Influence of non-osteoporotic treatments in patients on active anti-osteoporotic therapy: evidence from the OSTEOMED registry.

PURPOSE: To evaluate the effect of different non-osteoporotic drugs on the increase or decrease in the risk of incident fragility fractures (vertebral, humerus or hip) in a cohort of patients diagnosed with osteoporosis on active anti-osteoporotic therapy. METHODS: For this retrospective longitudinal study, baseline and follow-up data on prescribed non-osteoporotic treatments and the occurrence of vertebral, humerus or hip fractures in 993 patients from the OSTEOMED registry were analyzed using logistic regression models. The drugs evaluated with a possible beneficial effect were thiazides and statins, while the drugs evaluated with a possible harmful effect were antiandrogens, aromatase inhibitors, proton pump inhibitors, selective serotonin reuptake inhibitors, benzodiazepines, GnRH agonists, thyroid hormones, and oral and inhaled corticosteroids. RESULTS: Logistic regression analyses indicated that no treatment significantly improved fracture risk, with the only treatments that significantly worsened fracture risk being letrozole (OR = 0.18, p-value = 0.03) and oral corticosteroids at doses ≤ 5 mg/day (OR = 0.16, p-value = 0.03) and > 5 mg/day (OR = 0.27, p-value = 0.04). CONCLUSION: The potential beneficial or detrimental effects of the different drugs evaluated on fracture risk are masked by treatment with anabolic or antiresorptive drugs that have a more potent action on bone metabolism, with two exceptions: letrozole and oral corticosteroids. These findings may have important clinical implications, as patients receiving these treatments are not fully protected by bisphosphonates, which may imply the need for more potent anti-osteoporotic drugs such as denosumab or teriparatide.

Comorbidity and osteoporotic fracture: approach through predictive modeling techniques using the OSTEOMED registry.

PURPOSE: To examine the response to anti-osteoporotic treatment, considered as incident fragility fractures after a minimum follow-up of 1 year, according to sex, age, and number of comorbidities of the patients. METHODS: For this retrospective observational study, data from baseline and follow-up visits on the number of comorbidities, prescribed anti-osteoporotic treatment and vertebral, humerus or hip fractures in 993 patients from the OSTEOMED registry were analyzed using logistic regression and an artificial network model. RESULTS: Logistic regression showed that the probability of reducing fractures for each anti-osteoporotic treatment considered was independent of sex, age, and the number of comorbidities, increasing significantly only in males taking vitamin D (OR = 7.918), patients without comorbidities taking vitamin D (OR = 4.197) and patients with ≥ 3 comorbidities taking calcium (OR = 9.412). Logistic regression correctly classified 96% of patients (Hosmer-Lemeshow = 0.492) compared with the artificial neural network model, which correctly classified 95% of patients (AUC = 0.6). CONCLUSION: In general, sex, age and the number of comorbidities did not influence the likelihood that a given anti-osteoporotic treatment improved the risk of incident fragility fractures after 1 year, but this appeared to increase when patients had been treated with risedronate, strontium or teriparatide. The two models used classified patients similarly, but predicted differently in terms of the probability of improvement, with logistic regression being the better fit.

Multiple vertebral fractures after suspension of denosumab. A series of 56 cases.

BACKGROUND: Denosumab is a monoclonal antibody approved for the treatment of postmenopausal osteoporosis. The withdrawal of denosumab produces an abrupt loss of bone mineral density and may cause multiple vertebral fractures (MVF). OBJECTIVE: The objective of this study is to study the clinical, biochemical, and densitometric characteristics in a large series of postmenopausal women who suffered MVF after denosumab withdrawal. Likewise, we try to identify those factors related to the presence of a greater number of vertebral fractures (VF). PATIENTS AND METHODS: Fifty-six patients (54 women) who suffered MVF after receiving denosumab at least for three consecutive years and abruptly suspended it. A clinical examination was carried out. Biochemical bone remodelling markers (BBRM) and bone densitometry at the lumbar spine and proximal femur were measured. VF were diagnosed by magnetic resonance imaging MRI, X-ray, or both at dorsal and lumbar spine. RESULTS: Fifty-six patients presented a total of 192 VF. 41 patients (73.2%) had not previously suffered VF. After discontinuation of the drug, a statistically significant increase in the BBRM was observed. In the multivariate analysis, only the time that denosumab was previously received was associated with the presence of a greater number of VF (P = .04). CONCLUSIONS: We present the series with the largest number of patients collected to date. 56 patients accumulated 192 new VF. After the suspension of denosumab and the production of MVF, there was an increase in the serum values of the BBRM. The time of denosumab use was the only parameter associated with a greater number of fractures.

