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.

Are patients with hypermobile Ehlers-Danlos syndrome or hypermobility spectrum disorder so different?

Diagnosing hypermobile Ehlers-Danlos syndrome (hEDS) remains challenging, despite new 2017 criteria. Patients not fulfilling these criteria are considered to have hypermobile spectrum disorder (HSD). Our first aim was to evaluate whether patients hEDS were more severely affected and had higher prevalence of extra-articular manifestations than HSD. Second aim was to compare their outcome after coordinated physical therapy. Patients fulfilling hEDS/HSD criteria were included in this real-life prospective cohort (November 2017/April 2019). They completed a 16-item Clinical Severity Score (CSS-16). We recorded bone involvement, neuropathic pain (DN4) and symptoms of mast cell disorders (MCAS) as extra-articular manifestations. After a standardized initial evaluation (T0), all patients were offered the same coordinated physical therapy, were followed-up at 6 months (T1) and at least 1 year later (T2), and were asked whether or not their condition had subjectively improved at T2. We included 97 patients (61 hEDS, 36 HSD). Median age was 40 (range 18-73); 92.7% were females. Three items from CSS-16 (pain, motricity problems, and bleeding) were significantly more severe with hEDS than HSD. Bone fragility, neuropathic pain and MCAS were equally prevalent. At T2 (20 months [range 18-26]) 54% of patients reported improvement (no difference between groups). On multivariable analysis, only family history of hypermobility predicted (favorable) outcome (p = 0.01). hEDS and HDS patients showed similar disease severity score except for pain, motricity problems and bleeding, and similar spectrum of extra-articular manifestations. Long-term improvement was observed in > 50% of patients in both groups. These results add weight to a clinical pragmatic proposition to consider hEDS/HSD as a single entity that requires the same treatments.

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.

Synovitis in rheumatoid arthritis detected by grey scale ultrasound predicts the development of erosions over the next three years.

OBJECTIVES: To evaluate grey scale US (GSUS) and power Doppler US synovitis (PDUS), separately or in combination (CombUS), to predict joint damage progression in RA. METHODS: In this cohort study nested in the Swiss RA register, all patients with sequential hand radiographs at their first US assessment were included. We analysed the summations of semi-quantitative GSUS, PDUS and CombUS assessments of both wrists and 16 finger joints (maximum 54 points) at their upper limit of normal, their 50th, 75th or 87.5th percentiles for the progression of joint damage (ΔXray). We adjusted for clinical disease activity measures at baseline, the use of biological DMARDs and other confounders. RESULTS: After a median of 35 months, 69 of 250 patients with CombUS (28%), 73 of 259 patients with PDUS (28%) and 75 of 287 patients with available GSUS data (26%) demonstrated joint damage progression. PDUS beyond upper limit of normal (1/54), GSUS and CombUS each at their 50th (9/54 and 10/54) and their 75th percentiles (14/54 and 15/54) were significantly associated with ΔXray in crude and adjusted models. In subgroup analyses, GSUS beyond 14/54 and CombUS higher than 15/54 remained significantly associated with ΔXray in patients on biological DMARDs, while clinical disease activity measures had no significant prognostic power in this subgroup. CONCLUSION: Higher levels of GSUS and CombUS are associated with the development of erosions. GSUS appears to be an essential component of synovitis assessment and an independent predictor of joint damage progression in patients on biological DMARDs.

"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.

[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.

Hepatosplenomegaly, pneumopathy, bone changes and fronto-temporal dementia: Niemann-Pick type B and SQSTM1-associated Paget's disease in the same individual.

