Summary The IOF Epidemiology and Quality of Life Working Group has reviewed the potential role of population screening for high hip fracture risk against well-established criteria. The report concludes that such an approach should strongly be considered in many health care systems to reduce the burden of hip fractures. Introduction The burden of long-term osteoporosis management falls on primary care in most healthcare systems. However, a wide and stable treatment gap exists in many such settings; most of which appears to be secondary to a lack of awareness of fracture risk. Screening is a public health measure for the purpose of identifying individuals who are likely to benefit from further investigations and/or treatment to reduce the risk of a disease or its complications. The purpose of this report was to review the evidence for a potential screening programme to identify postmenopausal women at increased risk of hip fracture. Methods The approach took well-established criteria for the development of a screening program, adapted by the UK National Screening Committee, and sought the opinion of 20 members of the International Osteoporosis Foundation’s Working Group on Epidemiology and Quality of Life as to whether each criterion was met (yes, partial or no). For each criterion, the evidence base was then reviewed and summarized. Results and Conclusion The report concludes that evidence supports the proposal that screening for high fracture risk in primary care should strongly be considered for incorporation into many health care systems to reduce the burden of fractures, particularly hip fractures. The key remaining hurdles to overcome are engagement with primary care healthcare professionals, and the implementation of systems that facilitate and maintain the screening program.

Own health state utility values (HSUV, “experience-based utility”) is important for economic valuation and other purposes. There is only one preference-based EQ-5D value set derived from direct patient experience. Furthermore, the impact of interactions between EQ-5D dimensions on HSUV is poorly understood. Therefore we constructed a value set using direct patient experience and explored the impact of interactions between health states. The ICUROS was a multinational prospective observational study on the consequences of fragility fracture. In the study, patients who sustained a fragility fracture completed EQ-5D-3L and Time-trade-off (TTO) questionnaires for five time points: before fracture (recall), within two weeks after fracture, and at 4, 12 and 18 months after fracture. We derived a value set by fitting a random intercept linear model with TTO as the dependent variable and ‘moderate’ (Level 2, “L2”) or ‘severe’ impairment (Level 3, “L3”) in each EQ-5D dimension as dummy variables. We also explored the potential impact of interactions between impairment in dimensions using rigorous Lasso regression with cluster robust standard errors. In total 4,873 patients reported 17,779 EQ-5D and TTO pairs. Mean (SD) age at study enrolment was 71 (11) years and 81% were women. In the random intercept model, all coefficients had the expected sign and were statistically significant (p<0.001). The resulting value set was: 0.92 - 0.03xMobillityL2 - 0.08xMobillityL3 - 0.12xSelf-careL2 - 0.14xSelf-careL3 - 0.02xUsual ActivitiesL2 - 0.03xActivitiesL3 - 0.02xPain/DiscomfortL2 - 0.10xPain/DiscomfortL3 - 0.05xAnxiety/DepressionL2 ´- 0.11xAnxiety/DepressionL3. The Lasso regression indicated that interactions between mobility and self-care, anxiety/depression and self-care, and anxiety/depression and usual activities may be important. This experience-based EQ-5D-3L value set had consistently ordered and statistically significant coefficients, demonstrating face validity. Furthermore, the results show that explicit modelling of interactions may improve the predictive power of EQ-5D value sets. Compared to value sets based on hypothetical health, the decrements associated with impaired health were generally smaller.

X-linked hypophosphatemia (XLH) is a rare genetic disease, serious, debilitating and deforming condition, characterized by renal phosphate wasting. XLH is caused by loss of function of the PHEX gene resulting in enhanced secretion of the phosphaturic hormone FGF23 and leading defective bone mineralization, leading to rickets and impaired physical function.This disease, which affects 1:20.000 people, results in impaired quality of life (QoL) of patients, since, despite the treatments, suffer progressive and debilitating complications. The main objective of the study was to determine QoL of patients, children and adults suffering XLH, as well as their caregivers. A multicentre, observational and cross-sectional study has been carried out by a scientific committee consisted of 17 health professionals experts in XLH. QoL was assessed with the following EuroQol-5 Dimensions (EQ-5D) questionnaires: the EQ-5D-3L proxy (completed by caregivers or parents of children under 12 years), the EQ-5D-3L (completed by patients aged between 12 and 18 years), and the EQ-5D-5L (completed by adult patients and caregivers). The total number of participants for this project was 50 patients, 21 children and 29 adults, and their corresponding caregivers. Children had mobility problems due to difficulties walking, moderate pain or discomfort, problems doing their daily activities and felt anxious or depressed. In addition, children showed problems washing or dressing themselves. Similarly, a high percentage of adults were unable to walk, suffered extreme pain, showed difficulties to carry out their daily activities, and reported anxiety and depression. Moreover, the results of QoL for caregivers and parents were slightly lower than the general Spanish population. In conclusion, both children and adults, showed an important deterioration in QoL that were worse than the general Spanish population. These findings suggest the need for new treatments, as in many cases, the conventional treatment does not prevent disease complications and the impairment of QoL.