¿Es necesario modificar los ensayos clínicos sobre osteoporosis? El grave problema de denosumab / Is it necessary to modify the clinical trials about osteoporosis? The serious problem of denosumab

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Cholecalciferol or Calcifediol in the Management of Vitamin D Deficiency.

Vitamin D deficiency is a global health problem due to its high prevalence and its negative consequences on musculoskeletal and extra-skeletal health. In our comparative review of the two exogenous vitamin D supplementation options most used in our care setting, we found that cholecalciferol has more scientific evidence with positive results than calcifediol in musculoskeletal diseases and that it is the form of vitamin D of choice in the most accepted and internationally recognized clinical guidelines on the management of osteoporosis. Cholecalciferol, unlike calcifediol, guarantees an exact dosage in IU (International Units) of vitamin D and has pharmacokinetic properties that allow either daily or even weekly, fortnightly, or monthly administration in its equivalent doses, which can facilitate adherence to treatment. Regardless of the pattern of administration, cholecalciferol may be more likely to achieve serum levels of 25(OH)D (25-hydroxy-vitamin D) of 30-50 ng/mL, an interval considered optimal for maximum benefit at the lowest risk. In summary, the form of vitamin D of choice for exogenous supplementation should be cholecalciferol, with calcifediol reserved for patients with liver failure or severe intestinal malabsorption syndromes.

Suplementación con vitamina D y salud musculoesquelética. Una necesidad discutida / Vitamin D supplementation and musculoskeletal health. A controversial necessity

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Tendencias de actuación de los cirujanos de columna respecto a la osteoporosis / Trends and attitudes of spine surgeons regarding osteoporosis

Antecedentes y objetivos: Con cada vez mayor frecuencia neurocirujanos y otros especialistas nos vemos afrontados al tratamiento de pacientes con osteoporosis que requieren una cirugía de fusión de columna. Pese a existir tratamientos farmacológicos efectivos e innovaciones en las técnicas quirúrgicas que pueden beneficiar a estos pacientes, se han reportado tasas bajas de diagnóstico y tratamiento preoperatorio de osteoporosis, además de una escasa participación de los cirujanos de columna en este ámbito. El objetivo de este estudio fue evaluar las tendencias en el diagnóstico y tratamiento respecto a la osteoporosis en los cirujanos de raquis de la comunidad neuroquirúrgica. Material y métodos: Se realizó una encuesta electrónica con 10 preguntas de opción múltiple a los miembros de la Sociedad Española de Neurocirugía (SENEC). Se valoraron: 1) papel del cirujano de columna frente a la osteoporosis en la artrodesis de raquis, 2) la influencia de osteoporosis en la seudoartrosis y 3) tendencias de tratamiento respecto a las fracturas vertebrales osteoporóticas. Resultados: Obtuvimos un total de 77 cuestionarios respondidos. En los pacientes con sospecha de osteoporosis, un 32,5% de los encuestados no se plantea ninguna medida para diagnosticarla antes de una artrodesis vertebral. En osteoporóticos sin tratamiento, un 37,7% procedería con la cirugía sin tratamiento o lo haría después de la cirugía. El 48% de los respondedores optaría por modificar su estrategia quirúrgica en los pacientes con osteoporosis. La técnica quirúrgica preferida fue la colocación de tornillos cementados (70%). En la seudoartrosis, el 46,1% no considera necesario el diagnóstico de osteoporosis para una reintervención. En las fracturas vertebrales osteoporóticas, el 80,5% de los cirujanos se plantea alguna medida que facilitara el tratamiento de la osteoporosis. Conclusiones: Una mayor participación del cirujano de columna mejoraría el diagnóstico y tratamiento preoperatorio de la osteoporosis en las cirugías de artrodesis vertebral y seudoartrosis. En las fracturas vertebrales existe una mejor concienciación para optimizar el tratamiento y el seguimiento de la osteoporosis