Data from exome sequencing show that a proportion of individuals in whom a genetic disorder is suspected turn out to have not one, but two to four distinct ones. This may require an evolution in our diagnostic attitude towards individuals with complex disorders. We report a patient with splenomegaly, pneumopathy, bone changes and fronto-temporal dementia (FTD). "Sea-blue histiocytes" in his bone marrow pointed to a lysosomal storage disease. Homozygosity for a pathogenic mutation in the SMPD1 gene confirmed Niemann-Pick disease type B (NPD-B). Mild cognitive impairment and abnormal brain FDG PET were consistent with FTD. We initially tried to fit the skeletal and neurologic phenotype into the NPD-B diagnosis. However, additional studies revealed a pathogenic mutation in the SQSTM1 gene. Thus, our patient had two distinct diseases; NPD-B, and Paget's disease of bone with FTD. The subsequent finding of a mutation in SQSTM1 gene ended our struggle to explain the combination of findings by a singular "unifying" diagnosis and allowed us to make specific therapeutic decisions. SQSTM1 mutations have been reported in association with FTD, possibly because of defective autophagy. Bisphosphonates may be beneficial for PDB, but since they are known to inhibit acid sphingomyelinase activity, we refrained from using them in this patient. While the principle of looking for unifying diagnosis remains valid, physicians should consider the possibility of co-existing multiple diagnoses when clinical features are difficult to explain by a single one. Accurate diagnostic work-up can guide genetic counseling but also lead to better medical management.

Stopping Denosumab.

PURPOSE OF REVIEW: Denosumab discontinuation is associated with a rebound effect manifesting by an increased risk of multiple spontaneous vertebral fractures. The purpose of this review is to (1) better characterize this risk and (2) find solutions to avoid it. RECENT FINDINGS: In the absence of a potent bisphosphonate prescription at denosumab discontinuation, the frequency of multiple vertebral fractures is common or frequent (≥ 1/100 and < 1/10). In five recent case series, the median number of vertebral fractures was 5 within 7 to 20 months (median 11) after the last denosumab injection. Prescribing bisphosphonate before starting denosumab and/or after stopping denosumab may reduce this risk. However, only small case series have evaluated these strategies. After the second denosumab dose, there is a rebound effect with an increased risk of multiple vertebral fractures. A potent bisphosphonate prescribed at denosumab discontinuation could reduce this risk. As denosumab discontinuation is characterized by many uncertainties, denosumab is a second-line treatment for osteoporosis. Studies are urgently needed to define the management of denosumab discontinuation.

[What can we do at the discovery of an osteroporotic vertebral fracture†?] / Que faire face à une fracture vertébrale ostéoporotique†?

Osteoporotic vertebral fractures (VF) are common and can induce acute and chronic pain, having a negative impact on quality of life and lifespan. One man and one women over five will have one or more osteoporotic VF after the age of 50. The screening of these fractures is important because they are predictive of subsequent fractures. Most of the vertebral fractures are asymptomatic and therefore under-diagnosed. Clinics is the first screening tool and radiologic imaging will confirm any suspicion. The initiation of anti-fracture treatment is crucial to avoid future fractures. Physiotherapy and analgesics are part of the management of pain as well as vertebroplasty or kyphoplasty.

Les fractures vertébrales (FV) ostéoporotiques sont fréquentes et sont à l'origine de douleurs aiguës et chroniques ayant un impact important sur la qualité et la durée de vie. Un homme et une femme sur cinq présenteront une ou plusieurs FV ostéoporotiques après l'âge de 50 ans. Le dépistage de ces fractures est important car elles sont fortement prédictives de fractures subséquentes. La majorité des FV (> 60 %) sont asymptomatiques donc sous-diagnostiquées. L'examen clinique est le premier outil de dépistage des FV et les différentes imageries permettront de confirmer le diagnostic. L'initiation d'un traitement anti-fracturaire est primordiale afin d'éviter de futures fractures. La physiothérapie et les traitements antalgiques aideront à la gestion de la douleur, parfois renforcée par la vertébroplastie ou la kyphoplastie.

[How to manage the rebound effect at denosumab discontinuation and avoid multiple vertebral fractures?] / Comment gérer l'effet rebond à l'arrêt du dénosumab et éviter les fractures vertébrales multiples†?

