Clinical Use of Trabecular Bone Score: The 2023 ISCD Official Positions.

Osteoporosis can currently be diagnosed by applying the WHO classification to bone mineral density (BMD) assessed by dual-energy x-ray absorptiometry (DXA). However, skeletal factors other than BMD contribute to bone strength and fracture risk. Lumbar spine TBS, a grey-level texture measure which is derived from DXA images has been extensively studied, enhances fracture prediction independent of BMD and can be used to adjust fracture probability from FRAX® to improve risk stratification. The purpose of this International Society for Clinical Densitometry task force was to review the existing evidence and develop recommendations to assist clinicians regarding when and how to perform, report and utilize TBS. Our review concluded that TBS is most likely to alter clinical management in patients aged ≥ 40 years who are close to the pharmacologic intervention threshold by FRAX. The TBS value from L1-L4 vertebral levels, without vertebral exclusions, should be used to calculate adjusted FRAX probabilities. L1-L4 vertebral levels can be used in the presence of degenerative changes and lumbar compression fractures. It is recommended not to report TBS if extreme structural or pathological artifacts are present. Monitoring and reporting TBS change is unlikely to be helpful with the current version of the TBS algorithm. The next version of TBS software will include an adjustment based upon directly measured tissue thickness. This is expected to improve performance and address some of the technical factors that affect the current algorithm which may require modifications to these Official Positions as experience is acquired with this new algorithm.

Quality Indicators for the Diagnosis and Management of Primary Hyperparathyroidism.

IMPORTANCE: Primary hyperparathyroidism (pHPT) is a common endocrine disorder with many diagnostic and treatment challenges. Despite high-quality guidelines, care is variable, and there is low adherence to evidence-based treatment pathways. OBJECTIVE: To develop quality indicators (QIs) to evaluate the diagnosis and treatment of pHPT that could measure, improve, and optimize quality of care and outcomes for patients with this disease. DESIGN, SETTING, AND PARTICIPANTS: This quality improvement study used a guideline-based approach to develop QIs that were ranked by a Canadian 9-member expert panel of 3 endocrinologists, 3 otolaryngologists, and 3 endocrine surgeons. Data were analyzed between September 2020 and May 2021. MAIN OUTCOMES AND MEASURES: Candidate indicators (CIs) were extracted from published primary hyperparathyroidism guidelines and summarized with supporting evidence. The 9-member expert panel rated each CI on the validity, reliability, and feasibility of measurement. Final QIs were selected from CIs using the modified RAND-University of California, Los Angeles appropriateness methodology. All panelists were then asked to rank the top 5 QIs for primary, endocrine, and surgical care. RESULTS: Forty QIs were identified and evaluated by the expert panel. After 2 rounds of evaluations and discussion, a total of 18 QIs were selected as appropriate measures of high-quality care. The top 5 QIs for primary, endocrine, and surgical care were selected following panelist rankings. CONCLUSIONS AND RELEVANCE: This quality improvement study proposes 18 QIs for the diagnosis and management of pHPT. Furthermore, the top 5 QIs applicable to physicians commonly treating pHPT, including general physicians, internists, endocrinologists, otolaryngologists, and surgeons, are included. These QIs not only assess the quality of care to guide the process of improvement, but also can assess the implementation of evidence-based guideline recommendations. Using these indicators in clinical practice and health system registries can improve quality and cost-effectiveness of care for patients with pHPT.

Basal insulin plus GLP-1 RA or SGLT2 inhibitor was noninferior to basal-bolus insulin intensification for HbA1c in T2DM.

SOURCE CITATION: Giugliano D, Longo M, Caruso P, et al. Feasibility of simplification from a basal-bolus insulin regimen to a fixed-ratio formulation of basal insulin plus a GLP-1RA or to basal insulin plus an SGLT2 inhibitor: BEYOND, a randomized, pragmatic trial. Diabetes Care. 2021;44:1353-60. 33883195.

Effects of Whole-Body Vibration Therapy on Distal Tibial Myotendinous Density and Volume: A Randomized Controlled Trial in Postmenopausal Women.

Whole-body vibration (WBV) therapy has been proposed as a therapy to reduce sarcopenia and improve muscle strength. The purpose of this study was to explore whether 12 months of WBV therapy increases myotendinous density and volume of the distal tibia as measured by HR-pQCT in postmenopausal women in a parallel group, randomized controlled trial with 1:1:1 allocation to three arms. Postmenopausal women (N = 202) with low hip BMD were randomized to 20 min daily of 0.3g 30-Hz WBV therapy, 0.3g 90-Hz WBV therapy using the Juvent platform (Juvent, Somerset, NJ, USA), or no WBV. The main outcome measure was myotendinous density (HU) and volume (mm3) at the distal tibia measured at baseline and 12 months with HR-pQCT. There were no significant effects on myotendinous density or volume at the distal tibia after 12 months of daily 30- or 90-Hz WBV therapy compared with no WBV therapy. Mean change (SD) in myotendinous density from baseline was 4.6 (5.7) HU in the 30-Hz WBV group, 3.9 (6.1) HU in the 90-Hz WBV group, and 3.9 (5.4) HU in the control group (p = 0.70). Mean change (SD) in myotendinous volume from baseline was -7 (503) mm3 in the 30-Hz WBV group, 111 (615) mm3 in the 90-Hz WBV group, and 35 (615) mm3 in the control group (p = 0.50). In conclusion, WBV therapy at 30- or 90-Hz for 12 months had no significant effects on myotendinous density or volume at the distal tibia as measured by HR-pQCT in postmenopausal women. © 2018 The Authors. JBMR Plus Published by Wiley Periodicals, Inc. on behalf of the American Society for Bone and Mineral Research.