Background and objectives: Neurosurgeons and other specialists are increasingly having to treat patients with osteoporosis who require spinal fusion surgery. Although there are effective pharmacological treatments and innovations in surgical techniques that can benefit these patients, low rates of diagnosis and preoperative treatment of osteoporosis have been reported, in addition to the limited participation of spine surgeons in this area. The objective of this study was to evaluate trends in diagnosis and treatment of osteoporosis with regard to spine surgeons of the neurosurgical community. Material and methods: An electronic survey with 10 multiple-choice questions was issued to Spanish Neurosurgery Society (SENEC) members. The following were evaluated: 1) the surgeon's role regarding osteoporosis in spinal arthrodesis, 2) the influence of osteoporosis in pseudarthrosis, and 3) treatment trends in relation to osteoporotic vertebral fractures. Results: A total of 77 completed questionnaires were obtained. In patients with suspected osteoporosis, 32.5% of respondents did not consider any measure to diagnose it before spinal arthrodesis. In osteoporosis without treatment, 37.7% would proceed with surgery without treatment or would do so after surgery. A total of 48% of respondents would choose to modify their surgical strategy in patients with osteoporosis. The preferred surgical technique was the placement of augmentation screws (70%). In pseudarthrosis, 46.1% did not consider an osteoporosis diagnosis to be necessary for a reoperation. In osteoporotic vertebral fractures, 80.5% of surgeons considered some measure that would facilitate the treatment of osteoporosis. Conclusions: Greater participation of the spine surgeon could improve the diagnosis and preoperative treatment of osteoporosis in spinal arthrodesis surgery and pseudarthrosis. In vertebral fractures, there is greater awareness of the optimisation of treatment and monitoring of osteoporosis

Hip fractures following denosumab discontinuation: three clinical cases reports.

A significant loss of bone mineral density and the appearance of multiple vertebral fractures after discontinuation of denosumab treatment have been described. To date, no hip fractures have been reported. We present three cases of patients who suffered femoral fractures after denosumab suppression.

[How does the new spinal-cord-injured patient profile influence bladder management?] / ¿Cómo afecta el nuevo perfil del lesionado medular al manejo vesical?

OBJECTIVES: To describe the bladder management in spinal cord injury and to verify if the increase in the age of the patient who is suffering a spinal cord injury in recent years is conditioning a change in its treatment. METHODS: We performed a retrospective review of all acute traumatic spinal cord injured patients in Canary Islands between 2001-2015. Data were collected from the hospital records of a regional referral Spinal Cord Unit. RESULTS: The sample included 250 patients. Patients' mean age was observed to increase from 38 to 47 years during the study (p<0.05). Clean Intermittent Catheterization (CIC) was the most used bladder emptying method (42.4%), followed by normal voiding (NV) (26.4%) and permanent derivation (PD) (23.6%). There was a decrease in CIC use (48.1% to 40.3%) and an increase in PD use (13.5% to 32.5%) ( p<0.05 ). Cervical injuries were associated with NV (35.8%), while thoracic and lumbar injuries were associated with IC (67% and 41.7% respectively). Patients discharged to a health care residence were associated with IC (81.8%) (p<0.05). CONCLUSIONS: CIC is currently the most frequently used bladder emptying method in spinal cord injured patients in our population. The mean age of new spinal cord injury patients is progressively increasing and it promotes the use of indwelling catheter with an increased risk of urologic complications.