Denosumab discontinuation is associated with a severe rebound effect combining elevation of bone remodeling markers for two years and loss of the gained bone density. In the absence of a potent bisphosphonate prescription at denosumab discontinuation, multiple vertebral fractures are frequent. The median number of vertebral fractures is 5, within 7 to 20 months (median 11) after the last denosumab injection. A potent bisphosphonate prescribed at denosumab discontinuation may reduce this risk. This strategy requires close monitoring of bone remodeling markers and adjustment of treatment if bone remodeling is not controlled.

L'arrêt du dénosumab est associé à un effet rebond sévère associant élévation des marqueurs du remodelage osseux pour deux ans et perte du gain de densité osseuse. A l'arrêt du dénosumab, en l'absence de prescription d'un puissant bisphosphonate, la fréquence des fractures vertébrales multiples est élevée. Le nombre médian de fractures vertébrales est de 5 dans les 7 à 20 mois (médiane 11) suivant la dernière injection de dénosumab. Un bisphosphonate puissant prescrit à l'arrêt du traitement de dénosumab pourrait réduire ce risque. Cette stratégie nécessite un suivi serré des marqueurs du remodelage osseux et un ajustement du traitement si le remodelage osseux n'est pas suffisamment contrôlé.

[Drugs induced osteopathies]. / Syndromes iatrogènes : les ostéopathies induites.

Drug induced bone diseases concerns : induced osteoporosis, induced osteomalacia (by loss of calcium, phosphate or vitamin D) and induced sarcopenia. Some of these drugs are well known, such as anti-hormones, corticotherapy (which could induce all of osteoporosis, osteomalacia and sarcopenia). In the present article, we will focus on 3 others less known but frequently used drugs : iron replacement, proton pump inhibitors therapy, and serotonin reuptake inhibitor antidepressants treatment. For each of them we will discuss the pathophysiological mechanism leading to bone fragility as well as the recommendations of prevention / management to be proposed in case of absolute necessity of the treatment.

Les pathologies osseuses induites par les médicaments regroupent : les ostéoporoses induites et les ostéomalacies sur carence ou pertes induites du calcium, du phosphate ou de la vitamine D. On peut aussi y ajouter les sarcopénies iatrogéniques. Certains de ces médicaments sont bien connus, comme les antihormones ou la cortisone qui, à elle seule, agit sur les 3 entités. Dans cet article, nous aborderons 3 autres familles de médicaments provoquant des pathologies osseuses, probablement moins connus mais pourtant très prescrits : les traitements substitutifs en fer, les inhibiteurs de la pompe à protons et les antidépresseurs sélectifs de la recapture de la sérotonine. Pour chacun d'entre eux, nous verrons le mécanisme physiopathologique conduisant à la fragilité osseuse ainsi que les règles de prévention/prise en charge à proposer en cas de nécessité absolue du traitement.

[Phosphocalcic anomalies and bone fragility keys for the general practitioner]. / Bilan phosphocalcique perturbé dans le cadre d'une fragilité osseuse : des clés pour le praticien.

How to recognize secondary causes of bone fragility in relation with an abnormal calcium and phosphate laboratory in general practice ? Through clinical cases presentations we will discuss the calcium and phosphate abnormalities which can be related to bone fragility and for which a-specific approach must be proposed. It can be abnormal results of calcium, phosphate or vitamin D. Some causes are frequent, others are iatrogenic, and others are related to a rare disease sometimes of genetic cause which consequences are more important than expected.

Comment reconnaître les causes secondaires de fragilité osseuse liées à un bilan phosphocalcique perturbé au cabinet ? A travers des vignettes cliniques, nous aborderons les désordres phosphocalciques qui peuvent être à l'origine d'une fragilité osseuse et pour lesquels une prise en charge indépendante doit être proposée. Il peut s'agir de la découverte d'une anomalie du calcium, du phosphate ou de la vitamine D. Certaines causes sont fréquentes, d'autres iatrogènes, et d'autres débouchent sur le diagnostic d'une maladie rare parfois de cause génétique dont les conséquences sont plus importantes que prévu.