The International Costs and Utilities Related to Osteoporotic fractures Study (ICUROS) is an ongoing 18 months prospective observational study with the objective of estimating resource use and health related quality of life related to osteoporotic fractures. This study aims to describe the resource utilization after vertebral fractures (sustained during 2007-2012) pooled from nine countries: Australia, Austria, France, Italy, Lithuania, Mexico, Russia, Spain, and the UK. Patients studied were ≥ 50 years and lived at home prior to fracture. Data were collected through patient interviews and review of medical records: at baseline, 4, 12, and 18 months after fracture. Only resource use related to the fracture event was collected. There were 636, 572, and 536 patients available for analysis at 4, 12 and 18 months follow-up, respectively. The mean age (±SD) at fracture was 70±10 years and 81% were women. 45% of patients were hospitalized. Mean hospital length of stay (LoS) (±SD) was 5.7±12.4 days during months 0-4 and 0.9±9.8 during months 5-18. The mean number of physician visits (±SD) was 2.8±2.7 during months 0-4 and 1.9±3.4 between months 5-18. The mean number of nurse visits (±SD) was 1.4±8.5 and 1.5±19.9 during the corresponding periods, respectively. During months 0-4, 72% of patients used analgesics, 59% calcium/vitamin D, and 41% pharmacological interventions for osteoporosis. The respective uptakes for months 5-18 were 56%, 55% and 34%. The majority of health care consumption related to vertebral fracture occurs during the first 4 months but substantial consumption persists up to 18 months after fracture.

The International Costs and Utilities Related to Osteoporotic fractures Study (ICUROS) is an ongoing 18 months prospective observational study with the objective of estimating resource use and health related quality of life related to osteoporotic fractures. This study aims to describe the resource utilization for hip fractures (sustained during 2007-2012) pooled from 10 countries: Australia, Austria, Estonia, France, Italy, Lithuania, Mexico, Russia, Spain, and the UK. Patients studied were ≥ 50 years and lived at home prior to fracture. Data were collected through patient interviews and review of medical records: at baseline and 4, 12, and 18 months after fracture. Only resource use related to the fracture event was collected. There were 1,795, 1,435, 1,256 patients available for analysis at 4, 12 and 18 months follow-up, respectively. The mean age (±SD) at fracture was 77±10 years and 79% were women. 96% of patients were hospitalized. Mean hospital length of stay (LoS) (±SD) was 17.2±20.4 days during months 0-4 and 1.2±6.8 during months 5-18. Mean LoS varied from 9.3 days to 26.5 days during months 0-4 across countries. The mean number of physician visits (±SD) was 2.8±3.1 during months 0-4 and 2.5±5.6 between months 5-18. The mean number of nurse visits (±SD) was 2.4±9.6 and 3.8±31.9 during corresponding periods, respectively. During months 0-4, 65% of patients used analgesics, 41% calcium/vitamin D, and 27% pharmacological interventions for osteoporosis. The respective uptakes for months 5-18 were 47%, 46% and 25%. Almost all patients were hospitalized after fracture and the mean number of inpatient days is high, although there is a large variation. The vast majority of health care consumption in relation to fracture occurs during the first 4 months but substantial consumption persists up to 18 months after fracture.

The Committee of Scientific Advisors of International Osteoporosis Foundation (IOF) recommends that papers describing the descriptive epidemiology of osteoporosis using bone mineral density (BMD) at the femoral neck include T-scores derived from an international reference standard.

Los efectos adversos del hipertiroidismo en el hueso están descritos desde hace años. Las hormonas tiroideas son necesarias para el crecimiento, la maduración, el metabolismo y el remodelado óseo. No obstante, la tirotoxicosis no tratada cursa con un aumento del remodelado, osteopenia u osteoporosis y un incremento en el riesgo de fractura. Desde la introducción de fármacos antitiroideos y el radioyodo, la patología ósea hipertiroidea es menos frecuente. A continuación se presenta un caso poco habitual de una paciente con tirotoxicosis asintomática que debuta con un aumento del remodelado óseo.