OBJETIVOS: Describir el manejo vesical en pacientes con una lesión medular y comprobar si el aumento de la edad media del paciente que está sufriendo una lesión medular en los últimos años está condicionando un cambio en su tratamiento.MATERIALES Y MÉTODOS: Hemos realizado un estudio retrospectivo de todos los pacientes que han sufrido una lesión medular traumática aguda en Canarias entre el 2001-2015. Los datos se han recogido del registro hospitalario de una unidad de referencia regional para la lesión medular. RESULTADOS: La muestra ha sido de 250 pacientes. La media de edad del paciente aumentó de 38 a 47 años a lo largo del estudio (p< 0,05). El cateterismo intermitente (CI) fue el método de vaciado vesical más usado (42,4%) seguido de la micción voluntaria (MV) (26,4%) y la derivación permanente (DP) (23,6%). Durante este tiempo hubo un descenso en el uso del CI (48,1% a 35,4%) y un aumento de la DP (13,5% a 32,5%) (p< 0,05). Las lesiones cervicales se relacionaron con la MV (35,8%) mientras que las lesiones dorsales y lumbares lo hicieron con el CI (67% y 41,7% respectivamente). El destino al alta a una residencia se asoció con la DP (81,8%) (p<0,05). CONCLUSIONES: El CI es actualmente el método de vaciado vesical más usado en el lesionado medular en nuestro medio. El aumento de la edad media del paciente que sufre una lesión medular está favoreciendo un progresivo incremento de la derivación permanente con el riesgo de complicaciones urológicas que puede ocasionar.

¿Cómo afecta el nuevo perfil del lesionado medular al manejo vesical? / How does the new spinal-cord-injured patient profile influence bladder management?

Objetivos: Describir el manejo vesical en pacientes con una lesión medular y comprobar si el aumento de la edad media del paciente que está sufriendo una lesión medular en los últimos años está condicionando un cambio en su tratamiento. Materiales y métodos: Hemos realizado un estudio retrospectivo de todos los pacientes que han sufrido una lesión medular traumática aguda en Canarias entre el 2001-2015. Los datos se han recogido del registro hospitalario de una unidad de referencia regional para la lesión medular. Resultados: La muestra ha sido de 250 pacientes. La media de edad del paciente aumentó de 38 a 47 años a lo largo del estudio (p< 0,05). El cateterismo intermitente (CI) fue el método de vaciado vesical más usado (42,4%) seguido de la micción voluntaria (MV) (26,4%) y la derivación permanente (DP) (23,6%). Durante este tiempo hubo un descenso en el uso del CI (48,1% a 35,4%) y un aumento de la DP (13,5% a 32,5%) (p< 0,05). Las lesiones cervicales se relacionaron con la MV (35,8%) mientras que las lesiones dorsales y lumbares lo hicieron con el CI (67% y 41,7% respectivamente). El destino al alta a una residencia se asoció con la DP (81,8%) (p<0,05). Conclusiones: El CI es actualmente el método de vaciado vesical más usado en el lesionado medular en nuestro medio. El aumento de la edad media del paciente que sufre una lesión medular está favoreciendo un progresivo incremento de la derivación permanente con el riesgo de complicaciones urológicas que puede ocasionar

Objectives: To describe the bladder management in spinal cord injury and to verify if the increase in the age of the patient who is suffering a spinal cord injury in recent years is conditioning a change in its treatment. Methods: We performed a retrospective review of all acute traumatic spinal cord injured patients in Canary Islands between 2001-2015. Data were collected from the hospital records of a regional referral Spinal Cord Unit. Results: The sample included 250 patients. Patients' mean age was observed to increase from 38 to 47 years during the study (p < 0.05). Clean Intermittent Catheterization (CIC) was the most used bladder emptying method (42.4%), followed by normal voiding (NV) (26.4%) and permanent derivation (PD) (23.6%). There was a decrease in CIC use (48.1% to 40.3%) and an increase in PD use (13.5% to 32.5%) (p < 0.05). Cervical injuries were associated with NV (35.8%), while thoracic and lumbar injuries were associated with IC (67% and 41.7% respectively). Patients discharged to a health care residence were associated with IC (81.8%) (p < 0.05). Conclusions: CIC is currently the most frequently used bladder emptying method in spinal cord injured patients in our population. The mean age of new spinal cord injury patients is progressively increasing and it promotes the use of indwelling catheter with an increased risk of urologic complications

Trends and attitudes of spine surgeons regarding osteoporosis. / Tendencias de actuación de los cirujanos de columna respecto a la osteoporosis.