[Denosumab in clinical practice : beware before, during and after]. / Dénosumab en routine clinique: précautions à prendre avant, pendant et après.

Denosumab is a very effective treatment of osteoporosis, easy to use and very well tolerated. Due to some associated risks, a close clinical follow-up is necessary. Before the first injection, it is necessary to correct hypocalcaemia or vitamin D deficiency when present. Calcemia has to be followed in case of renal insufficiency. Injections of denosumab should be done scrupulously every 6 months (± 3 weeks). Discontinuation of denosumab is associated with a severe rebound effect characterized by increased markers of bone remodeling, a rapid decrease of bone density values, and a risk of multiple spontaneous vertebral fractures. The administration of a potent bisphosphonate (zoledronate, alendronate) minimises or avoids this rebound effect.

Le dénosumab est un traitement très efficace de l'ostéoporose, simple d'utilisation et très bien toléré. Au vu de certains risques associés, un suivi clinique rapproché est nécessaire. Lors de son initiation, il faut corriger une hypocalcémie ou un déficit en vitamine D. Il faut suivre la calcémie en présence d'une insuffisance rénale. Les injections de dénosumab sont à faire scrupuleusement tous les 6 mois (± 3 semaines). L'arrêt du dénosumab s'accompagne d'un effet rebond sévère, caractérisé par une augmentation des marqueurs du remodelage osseux, une diminution rapide des valeurs de densité osseuse et un risque de fractures vertébrales multiples spontanées. L'administration d'un bisphosphonate puissant (zolédronate, alendronate) permet de pallier cet effet rebond.

Reproducibility of Vertebral Fracture Assessment Readings From Dual-energy X-ray Absorptiometry in Both a Population-based and Clinical Cohort: Cohen's and Uniform Kappa.

Vertebral fracture assessments (VFAs) using dual-energy X-ray absorptiometry increase vertebral fracture detection in clinical practice and are highly reproducible. Measures of reproducibility are dependent on the frequency and distribution of the event. The aim of this study was to compare 2 reproducibility measures, reliability and agreement, in VFA readings in both a population-based and a clinical cohort. We measured agreement and reliability by uniform kappa and Cohen's kappa for vertebral reading and fracture identification: 360 VFAs from a population-based cohort and 85 from a clinical cohort. In the population-based cohort, 12% of vertebrae were unreadable. Vertebral fracture prevalence ranged from 3% to 4%. Inter-reader and intrareader reliability with Cohen's kappa was fair to good (0.35-0.71 and 0.36-0.74, respectively), with good inter-reader and intrareader agreement by uniform kappa (0.74-0.98 and 0.76-0.99, respectively). In the clinical cohort, 15% of vertebrae were unreadable, and vertebral fracture prevalence ranged from 7.6% to 8.1%. Inter-reader reliability was moderate to good (0.43-0.71), and the agreement was good (0.68-0.91). In clinical situations, the levels of reproducibility measured by the 2 kappa statistics are concordant, so that either could be used to measure agreement and reliability. However, if events are rare, as in a population-based cohort, we recommend evaluating reproducibility using the uniform kappa, as Cohen's kappa may be less accurate.

Anti-tumor necrosis factor drug survival in axial spondyloarthritis is independent of the classification criteria.