Introduction:Postmenopausal osteoporosis is a chronic disease requiring treatment that balances long-term fracture efficacy against risk.Methods:We reviewed the efficacy and safety of calcium and vitamin D, the selective estrogen receptor modulators (SERMs), the bisphosphonates, denosumab, and strontium ranelate in studies of 3 years or longer.Results:Six trials lasted for 5 years, and seven went beyond that. The evidence beyond 5 years is generally weak, mainly due to methodological issues (open-label design, small samples, or absence of placebo control). Although calcium and vitamin D appear to be beneficial, the data are insufficient to evaluate benefits and risk beyond 3 years. The fracture efficacy of SERMs beyond 5 years is not known, though increases in bone mineral density (BMD) appear to be maintained. The SERMs have good long-term safety, including protective effects against breast cancer. The bisphosphonates have established fracture efficacy to 3 years, and 4 or 5 years with alendronate and risedronate. The evidence beyond 5 years indicates sustained increases in BMD. The safety of the bisphosphonates does not appear to be modified with time, with the possible exceptions of atypical subtrochanteric fracture and other events of unknown frequency. Denosumab has been tested up to 5 years, with continued increased in BMD and no reported safety issues. There is evidence for fracture efficacy of strontium ranelate, and sustained increases in BMD over 10 years. Strontium ranelate has good long-term safety.Conclusion:Robust long-term studies are relatively rare for the osteoporosis treatments, and generally show maintenance of BMD and, for some agents, an additional reduction in fracture incidence.

In an open-label extension study, BMD increased continuously with strontium ranelate over 10 years in osteoporotic women (P < 0.01). Vertebral and nonvertebral fracture incidence was lower between 5 and 10 years than in a matched placebo group over 5 years (P < 0.05). Strontium ranelate's antifracture efficacy appears to be maintained long term.

espanolLa osteoporosis masculina es un problema clinicamente significativo, aunque los factores predictivos de baja masa osea no son bien conocidos. Nuestro objetivo fue conocer la prevalencia de osteoporosis densitometrica en varones sanos de edad avanzada, caracterizar el remodelado oseo en estos sujetos e investigar la capacidad predictiva de distintos parametros antropometricos y hormonales para identificar a los sujetos con baja masa osea (osteoporosis). Cien voluntarios mayores de 55 anos fueron evaluados transversalmente. Se midio la densidad mineral osea mediante absorciometria con doble haz de rayos X en columna lumbar y cadera y se evaluaron los siguientes parametros antropometricos: peso, talla, indice de masa corporal, indice cintura-cadera y volumen testicular. Los parametros hormonales evaluados fueron testosterona total, libre y biodisponible, estradiol, SHBG, IGF-1, IGFBP-1, iPTH y 1,25 vitamina D3. Los marcadores del turnover oseo que se midieron fueron osteocalcina y telopeptido carboxiterminal del colageno I en suero (ICTP). Un sujeto fue excluido por hipogonadismo primario. El 28,2% presentaban criterios densitometricos de osteoporosis (T-score lumbar y/o femoral EnglishMasculine osteoporosis is a clinically significant problem, although the predictive factors of low bone mass are not well known. Our objective was to know the prevalence of densitometric osteoporosis in healthy elderly males, characterize bone remodeling in these subjects and investigate the predictive capacity of different anthropometrics and hormonal parameters to identify low bone mass subjects (osteoporosis). One hundred volunteers > 55 years were evaluated cross-sectionally. Bone mineral density (BMD) was measured by DXA in lumbar spine and hip and the following anthropometrics parameters were measured: weight, height, BMI, waist-hip index and testicular volume. The hormonal parameters evaluated were total free and bioavailable testosterone, estradiol, SHBG, IGF-1, IGFBP-1, iPTH and 1.25 vitamin D3. The bone turnover markers that were measured were C-terminal telopeptide of type I collagen in serum (ICTP). One subject was excluded due to primary hypogonadism. A total of 28.2% presented densitometric criteria of osteoporosis (spinal and/or femoral T-score

