus concrètes, à chaque étape de la prise en charge de l'ostéoporose : dépistage, diagnostic, prise en charge médicamenteuse et évaluation pronostique. L'implémentation de tels modèles pourrait aider les professionnels de santé, aussi bien dans l'optimisation du flux du travail que dans la prise en charge clinique du patient.

[The year 2022 placed in perspective by hospital internists]. / Année 2022 mise en perspective par les internistes hospitaliers.

According to PubMed statistics when writing this review, the year 2022 is expected to mark the first dip in the number of articles published in relation to the Covid-19 pandemic. This review, without any mention to Sars-CoV-2, highlight this transition and addresses many topics in internal medicine: gastroenterology, cardiology, endocrinology, respiratory medicine, infectious diseases and venous access. Each year, the chief residents of the internal medicine ward in Lausanne university hospital (CHUV) in Switzerland meet up to share their readings: here is a selection of ten articles that have caught our attention, summarized and commented for you, which should change our daily practice.

D'après les statistiques PubMed au moment de la rédaction de cette revue, l'année 2022 devrait marquer le premier infléchissement du nombre d'articles publiés en relation avec la pandémie de Covid-19. Cette revue d'articles, sans écho au Sars-CoV-2, souligne cette transition et aborde de nombreux sujets de la médecine interne : gastroentérologie, cardiologie, endocrinologie, pneumologie, infectiologie et accès veineux. Chaque année, les cheffes et chefs de clinique du Service de médecine interne du CHUV se réunissent pour partager leurs lectures : voici une sélection de dix articles ayant retenu notre attention, revus et commentés pour vous, et qui devraient faire évoluer notre pratique quotidienne.

Bone Texture Assessment on Lateral VFAs Using the Texture Research Investigational Platform (TRIP) and its Fracture Discrimination Ability.

Texture Research Imaging Platform applies trabecular bone score (TBS) measurement principles to images acquired with multiple modalities to assess bone texture at various skeletal sites. This study aimed to assess the bone texture score in dual-energy X-ray absorptiometry-acquired lateral vertebral fracture assessment (VFA) images (BTSVFA), evaluate its reproducibility, and vertebral fracture discrimination ability. Subjects included 178 VF cases and 178 non-VF controls, 136 women and 42 men in each group, age 55-92 years, from two research centers. Cases and controls were matched for age (±5 years), body mass index (±5 kg/m2) and TBS. All participants underwent dual-energy X-ray absorptiometry TBS assessment from standard posterior-anterior lumbar spine scans and BTSVFA assessment. VF presence was determined using VFA images applying the Genant's method. BTSVFA was lower among fractured women compared to non-fractured (0.626 ± 0.109 vs 0.675 ± 0.099, p < 0.01), but not among men. In a binary logistic regression adjusted for study center and sex, for each SD lower BTSVFA, there was a 40% increase (OR 1.40, 95% CI (1.13-1.74)) in the risk of having a prevalent VF; area under the curve (95% CI) 0.616 (0.557-0.675). Inter-assessor and inter-centers ICCs for BTSVFA measurements were very good; 0.96 (0.64-0.99) and 0.98 (0.95-0.99), respectively. The BTSVFA precision (coefficient of variation) was 2.42%. This feasibility study demonstrates the potential to assess trabecular bone texture in lateral VFA images with good reproducibility. BTSVFA can discriminate between fractured and non-fractured women independent of their age, body mass index and TBS. In conclusion, BTSVFA, a potential trabecular texture assessment that excludes the posterior elements, may have value in fracture prediction or as a novel approach to be further investigated in spine surgery planning.

Quantitative Ultrasound (QUS) in the Management of Osteoporosis and Assessment of Fracture Risk: An Update.

Quantitative ultrasound (QUS) presents a low cost and readily available alternative to DXA measurements of bone mineral density (BMD) for osteoporotic fracture risk assessment. It is performed in a variety of skeletal sites, among which the most widely investigated and clinically used are first the calcaneus and then the radius. Nevertheless, there is still uncertainty in the incorporation of QUS in the clinical management of osteoporosis as the level of clinical validation differs substantially upon the QUS models available. In fact, results from a given QUS device can unlikely be extrapolated to another one, given the technological differences between QUS devices. The use of QUS in clinical routine to identify individuals at low or high risk of fracture could be considered primarily when central DXA is not easily available. In this later case, it is recommended that QUS bone parameters are used in combination with established clinical risk factors for fracture. Currently, stand-alone QUS is not recommended for treatment initiation decision making or follow-up. As WHO classification of osteoporosis thresholds cannot apply to QUS, thresholds specific for given QUS devices and parameters need to be determined and cross-validated widely to have a well-defined and certain use of QUS in osteoporosis clinical workflow. Despite the acknowledged current clinical limitations for QUS to be used more widely in daily routine, substantial progresses have been made and new results are promising.