BACKGROUND AND OBJECTIVES: Neurosurgeons and other specialists are increasingly having to treat patients with osteoporosis who require spinal fusion surgery. Although there are effective pharmacological treatments and innovations in surgical techniques that can benefit these patients, low rates of diagnosis and preoperative treatment of osteoporosis have been reported, in addition to the limited participation of spine surgeons in this area. The objective of this study was to evaluate trends in diagnosis and treatment of osteoporosis with regard to spine surgeons of the neurosurgical community. MATERIAL AND METHODS: An electronic survey with 10 multiple-choice questions was issued to Spanish Neurosurgery Society (SENEC) members. The following were evaluated: 1) the surgeon's role regarding osteoporosis in spinal arthrodesis, 2) the influence of osteoporosis in pseudarthrosis, and 3) treatment trends in relation to osteoporotic vertebral fractures. RESULTS: A total of 77 completed questionnaires were obtained. In patients with suspected osteoporosis, 32.5% of respondents did not consider any measure to diagnose it before spinal arthrodesis. In osteoporosis without treatment, 37.7% would proceed with surgery without treatment or would do so after surgery. A total of 48% of respondents would choose to modify their surgical strategy in patients with osteoporosis. The preferred surgical technique was the placement of augmentation screws (70%). In pseudarthrosis, 46.1% did not consider an osteoporosis diagnosis to be necessary for a reoperation. In osteoporotic vertebral fractures, 80.5% of surgeons considered some measure that would facilitate the treatment of osteoporosis. CONCLUSIONS: Greater participation of the spine surgeon could improve the diagnosis and preoperative treatment of osteoporosis in spinal arthrodesis surgery and pseudarthrosis. In vertebral fractures, there is greater awareness of the optimisation of treatment and monitoring of osteoporosis.

Seudohernia abdominal tras lesión medular. A propósito de 3 casos / Abdominal pseudohernia after spinal cord injury: Report of three cases

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Change in the profile of traumatic spinal cord injury over 15 years in Spain.

BACKGROUND: Traumatic spinal cord injury remains a serious public health and social problem. Although incidence rates are decreasing in our environment, it is a high cost condition that is associated with great disability. The objective of this study was to describe the epidemiological and demographic characteristics of traumatic spinal cord injury and to analyse its epidemiological changes. METHODS: This study was an observational study with prospective monitoring of all traumatic spinal cord injury patients in the Canary Islands, Spain (2.1 million inhabitants) between 2001 and 2015. RESULTS: Over the specified period of the study, 282 patients suffered a traumatic spinal cord injury. The crude incidence rate was 9.3 cases per million people/year. The patients' mean age increased from 38 years (2001-2005) to 48 years (2011-2015) (p < 0.05). Overall, 80.1% of patients were males. The trauma mechanisms of spinal cord injury were falls in 44%, traffic accidents in 36.5%, diving accidents in 8.9% and others in 10.7%. While traffic accidents decreased, falls increased, particularly in the elderly (p < 0.05). The most frequently affected level was the cervical spine (50.9%), and incomplete tetraplegia was the most prevalent group (29.8%). A total of 76.6% of all patients suffered a vertebral fracture, and 91.6% of these required surgery. Among 282 patients, 12.5% were transferred to residences. The patients transferred increased from 8.5% in the first period to 20.0% (p < 0.05) in the last period. Such cases were related to age, cervical level injuries and injuries associated with poor functionality (p < 0.05). CONCLUSIONS: The rise in the number of falls among the older population, as well as the reduction in traffic accidents, decreased the incidence of traumatic spinal cord injury in our environment. This change in the profile of new traumatic spinal cord injuries led us to reformulate the functional objectives planned for these patients upon admission to specialized units, to plan destination-upon-discharge in advance and to promote campaigns to prevent spinal cord injury in older adults.

High Serum Retinol as a Relevant Contributor to Low Bone Mineral Density in Postmenopausal Osteoporotic Women.