espanolIntroduccion. La densitometria osea es la mejor opcion para detectar osteoporosis en mujeres postmenopausicas, aunque su uso puede estar limitado por la disponibilidad del equipo y su coste. La intencion de este estudio ha sido desarrollar un cuestionario simple para identificar los factores de riesgo de baja masa osea y medir el caracter predictivo de osteoporosis de cada factor. Pacientes y metodos. Se realizo un estudio poblacional en forma de encuesta transversal a 105 mujeres postmenopausicas con edades entre 41 y 86 anos. El cuestionario incluia datos de edad, peso y talla de las pacientes, historia de toma de farmacos, anos de menopausia, existencia de menopausia precoz, ooforectomia, fractura despues de los 50 anos, historia familiar de osteoporosis, actividad fisica, sintomas de demencia, consumo de tabaco, de alcohol y baja ingesta de calcio. La densidad mineral osea (DMO) de la columna lumbar y cuello femoral se midio usando absorciometria radiologica de doble haz (DXA Hologic 4500), clasificando las mujeres como «normales» o «anormales» basado en los criterios de la Organizacion Mundial de la Salud (OMS). Se realizo analisis de regresion multiple por el metodo de entrada de variables por pasos sucesivos (stepwise), usando los valores de DMO como variable dependiente, y como variables independientes, cada uno de los factores evaluados en el cuestionario, ademas de la edad, el peso, la talla y el indice de masa corporal (IMC), excluyendose los factores que no mostraban relacion con la DMO (p > 0,05). Se desarrollo un sistema simple de puntuacion basado en un modelo de regresion: mas de diez anos de menopausia (5), fractura previa (4), historia familiar de osteoporosis (2), peso ( 60kg:1) y edad (70 o > 70 anos:3; 60-69:2; 50-59:1). Resultados. El punto de corte para discriminar entre mujeres normales y con osteopenia fue 5: sensibilidad 59%; especificidad 71,4% en columna lumbar y 73,4% y 65,7%, respectivamente en cuello de femur. El punto de corte para discriminar entre mujeres normales y con osteoporosis fue 8: sensibilidad 75,6%; especificidad 90,5% en columna lumbar; 86,7% y 84,6%, respectivamente en cuello femoral. Conclusiones. El uso de un cuestionario simple en mujeres postmenopausicas que puntue los factores de riesgo de masa osea baja puede ser util para facilitar el diagnostico de osteopenia u osteoporosis. Este cuestionario deberia ser validado posteriormente con una muestra mayor de mujeres postmenopausicas y en varones. EnglishIntroduction. Bone densitometry is the best option to detect osteoporosis in postmenopausal women, although its use may be limited by the availability of equipment and cost. The aim of this study was to develop a simple questionnaire to identify the risk factors for low bone mass and assess the predictive character of osteoporosis of each factor Patients and methods. A cross-sectional population-based study was completed on 105 postmenopausal women, aged between 41 and 86. The questionnaire included details of the patient's age, height and weight, drug history, years of menopause, existence of early menopause, oophorectomy, fracture history - after the age of 50, family history of osteoporosis, physical activity, symptoms of dementia, smoking, alcohol consumption, and low calcium intake. BMD of the lumbar spine and femoral neck were measured using dual-energy X-ray absorptiometry (DXA Hologic 4500), which classified the women as «normal» or «abnormal» (osteopenia and osteoporosis), based on the WHO criteria. Univariate analysis was used to exclude factors that did not show a relationship with BMD (p > 0.05). Multivariate stepwise forward linear regression analysis, using BMD values as the dependent variable, were performed to identify the remaining factors, these being the most predictive factors of low bone density at the lumbar spine, and at the femoral neck. Sensitivity, specificity and predictive values, by receiver operating curves were also analysed. A simple scoring system was devised based on a regression model: more than ten years of menopause (5), prior fracture (4), osteoporosis family history (2), weight ( 60:1) and age (70 or > 70:3; 60-69:2; 50-59:1). Results. The cut-off score, to discriminate between normal and osteopenic women, was 5: sensitivity 59%; specificity 71,4% at lumbar spine, and 73,4% and 65,7% respectively, at the femoral neck. The cut-off score, to discriminate between normal and osteoporotic women, was 8: sensitivity 75,6%; specificity 90,5% at lumbar spine, and 86,7% and 84,6% respectively, again at the femoral neck. Conclusion. In summary, the use of a simple questionnaire to score for risk factors of low bone mass, could be useful to facilitate the diagnosis of osteopenia or osteoporosis. However our questionnaire should be further validated on a larger sample of a postmenopausal population, and in men.