Management of patients at very high risk of osteoporotic fractures through sequential treatments.

Osteoporosis care has evolved markedly over the last 50 years, such that there are now an established clinical definition, validated methods of fracture risk assessment and a range of effective pharmacological agents. Currently, bone-forming (anabolic) agents, in many countries, are used in those patients who have continued to lose bone mineral density (BMD), patients with multiple subsequent fractures or those who have fractured despite treatment with antiresorptive agents. However, head-to-head data suggest that anabolic agents have greater rapidity and efficacy for fracture risk reduction than do antiresorptive therapies. The European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) convened an expert working group to discuss the tools available to identify patients at high risk of fracture, review the evidence for the use of anabolic agents as the initial intervention in patients at highest risk of fracture and consider the sequence of therapy following their use. This position paper sets out the findings of the group and the consequent recommendations. The key conclusion is that the current evidence base supports an "anabolic first" approach in patients found to be at very high risk of fracture, followed by maintenance therapy using an antiresorptive agent, and with the subsequent need for antiosteoporosis therapy addressed over a lifetime horizon.

Role of vitamin D supplementation in the management of musculoskeletal diseases: update from an European Society of Clinical and Economical Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) working group.

Vitamin D is a key component for optimal growth and for calcium-phosphate homeostasis. Skin photosynthesis is the main source of vitamin D. Limited sun exposure and insufficient dietary vitamin D supply justify vitamin D supplementation in certain age groups. In older adults, recommended doses for vitamin D supplementation vary between 200 and 2000 IU/day, to achieve a goal of circulating 25-hydroxyvitamin D (calcifediol) of at least 50 nmol/L. The target level depends on the population being supplemented, the assessed system, and the outcome. Several recent large randomized trials with oral vitamin D regimens varying between 2000 and 100,000 IU/month and mostly conducted in vitamin D-replete and healthy individuals have failed to detect any efficacy of these approaches for the prevention of fracture and falls. Considering the well-recognized major musculoskeletal disorders associated with severe vitamin D deficiency and taking into account a possible biphasic effects of vitamin D on fracture and fall risks, an European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) working group convened, carefully reviewed, and analyzed the meta-analyses of randomized controlled trials on the effects of vitamin D on fracture risk, falls or osteoarthritis, and came to the conclusion that 1000 IU daily should be recommended in patients at increased risk of vitamin D deficiency. The group also addressed the identification of patients possibly benefitting from a vitamin D loading dose to achieve early 25-hydroxyvitamin D therapeutic level or from calcifediol administration.

[Osteoporosis]. / Ostéoporose.

The year 2021 is marked by several articles aimed at better risk stratification of osteoporosis to define the groups of patients at very high risk of fractures or at imminent risk of fractures. This stratification determines who should benefit from a first line bone anabolic treatment. A review of the current state of osteoporosis was therefore essential; it shows that Switzerland is lagging. In terms of prevention of bone fragility, dairy products are probably a leading strategy, especially in the elderly. The practical management of denosumab discontinuation is finally better understood. Finally, with the arrival of a new treatment, Burosumab, we are experiencing a therapeutic revolution for rare hypophosphatemic diseases.

L'année 2021 est marquée par des articles visant à une meilleure stratification du risque d'ostéoporose pour définir les groupes à très haut risque ou à risque imminent de fractures. Cette stratification détermine qui doit bénéficier d'un traitement anabolisant osseux en première ligne. Un état des lieux de l'ostéoporose était donc indispensable ; il montre que la Suisse accuse un certain retard. En termes de prévention de la fragilité osseuse, les produits laitiers sont probablement une stratégie de premier plan, notamment chez les personnes âgées. La gestion pratique de l'arrêt du dénosumab est enfin mieux comprise. Finalement, grâce à l'arrivée d'un nouveau traitement, le burosumab, nous vivons une révolution thérapeutique pour les maladies rares hypophosphatémiques.

