The Official Positions of the International Society for Clinical Densitometry: vertebral fracture assessment.

Vertebral fracture assessment (VFA) is a low-cost method of accurately identifying individuals who have clinically unrecognized or undocumented vertebral fractures at the time of bone density test. Because prevalent vertebral fractures predict subsequent fractures independent of bone mineral density and other clinical risk factors, their recognition is an important part of strategies to identify those who are at high risk of fracture, so that prevention therapies for those individuals can be implemented. The 2007 Position Development Conference developed detailed guidelines regarding the indications for acquisition of, and interpretation and reporting of densitometric VFA tests. The purpose of the 2013 VFA Task Force was to simplify the indications for VFA yet keep them evidence based. The Task Force reviewed the literature published since the 2007 Position Development Conference and developed prediction models based on 2 large cohort studies (the Study of Osteoporotic Fractures and the Osteoporotic Fractures in Men Study) and the densitometry database of the University of Chicago. Based on these prediction models, indications for VFA were reduced to a simplified set of criteria based on age, historical height loss, use of systemic glucocorticoid therapy, and self-reported but undocumented prior vertebral fracture.

Indications of DXA in women younger than 65 yr and men younger than 70 yr: the 2013 Official Positions.

Dual-energy X-ray absorptiometry (DXA) is the method of choice to assess fracture risk for women 65 yr and older and men 70 yr and older. The 2007 International Society for Clinical Densitometry Official Positions had developed guidelines for assessing bone density in younger women during and after the menopausal transition and in men 50-69 yr and the 2008 National Osteoporosis Foundation (NOF) guidelines recommended testing in postmenopausal women younger than 65 yr and men 50-69 yr only in the presence of clinical risk factors. The purpose of the 2013 DXA Task Force was to reassess the NOF guidelines for ordering DXA in postmenopausal women younger than 65 yr and men 50-69 yr. The Task Force reviewed the literature published since the 2007 Position Development Conference and 2008 NOF, reviewing clinical decision rules such as the Osteoporosis Screening Tool and FRAX and sought to keep recommendations simple to remember and implement. Based on this assessment, the NOF guidelines were endorsed; DXA was recommended in those postmenopausal women younger than 65 yr and men 50-69 yr only in the presence of clinical risk factors for low bone mass, such as low body weight, prior fracture, high-risk medication use, or a disease or condition associated with bone loss.

Relationship between vitamin D status and incidence of vascular events in the Veterans Affairs Diabetes Trial.

OBJECTIVE: Few studies have examined the relationship between vitamin D levels and incident cardiovascular events in large well-characterized patient cohorts. Therefore, our objective was to determine if low vitamin D levels predicted vascular complications of diabetes. METHODS: Prospective analysis of 936 veterans with type 2 diabetes (59.7 ± 8.4 years, 96.9% male) who participated in the Veteran Affairs Diabetes Trial (VADT) was conducted. 25(OH)-vitamin D was measured a median of two years after entry and participants were subsequently followed 3.7 years. Hazard ratios (HRs) were calculated for cardiovascular endpoints in relation to 25(OH)-vitamin D quartile. For microvascular endpoints, logistic regression was used to calculate odds ratios. RESULTS: After adjusting for age, minority status, treatment arm and history of prior event, individuals in the lowest vitamin D quartile (i.e., 1-15.9 ng/ml) were at similar risk of MI [HR = 1.13 (95% CI: 0.53, 2.42)], CHD [HR = 0.87 (95% CI: 0.49, 1.55)], congestive heart failure [HR = 1.44 (95% CI: 0.67, 3.06)], and death from any cause [HR = 1.04 (95% CI: 0.53, 2.04)] as individuals in the highest vitamin D quartile (i.e., 29.9-77.2 ng/ml). Similarly, there were no differences in the odds associated with retinopathy or renal disease onset or progression in the lowest versus highest vitamin D quartile. CONCLUSIONS: These data indicate that vitamin D status had no significant impact on the incidence of vascular events in a cohort of high-risk veterans with diabetes in which traditional risk factors were managed according to current treatment guidelines.

Bone geometry profiles in women with and without SLE.

Recent studies have reported an increased risk of fracture among patients with systemic lupus erythematosus (SLE) in comparison with the general population. The aim of this study was to examine associations between SLE status and bone geometry in white and African-American women. We compared hip BMD and bone geometry parameters among SLE women and control individuals using hip structure analysis (HSA). One-hundred and fifty-three dual-energy X-ray absorptiometry (DXA) scans from the Study of Lupus Vascular and Bone Long Term Endpoints (68.7% white and 31.3% African American) and 4920 scans from the Third National Health and Nutrition Examination Survey (59.3% white and 40.7% African American) were analyzed. Linear regression was used to examine BMD and bone geometry differences by SLE status and by race/ethnicity after adjusting for age and BMI. Significant differences were detected between SLE and control women. Among white women, age-adjusted BMD (g/cm(2)), section modulus (cm(3)), and cross-sectional areas (cm(2)) were lower among SLE women than among control women at the narrow neck (0.88 versus 0.83 g/cm(2), 1.31 versus 1.11 cm(2), and 2.56 versus 2.40 cm(2), p < 0.001, p < 0.01, and p < 0.0001, respectively), whereas buckling ratio was increased (10.0 versus 10.6, p < 0.01). Likewise, BMD, section modulus, and cross-sectional areas were decreased among African-American SLE women at all subregions, whereas buckling ratios were increased. There were significant bone geometry differences between SLE and control women at all hip subregions. Bone geometry profiles among SLE women were suggestive of increased fragility.

Skeletal manifestations of systemic autoimmune diseases.

PURPOSE OF REVIEW: There is an increased risk of osteoporotic fractures and osteonecrosis often at a young age among patients with certain systemic autoimmune diseases. The loss of bone mineral density and bone integrity seen with these diseases often cannot be explained by traditional risk factors alone. In this review, we focus on rheumatoid arthritis and systemic lupus erythematosus, two systemic autoimmune diseases in which skeletal manifestations have been well described. RECENT FINDINGS: There is recent evidence that autoimmunity and its associated inflammation and vitamin D deficiency play key roles in the pathogenesis of adverse skeletal effects. SUMMARY: Understanding these processes carries implications for the prevention and treatment of osteoporosis and osteonecrosis among patients with autoimmune diseases.

The importance of inflammation and vitamin D status in SLE-associated osteoporosis.

Epidemiological studies demonstrate an increased prevalence of low bone mineral density (BMD) and fragility fracture among systemic lupus erythematosus (SLE) patients in comparison to the general population. Although corticosteroid usage is a common cause of low BMD in this patient population, there is evidence that other factors are also involved. Recent publications have demonstrated an association between the inflammatory nature of SLE and low BMD. Inflammation can adversely alter bone metabolism, leading to a detrimental effect on bone material and structure. In addition, several reports have highlighted the prevalence of inadequate vitamin D status among the SLE patient population. Inadequate vitamin D status can compound the problem of low BMD, leading to increased bone fragility among SLE patients.