To compare the impact of meeting specific classification criteria [modified New York (mNY), European Spondyloarthropathy Study Group (ESSG), and Assessment of SpondyloArthritis international Society (ASAS) criteria] on anti-tumor necrosis factor (anti-TNF) drug retention, and to determine predictive factors of better drug survival. All patients fulfilling the ESSG criteria for axial spondyloarthritis (SpA) with available data on the axial ASAS and mNY criteria, and who had received at least one anti-TNF treatment were retrospectively retrieved in a single academic institution in Switzerland. Drug retention was computed using survival analysis (Kaplan-Meier), adjusted for potential confounders. Of the 137 patients classified as having axial SpA using the ESSG criteria, 112 also met the ASAS axial SpA criteria, and 77 fulfilled the mNY criteria. Drug retention rates at 12 and 24 months for the first biologic therapy were not significantly different between the diagnostic groups. Only the small ASAS non-classified axial SpA group (25 patients) showed a nonsignificant trend toward shorter drug survival. Elevated CRP level, but not the presence of bone marrow edema on magnetic resonance imaging (MRI) scans, was associated with significantly better drug retention (OR 7.9, ICR 4-14). In this cohort, anti-TNF drug survival was independent of the classification criteria. Elevated CRP level, but not positive MRI, was associated with better drug retention.

Morphometric vertebral assessments via the use of dual X-ray absorptiometry for the evaluation of radiographic damage in ankylosing spondylitis: a pilot study.

We performed a pilot study to compare vertebral fracture assessments (VFA) and lateral X-rays in terms of inter- and intraobserver reliability and degree of correlation for the detection of syndesmophytes in ankylosing spondylitis (AS). We recruited 19 patients with AS and recent lumbar or cervical lateral X-rays with at least one syndesmophyte. Each patient underwent dual-energy X-ray absorptiometry with measurement of bone mineral density and dorso-lumbar VFA. Intra- and interreader reliability for VFA and X-rays were measured using 2 independent, blinded observers and Cohen's kappa values. An adapted modified Stoke Ankylosing Spondylitis Spinal Score (amSASSS) was generated with each method, and these 2 values correlated. For X-rays, intraobserver and interobserver agreement were 94.3% (κ = 0.83) and 98.6% (κ = 0.96), respectively; for VFA, corresponding values were 92.8% (κ = 0.79) and 93.8% (κ = 0.82). Overall agreement between the 2 techniques was 88.6% (κ = 0.72). The Pearson correlation coefficient for the 2 methods was 0.95 for the modified Stoke Ankylosing Spondylitis Spinal Score . Per dual-energy X-ray absorptiometry-generated bone mineral density, >50% of patients were osteopenic and 10% osteoporotic. In terms of reproducibility and correlation with X-rays, performing a VFA appears to be a candidate for assessing radiographic damage in AS, thought further research is necessary to justify this indication.

Spine trabecular bone score subsequent to bone mineral density improves fracture discrimination in women.

Bone mineral density (BMD) measured by dual-energy X-ray absorptiometry (DXA) is used to diagnose osteoporosis and assess fracture risk. However, DXA cannot evaluate trabecular microarchitecture. This study used a novel software program (TBS iNsight; Med-Imaps, Geneva, Switzerland) to estimate bone texture (trabecular bone score [TBS]) from standard spine DXA images. We hypothesized that TBS assessment would differentiate women with low trauma fracture from those without. In this study, TBS was performed blinded to fracture status on existing research DXA lumbar spine (LS) images from 429 women. Mean participant age was 71.3 yr, and 158 had prior fractures. The correlation between LS BMD and TBS was low (r = 0.28), suggesting these parameters reflect different bone properties. Age- and body mass index-adjusted odds ratios (ORs) ranged from 1.36 to 1.63 for LS or hip BMD in discriminating women with low trauma nonvertebral and vertebral fractures. TBS demonstrated ORs from 2.46 to 2.49 for these respective fractures; these remained significant after lowest BMD T-score adjustment (OR = 2.38 and 2.44). Seventy-three percent of all fractures occurred in women without osteoporosis (BMD T-score > -2.5); 72% of these women had a TBS score below the median, thereby appropriately classified them as being at increased risk. In conclusion, TBS assessment enhances DXA by evaluating trabecular pattern and identifying individuals with vertebral or low trauma fracture. TBS identifies 66-70% of women with fracture who were not classified with osteoporosis by BMD alone.