Diurnal Salivary Cortisol in Sarcopenic Postmenopausal Women: The OsteoLaus Cohort.

Sarcopenia, similar to hypercortisolism, is characterized by loss of muscle mass and strength. Cortisol circadian rhythm changes with aging (blunted late-day nadir values) were suggested to contribute to this decline. We aimed to explore the relationship between diurnal salivary cortisol values and sarcopenia diagnosis and its components in postmenopausal women. This is a cross-sectional study within the OsteoLaus population-based cohort in Lausanne (Switzerland). Participants had a body composition assessment by dual X-ray absorptiometry (DXA), a grip strength (GS) measure, and salivary cortisol measures (at awakening, 30 min thereafter, 11 AM (sc-11AM) and 8 PM (sc-8PM)). Associations between salivary cortisol and sarcopenia diagnosed by six different criteria (based on appendicular lean mass (ALM) assessed by DXA, and muscle strength by GS), and its components, were analyzed. 471 women aged > 50 years (63.0 ± 7.5) were included. Various definitions identified different participants as sarcopenic, who consistently presented higher salivary cortisol at 11 AM and/or 8 PM. There were no associations between salivary cortisol levels and ALM measures, either absolute or after correction to height squared (ALM index) or body mass index. GS was inversely correlated to sc-11AM (r = - 0.153, p < 0.001) and sc-8PM (r = - 0.118, p = 0.002). Each 10 nmol/l increase of sc-11AM, respectively sc-8PM, was associated with a GS decrease of 1.758 (SE 0.472) kg, respectively 2.929 (SE 1.115) kg. In postmenopausal women, sarcopenia is associated with higher salivary cortisol levels at 11 AM and 8 PM. An increase of daily free cortisol levels in the physiological range could participate to sarcopenia development by decreasing muscle function in postmenopausal women.

[Anticoagulant and bone fragility: which implications for clinical practice?] / Anticoagulation et fragilité osseuse : quelles implications pour la pratique clinique ?

The role of certain treatments in the development of bone fragility is well known. Since the 2000s, several studies, conducted in patients on long-term anticoagulants have suggested the involvement of vitamin K antagonist (VKA) in the occurrence of osteoporotic fractures. Since their launch in 2008, the new oral anticoagulants (NOACs) have been widely used. Compared to VKA, this drugs' class is associated with a lower fracture risk. Therefore, the presence of risk factors for fracture should be considered when prescribing long-term anticoagulants. In this line, the NOACs seem to be an interesting alternative for patients at risk of fracture requiring a long-term anticoagulation. Nevertheless, certain aspects remain to be clarified.

Le rôle joué par certains traitements pour favoriser une fragilité osseuse est bien connu. Depuis les années 2000, plusieurs études, menées chez des patients anticoagulés au long cours, évoquent l'implication des antivitamines K (AVK) dans la survenue de fractures ostéoporotiques. Depuis leur mise sur le marché en 2008, les nouveaux anticoagulants oraux (NACO) sont largement utilisés. Comparée aux AVK, cette classe médicamenteuse semble associée à un risque fracturaire moindre, menant à considérer la présence de facteurs de risque osseux lors de la prescription d'une anticoagulation au long cours. En ce sens, et bien que certains aspects restent à éclaircir, les NACO semblent être une alternative intéressante chez les patients présentant un risque fracturaire accru et la nécessité d'une anticoagulation au long cours.

[Towards an individualized bone health report focused on the patient - Bone parameters and treatment options]. / Vers un rapport de santé osseuse individualisé centré sur le patient - Les paramètres osseux et les possibilités de traite.

This article presents a novel approach of osteoporosis management, starting from the DXA scans performance, image quality, BMD and TBS assessment and interpretation, vertebral fracture assessment, decision making on treatment initiation and being finalized with patient`s further follow-up recommendations. A report based on this approach is soon to be implemented by the CiMO at CHUV. Among the thorough evaluation of the densitometric status of the patient, this report presents the first effort to incorporate into the osteoporosis clinical workflow the current evidence on TBS. It suggests practical ways to use TBS as in conjunction with BMD T-score or FRAX score to come up with the final scores that allow treatment initiation. Implementations in other non-Caucasian or non-Swiss clinical settings are to be accompanied by local validations.

