Mayumi Sakuma

Incidence and outcome of osteoporotic fractures in 2004 in Sado City, Niigata Prefecture, Japan

Osteoporotic fracture in elderly populations is increasing worldwide, but there are few data on the incidence and outcome of osteoporotic fractures, including upper extremity and vertebral fracture, during a certain period in a defined geographic area. The purpose of this study was to determine the incidence of osteoporotic fractures in a particular area: Sado City, Niigata Prefecture, Japan. From January to December 2004, osteoporotic fractures of the vertebra, hip, distal radius, and proximal humerus in Sado City were recorded. The incidence, age, gender, type of fracture (for hip fracture), right or left side (for distal radius, proximal humerus, and hip fracture), place of injury, cause of injury, outcome, hospitalization period, and patient status regarding taking of drugs for osteoporosis treatment were checked for each fracture. The incidence was calculated based on the whole population of Sado City. The incidence per 100 000 population was 232.8, 121.4, 108.6, and 37.1 for fractures of the vertebra, hip, distal radius, and proximal humerus, respectively. The total incidence of these four kinds of fracture was 499.9 per 100 000 persons per year. The average age at the time of injury was 81.4, 77.7, 75.7, and 60.2 years old for fractures of the hip, vertebra, proximal humerus, and distal radius, respectively. As the average age increased, the percentage of fractures that occurred indoors also increased; that is, a higher percentage of hip fractures occurred indoors, followed by fractures of the vertebra, proximal humerus, and distal radius. Most patients were not taking anti-osteoporosis drugs before fractures of the hip or vertebra. We determined the incidence of major osteoporotic fractures in 1 year in a defined geographic area. Our data showed that 81% of hip fracture patients also had a vertebral fracture and that the average age at the time of injury was higher for hip fractures than for vertebral fractures. Therefore, these results suggest that vertebral fracture leads to hip fracture, indicating that early fracture prevention and continuous prevention strategies through positive treatment are of importance in osteoporotic elderly people.

Serum 25-OHD insufficiency as a risk factor for hip fracture

The aging population and an increasing number of hip fractures worldwide have made prevention of hip fractures a matter of importance. The prevalence of hypovitaminosis D in patients with acute hip fracture has been reported widely in recent years, and the vitamin D nutritional status in such reports is usually evaluated based on serum 25-hydroxyvitamin D (25-OHD). The aim of this article is to review the relationship of serum 25-OHD and osteoporotic fracture and the prevalence of 25-OHD insufficiency in patients with hip fracture, including assessment of nutritional status, oral status, activity, and dementia. We conclude that the serum 25-OHD level may be a useful index for risk of hip fracture in elderly people.

Bone Formation Parameters of the Biopsied Ilium Differ between Subtrochanteric and Diaphyseal Atypical Femoral Fractures in Bisphosphonate-Treated Patients

Atypical femoral fractures (AFFs) are defined as atraumatic or low-trauma fractures located in the subtrochanteric or diaphyseal sites. Long-term bisphosphonates (BPs) are administered to prevent fragility fractures in patients with primary osteoporosis or collagen diseases who are already taking glucocorticoids (GCs). Long-term BP use is one of the most important risk factors for AFFs. Its pathogenesis is characterized by severely suppressed bone turnover (SSBT), but whether the characteristics of patients are different regarding to location of fracture site remains unknown. In this study, we compared the characteristics and bone histomorphometric findings between subtrochanteric and diaphyseal sites in patients with BP-associated AFFs. Nine women with BP-associated AFFs were recruited, including 3 with systemic lupus erythematosus, 2 with rheumatoid arthritis, 2 with primary osteoporosis, 1 with polymyalgia rheumatica, and 1 with sarcoidosis. Patients were divided into the subtrochanteric group (n = 5; average age, 52 years; BP treatment, 5.9 years) and the diaphyseal group (n = 4; average age, 77 years; BP treatment, 2.6 years). Compared with the diaphyseal group, the subtrochanteric group had significantly higher daily GC doses (average, 10.9 vs. 2.3 mg/day) and significantly lower serum 25-hydroxyvitamin-D levels (17.8 vs. 25.6 ng/mL). Bone histomorphometry of the biopsied iliac bone showed SSBT in 3 cases (subtrochanteric, n = 1; diaphyseal, n = 2). Osteoid volume and trabecular thickness were significantly lower in the subtrochanteric group than in the diaphyseal group. Bone formation was inhibited more severely in subtrochanteric than in the diaphyseal group due to the higher GC doses used.

Prevalence of frailty among community-dwellers and outpatients in Japan as defined by the Japanese version of the Cardiovascular Health Study criteria: Letters to the Editor

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Reply to Barone et al.: Hypovitaminosis D and secondary hyperparathyroidism in the elderly: risk factors for hip fracture or markers of frailty?

We note that in the current study an age-adjusted sub-group analysis was performed between the hip-fracture group and non-fracture controls (Table 3 in [1]). Significant differences in serum albumin, 25-OHD, and intact PTH level still persisted in this analysis. Since there was a higher prevalence of vitamin D insufficiency in hip-fracture patients and 25-OHD was related to the degree of functional dependence, we agree that hypovitaminosis D may be considered not only to be a risk factor for hip fracture but also as a useful index of vulnerability or frailty in elderly people. Regarding sHPTH, Barone et al. found no significant difference in the prevalence of sHPTH between hip-fracture patients and controls. In our study, there was a significant difference in serum intact PTH level between the hipfracture group and controls, but hypovitaminosis D was not associated with sHPTH in most hip-fracture patients (80%), as also shown previously [2]. Therefore, it appears that 25hydroxyvitamin D and PTH are independently associated with activity level or mortality in frail elderly people [3, 4]. It is of note that Barone et al. paid considerable attention to sHPTH, and we anticipate future development of the relationship between sHPTH and frailty in elderly people. However, hypovitaminosis D was the main theme of our study, and although we accept that sHPTH is a significant issue, our goal in the current study is to show that hypovitaminosis D is a significant index as a risk factor for hip fracture.

Reply to Fisher et al.: Calcium-PTH-vitamin D axis in older patients with hip fracture

A key aspect of the current study is that it was performed in an elderly population in a particular geographical area [1]. Of the hip fracture patients in the study who had a low serum 25-OHD level, only about 20% had an elevated PTH level (>65 pg/mL), as also shown previously [2]. We agree with Fisher et al. that the relationship between 25-OHD and intact PTH and the effects of these molecules on bone metabolism require further study. We are also interested in the relationship of dementia with ADL levels and 25-OHD levels. Fisher et al. reported that low levels of serum 25-OHD are more prevalent in hipfracture patients with dementia, compared to non-demented hip-fracture patients. Sato et al. reported that serum 25OHD levels are significantly lower in patients with Alzheimer’s disease (AD) [3]. They also reported that AD patients with lower BMD and low serum 25-OHD have an increased risk of hip fracture [4]. These results are in agreement with the findings in our study [1]. Regarding the relationship between ADL and 25-OHD, Nakamura et al. [5] reported that low serum 25-OHD levels are mainly associated with low ADL levels. Accumulation of further data linking 25-OHD and hip fracture is anticipated. This information should lead to better prevention of hip fracture in at-risk individuals, and to improved treatment of osteoporosis.