Incorporating living from the heart into medical education.

Medical training poses many challenges to trainees' wellbeing. To address the impact of learning in a high turnover, high volume, acute care setting in the General Internal Medicine Clinical Teaching Unit, the Chief Medical Resident, in this personal account, shares how she and the Spiritual Care Practitioner united to form an innovative partnership. The introduction of the skills of spiritual care practitioners, generally referred to patients and families, to support medical students and residents resulted in the co-development and co-implementation of a unique, reflective, one-hour session. The objective was to create a protected space and time to discuss the impact of training and clinical experiences on medical trainees' wellbeing, in the context of "living from the heart".

Running on empty: a review of nutrition and physicians' well-being.

Resident and physician burnout is a complex issue. Adequate nutrition and hydration play important roles in the maintenance of health and well-being of all individuals. Given the high prevalence of burnout in physicians, we believe that in addition to issues related to heavy workload, structure and length of shifts, the current status of physicians' nutrition and hydration and their effects on their work performance and well-being should also be addressed. In this review, we summarise the current evidence on the potential effects of nutrition and hydration on physicians' occupational well-being and performance, identify gaps and discuss opportunities to address nutrition as one of the important means of improving physicians' well-being.

Odanacatib for the treatment of osteoporosis.

INTRODUCTION: Osteoporosis and fragility fractures are important public health concerns. Cathepsin K inhibitors, including odanacatib , are a novel class of medications for osteoporosis whose mechanism of action is to directly inhibit bone resorption without killing osteoclasts, thereby permitting the complex coupling between bone resorption and formation to continue. AREAS COVERED: The physiological basis for the mechanism of action of cathepsin K inhibitors is covered in addition to a review of the preclinical, Phase I, Phase II and preliminary Phase III trial data of odanacatib. EXPERT OPINION: Evidence suggests that odanacatib has similar efficacy to bisphosphonates at increasing bone mineral density and decreasing risk of fragility fractures. Although odanacatib may preferentially inhibit bone resorption more than formation, the clinical significance of this difference in mechanism of action is not yet known. A careful analysis of the Phase III trial data is needed with specific attention to adverse events.

Effect of vitamin D status on clinical pregnancy rates following in vitro fertilization.

BACKGROUND: Recent studies suggest that vitamin D may play a role in human reproduction. Our goal was to investigate whether vitamin D levels are predictive of implantation and clinical pregnancy rates in infertile women following in vitro fertilization (IVF). METHODS: We prospectively evaluated vitamin D status, as determined by serum 25-hydroxy-vitamin D (25[OH]D) levels, in a cohort of 173 women undergoing IVF at Mount Sinai Hospital, Toronto, Ontario. Serum 25(OH)D samples were collected within 1 week before oocyte retrieval. We classified patients as having sufficient (≥ 75 nmol/L) or insufficient (or deficient; hereafter referred to as "insufficient"; < 75 nmol/L) serum levels of 25(OH)D. We compared patient demographics and IVF cycle parameters between groups. The primary outcome measure was clinical pregnancy (intrauterine sac visible on ultrasound performed 4-5 weeks after embryo transfer). RESULTS: Of the included women, 54.9% had insufficient 25(OH)D levels and 45.1% had sufficient levels. Women with sufficient levels had significantly higher rates of clinical pregnancy per IVF cycle started (52.5%) compared with women with insufficient levels (34.7%; p < 0.001). Implantation rates were also higher in the sufficient 25(OH)D group, but the results were not statistically significant. Multivariable logistic regression analysis (adjusted for age, body mass index and day 5 [v. day 3] embryo transfer) showed that serum 25(OH)D level may be a predictor of clinical pregnancy (adjusted odds ratio 1.01, 95% confidence interval 1.00-1.03). INTERPRETATION: Our findings suggest that women with sufficient levels of vitamin D are significantly more likely to achieve clinical pregnancy following IVF. Vitamin D supplementation could provide an easy and cost-effective way of improving pregnancy rates; this merits further investigation. TRIAL REGISTRATION: ClinicalTrials.gov, no. NCT01348594.

Concussion knowledge among medical students and neurology/neurosurgery residents.

BACKGROUND AND OBJECTIVES: Concussion is a prevalent brain injury in the community. While primary prevention strategies need to be enhanced, it is also important to diagnose and treat concussions expertly and expeditiously to prevent serious complications that may be life-threatening or long lasting. Therefore, physicians should be knowledgeable about the diagnosis and management of concussions. The present study assesses Ontario medical students' and residents' knowledge of concussion management. METHODS: A survey to assess the knowledge and awareness of the diagnosis and treatment of concussions was developed and administered to graduating medical students (n= 222) and neurology and neurosurgery residents (n = 80) at the University of Toronto. RESULTS: Residents answered correctly significantly more of the questions regarding the diagnosis and management of concussions than the medical students (mean = 5.8 vs 4.1, t= 4.48, p<0.01). Gender, participation in sports, and personal concussion history were not predictive of the number of questions answered correctly. Several knowledge gaps were identified in the sample population as a whole. Approximately half of the medical students and residents did not recognize chronic traumatic encephalopathy (n = 36) or the second impact syndrome (n = 44) as possible consequences of repetitive concussions. Twenty-four percent of the medical students (n = 18) did not think that "every concussed individual should see a physician" as part of management. CONCLUSIONS: A significant number of medical students and residents have incomplete knowledge about concussion diagnosis and management. This should be addressed by targeting this population during undergraduate medical education.