Cet article présente une approche nouvelle de la prise en charge de l'ostéoporose, à partir de la performance des DXA, de la qualité de l'image, de l'interprétation combinée de la densité minérale osseuse et du TBS, de la recherche des fractures vertébrales, de la décision de traiter et des stratégies de suivi du patient. Un nouveau rapport densitométrique basé sur cette approche sera bientôt mis en fonction par le Centre interdisciplinaire des maladies osseuses du CHUV. Il présente le premier effort pour incorporer dans le flux de travail clinique de l'ostéoporose les toutes dernières avancées sur le TBS. Il suggère des moyens pratiques pour utiliser le TBS en conjonction avec le T-score de la DMO ou le FRAX pour obtenir les scores finaux en vue d'initier un traitement spécifique pour un profil de risque individuel donné. L'utilisation dans d'autres contextes cliniques non caucasiens/suisses devra être validée.

[The Internal medicine articles that struck us the most in 2020]. / L'année 2020 mise en perspective par les internistes hospitaliers.

2020 has continued to bring important progress in all areas of internal medicine, impacting our daily practice. From a shift to oral stepdown antibiotics in infectious endocarditis, to new indications for apixaban, SLGT-2 inhibitors and macrolide antibiotics, passing by the catheter-based renal denervation in hypertension, early paracentesis in cirrhosis and new diagnostic criteria in pulmonary embolism, internal medicine journals are full of novelties. Every year, the chief residents of internal medicine at the Swiss University Hospital of Lausanne meet up to share their readings: here is their selection of eleven articles, summarized and commented for you.

L'année 2020 a vu de notables progrès dans tous les domaines de la médecine interne, avec un impact important sur notre pratique quotidienne. Du passage à une antibiothérapie orale dans l'endocardite infectieuse, aux nouvelles indications pour l'apixaban, les inhibiteurs du SGLT2 (sodium-glucose co-transporteur de type 2) et les macrolides en passant par la dénervation rénale dans l'hypertension artérielle, la ponction d'ascite et les changements de critères diagnostiques de l'embolie pulmonaire, les nouveautés abondent dans la littérature. Chaque année, les chefs de clinique du Service de médecine interne du CHUV se réunissent pour partager leurs lectures : voici une sélection de onze articles choisis, revus et commentés pour vous.

Sixty spontaneous vertebral fractures after denosumab discontinuation in 15 women with early-stage breast cancer under aromatase inhibitors.

PURPOSE: At denosumab discontinuation, bone turnover markers increase and the gained BMD is lost. In postmenopausal osteoporosis, there is an increased risk of spontaneous vertebral fractures (VFs) of about 1 to 10%, rarely described in women under denosumab for aromatase inhibitors (AI)-treated breast cancer. We aim to describe the characteristics of 15 patients under denosumab given for AI-treated early-stage breast cancer that presented VFs at its discontinuation. METHODS: Single-center retrospective case series of 15 patients. We report clinical data, dual X-ray absorptiometry values at denosumab initiation and discontinuation, and serum B-crosslaps dosage at the time of VF occurrence (before denosumab resumption). RESULTS: Fifteen women (66.4 ± 7.1 years at denosumab discontinuation) that received AI for 5.0 ± 0.6 years, denosumab 60 mg for 8.2 ± 2.0 doses, and developed 60 VFs at denosumab discontinuation, were followed for 24.4 ± 9.5 months. Patients suffered from 1 to 11 (mean 4.0 ± 1.9) clinical VFs within 7 to 16 months after last denosumab injection. VFs developed earlier in patients with longer denosumab treatment (R2 = 0.29, p = 0.04) and in patients without osteoporosis before denosumab (9.4 ± 2.0 vs. 13.0 ± 2.0 months; p = 0.005). Serum B-crosslaps at the time of VFs tended to be higher in patients with earlier VFs (R2 = 0.47; p = 0.06) or with longer denosumab treatment (R2 = 0.48; p = 0.06). Denosumab was resumed in all patients, then switched for a bisphosphonate in eight. No new VFs occurred during follow-up. CONCLUSIONS: Despite an apparently low fracture risk, women under denosumab for AI-treated early-stage breast cancer develop spontaneous VFs at denosumab discontinuation. This risk increases with treatment duration and may be prevented by a potent bisphosphonate.

"Inflammaging" and bone in the OsteoLaus cohort.