Objective. To examine the relationship between bone mineral density (BMD), fractures and fracture risk factors in a population of postmenopausal women from the Extremadura Community. Patients and methods. The patients consisted of a total of 304 postmenopausal women (aged between 50 and 79), 138 of which had no clinical history of a fracture (normal group), and 166 who had experienced a fracture after the age of 50 (fracture group). In the normal group the exclusion criteria were diseases and therapies, which might have an influence on bone metabolism, early menopause, long-term immobilization and prior fractures. BMD of the lumbar (L2-L4) and lateral spine, femoral neck and Ward's triangle were measured using dual-energy x-ray absorptiometry (DXA method). The following information was obtained using a comprehensive questionnaire: history of fracture, age of menopause, family history of osteoporosis and/or fractures, consumption of milk products, smoking, consumption of caffeine and alcohol, sun exposure, parity, physical activity and life environment. All statistics were analysed using the Statistical Package for Social Sciences (SPSS). Results. Between the two groups (normal and fracture) there were no differences in age, height, weight or body mass index (BMI), but there was a significant difference in the age of menopause (p < 0.001). The fracture group had lower BMD, at all measured sites, than the normal group (p < 0.001). Of the fracture group 19.9% had normal BMD, 45.8% osteopenics and 34.3% osteoporotics, with the mean age of fracture occurrence being at 59.8 ± 6.1. The fractures were distributed at the hip, Colles, and in lower extremities. Also, within the fracture group, there were two sub-groups. One group with more than one fracture and the other with fractures in different skeletal sites (ribs, pelvis, humerus, collar bone, fingers, shoulder-blade and elbow). Lower extremities fractures were the most frequent and the only ones with normal BMD. Those patients with a family history of osteoporosis and/or fractures had an odds ratio, for any location fracture, of 2.404 (IC 95%: 1.315-4.396) with a combined odds ratio for hip and Colles fractures of 4.242 (IC 95%: 2.028-8.875). Of the patients who had sun exposure of 30 minutes or more each day (high level), just 19.8% were in the fracture group with hip or Colles fractures, whereas the remaining 80.2% were in the normal group. There was no relationship between the frequency of fractures and physical activity, parity, caffeine and alcohol consumption. Conclusions. Women within the Extremadura Community - who are older than 50, have osteopenia, a family history of osteoporosis and/or fractures, experience an early menopause and reduced sun exposure - have a risk of hip or Colles fractures and an additional risk of multiple fractures in different skeletal sites, except in the lower extremities.

espanolEl objeto de este trabajo ha sido definir el grado de conocimiento de la osteoporosis en la poblacion femenina y si ha habido cambios en este conocimiento a lo largo del tiempo. De un total de 2.245 mujeres respondieron que conocian el significado de la palabra osteoporosis, 1.842 (82,5%). Solamente 1.245 (58,1%) tomaban productos lacteos; 950 encuestadas (44,3%) no realizaban ejercicio fisico regularmente; 594 (27,7%) habian realizado pruebas para el diagnostico de la osteoporosis. Existian antecedentes familiares de fracturas en 558 (26%). Cuatrocientas noventa y una mujeres (22,9%) reconocian haber presentado alguna fractura osea. Cuatrocientas once (19,2%) habian sido diagnosticadas de osteoporosis; y de estas, 78 (19%) estaban sin tratamiento farmacologico y de las tratadas, 187 (45%) tomaban calcio/vitamina D. Se revisa la percepcion del diagnostico y tratamiento desde el angulo del enfermo y de su medico y se concluye que es preciso sentar las bases de la educacion en ambos estamentos para conseguir posturas activas de la Administracion con objeto de estimular la prevencion de esta devastadora enfermedad. EnglishFrom a whole sample of 2.245 females, 1.842 women (82.5%) answered that they knew the meaning of «osteoporosis» word. Only 1.245 females (58.1%) consumed dairy products; 950 females (44.3%) did not perform physical exercise regularly; 594 females (27.7%) had received some test for osteoporosis diagnosis. In 558 (26%) had some past familiar history of bone fracture and 491 females (22.9%) reported some previous fracture: 411 females (19.2%) had been diagnosed from osteoporosis and 78 (19%) of them did not take any pharmacological treatment. Among treated 187 (45%) were usually receiving calcium/vitamin D. We review the perception of diagnosis and treatment of osteoporosis from the patient and doctor points of view, and we conclude that it is necessary to improve the education bases in both estates, to get actives manners of Public Health Service and to stimulate the prevention of this devastating disease. kw - conocimiento; poblacion femenina; osteoporosis; epidemiologia; prevencion kw - Knowledge; osteoporosis; female population; epidemiology; prevention