There is controversial information about the impact of vitamin A on bone. Some epidemiological studies show that excessive intake of vitamin A, or an excess of serum vitamin A, has related with adverse impact on bone mass; however, other studies did not find these links, and some authors have proposed that this vitamin might promote a better bone health. The present work aims to contribute to clarify the real role of vitamin A in bone tissue. For this purpose, a cross-sectional study of 154 osteoporotic non-treated postmenopausal women (> 65 years old) was carried out. Bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry. We assessed concentrations of serum retinol, osteocalcin, parathyroid hormone, alkaline phosphatase, calcium, and phosphorus. We also studied demographic and anthropometric parameters. Spearman's correlations between retinol levels and other variables found negative correlations with BMD in both lumbar spine (R = - 0.162, P < 0.01) and femoral neck (R = - 0.182, P < 0.01), as well as alkaline phosphatase (R = - 0.110; P < 0.05) and phosphorus (R = - 0.110; P < 0.05). A positive correlation between retinol and fertile window was observed (R = 0.158; P < 0.01). After multivariable adjustment, we still found a negative correlation between serum retinol and BMD, both at the lumbar spine (R = - 0.210; P < 0.01) and at the femoral neck (R = - 0.324, P < 0.001). It is concluded that elevated serum-retinol levels are associated with an increased risk of low bone mass and thus with osteoporotic fractures. Therefore, osteoporosis-risk assessment should include quantification of serum metabolite of vitamin A.

Lesión medular secundaria a zambullida en Canarias / Spinal cord injuries resulting from diving accidents in the Canary Islands

Objetivo: La zambullida es una de las principales causas de lesión medular, tras las caídas y los accidentes de tráfico. El objetivo de este estudio es conocer las características epidemiológicas y clínicas de estos pacientes en nuestro medio para realizar una mejor prevención. Material y métodos: Se ha realizado un estudio descriptivo retrospectivo de los pacientes que han sufrido una lesión medular de origen traumático tras una zambullida en la comunidad autónoma canaria desde el 2000 hasta el 2014 y que ingresaron en la Unidad de Lesionados Medulares del Hospital Universitario Insular de Gran Canaria. Resultados: De los 264 pacientes que ingresaron en nuestra unidad por una lesión medular traumática aguda, 23 (8,7%) fueron por una zambullida. Si se agrupan los pacientes por quinquenios, entre el 2000 y el 2005 se produjeron el 56% de las lesiones, entre el 2006 y el 2010 el 17% y entre el 2011 y el 2014 el 26%. Todos los pacientes eran varones, con una media de edad de 29años. El 65% eran menores de 30años. Veintidós de 23 pacientes sufrieron una fractura vertebral C5 —el nivel vertebral más afectado— y la fractura aplastamiento fue la más prevalente. El 86% fueron intervenidos quirúrgicamente. Todas las lesiones medulares fueron cervicales, siendo C6 el nivel neurológico afectado con más frecuencia. El 65% presentaban una lesión medular completa. Conclusiones: Las lesiones medulares tras una zambullida son la tercera causa de lesión medular traumática en nuestro medio. Afecta a varones jóvenes, y la presentación clínica más frecuente es una lesión medular cervical completa. Dado el carácter irreversible de la lesión, es de gran importancia la prevención, dirigida principalmente a la población juvenil

Objective: Diving accidents is one of the leading causes of spinal cord injury after falls and car accidents. The objective of this study was to determine the epidemiological and clinical characteristics of these patients in our setting to better prevent these injuries. Material and methods: We performed a retrospective, descriptive study of patients who have suffered from a traumatic spinal cord injury after a diving accident in the Canary Islands, Spain from 2000 to 2014. These patients were admitted to the Spinal Cord Unit of Hospital Universitario Insular de Gran Canaria. Results: Of the 264 patients admitted to our unit for acute traumatic spinal cord injury, 23 (8.7%) cases were due to diving. Grouping the patients into 5years periods, 56% of the injuries occurred in 2000-2005, 17% in 2006-2010 and 26% in 2011-2014. All patients were male, with a mean age of 29years. Approximately 65% were under 30years. A total of 22/23 patients had a fracture and injury most commonly occurred to the C5 vertebra. Burst fractures were the most common. A total of 86% of cases underwent surgery. All the spinal cord injuries were cervical, with C6 being the neurological level most often affected. A total of 65% of spinal cord injuries were complete injuries. Conclusions: Spinal cord injury secondary to diving accidents is the third leading cause of traumatic spinal cord injury in our setting. It affects young males and the most common clinical presentation is a complete cervical spinal cord injury. Given the irreversible nature of the injury, prevention, aimed mainly at young people, is of great importance