BACKGROUND: "Inflammaging" is a coined term that combines the processes of inflammation (within the normal range) and aging, since chronic, low-grade, systemic inflammation emerges with increasing age. Unlike high-level inflammation, with which deleterious effects on bone no longer need to be demonstrated, it is unclear whether inflammaging exerts deleterious effects on bone too. METHOD: We assessed associations between inflammaging - measured via cytokine levels (high-sensitivity C-reactive protein (hs-CRP); interleukin-1ß (IL-1ß); interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α)) - and bone parameters (prevalent and incident fractures, bone mineral density (BMD) and trabecular bone score (TBS)) in 1390 postmenopausal women from the OsteoLaus study. RESULTS: Mean (±SD) age was 64.5 ± 7.6 and mean bone mass index (BMI) 25.9 ± 4.5 kg/m2. Median hs-CRP, IL-1ß, IL-6 and TNF-α were 1.4 pg/ml, 0.57 pg/ml, 2.36 pg/ml and 4.82 pg/ml, respectively. In total, 10.50% of the participants had a prevalent, low-impact fracture; and, after 5-years of follow up, 5.91% had an incident, low-impact fracture. Mean T-score BMD was - 1.09 ± 1.53 for the spine, - 1.08 ± 1.02 for the femoral neck, and - 0.72 ± 0.96 for the total hip. Mean spine TBS was 1.320 ± 0.10. We found a positive association between hs-CRP and BMD at all sites, and between hs-CRP and the TBS, but none of these associations were significant after adjustment. We found no association between prevalent or incident fractures and hs-CRP. No association was found between IL-1ß, IL6 and TNF-α and BMD, TBS or fractures. CONCLUSION: Our results suggest that bone imaging and structure parameters are not associated with the low-grade cytokine levels (within the normal range) observed with inflammaging.

Unknown osteoporosis in older patients admitted to post-acute rehabilitation.

BACKGROUND: Osteoporotic fractures are associated with increased morbidity, mortality, and increased health care use. As the number of older adults increases, identifying those at increased risk for osteoporotic fractures has become of utmost importance to providing them with preventive and therapeutic interventions. AIMS: To determine the prevalence of unknown clinical and densitometric osteoporosis and to investigate the performance of different diagnostic strategies for osteoporosis in elderly patients admitted to rehabilitation. METHOD: This is an observational study. Eligible participants were older adults admitted to rehabilitation in an academic hospital in Switzerland over an 11-month period. Patients with previously unknown osteoporosis underwent dual-energy X-ray absorptiometry (DXA), vertebral fracture assessment (VFA), and history review for past fractures. RESULTS: Complete assessment was available for 252 patients. Previously undiagnosed osteoporosis was identified in 62.3% of these patients, a proportion that was higher among women (71.5%) than men (44.8%). DXA proved most sensitive, followed by VFA and history review. Results differed across gender: DXA remained the most sensitive single test among women, but VFA proved most sensitive in men. The best test to combine with history review was DXA in women (detection increasing from 47.5 to 93.2%) and VFA in men (detection increasing from 35.9 to 84.6%). CONCLUSIONS: Prevalence of previously unknown osteoporosis appears very high in elderly patients admitted to post-acute rehabilitation. The combination of history review of previous fractures with DXA in women and with VFA in men appears the best two-step strategy to improving detection of osteoporosis in this population.

[Vertebroplasty: the new CHUV consensus]. / Fracture vertébrale ostéoporotique aiguë et douloureuse - Proposition d'un algorithme décisionnel pour la cimentoplastie au CHUV.

Should we continue to treat patients suffering from an acute osteoporotic vertebral fracture with vertebroplasty ? What is the potential benefit ? What are its indications ? What are its risks ? Which way to perform it ? How to manage the osteoporosis evaluation and therapy ? In 2009 we published the «â€…CHUV consensus ¼ on the management of vertebral osteoporotic fractures by vertebroplasty. We here propose an update including recent knowledge on the management of vertebral fractures by bone insufficiency by percutaneous cementoplasty.

Doit-on continuer à traiter les patients souffrant d'une fracture vertébrale aiguë ostéoporotique par cimentoplastie ? Quel est le bénéfice potentiel ? Quelles sont ses indications ? Quels sont ses risques ? À qui les adresser ? Quand faire le bilan et le traitement de la maladie ostéoporotique ? En 2009, nous avions publié le consensus du CHUV de prise en charge par vertébroplastie des fractures vertébrales ostéoporotiques. Nous proposons une mise à jour incluant les connaissances récentes sur la prise en charge des fractures vertébrales par insuffisance osseuse par technique de cimentoplastie percutanée.