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Disc-related sciatica is a frequent condition. Most cases of sciatica evolve favorably. Although several randomized controlled trials have reported that surgery is more effective than conservative management in the short-term, no significant differences in pain or functional disability have been reported in the longer term. As such, discounting complications requiring urgent intervention, surgery is generally only performed in patients in whom medical treatment has failed. Our objective was to determine the rate and predictive factors of surgical treatment one year after in-hospital conservative management of disc-related sciatica.Retrospective, observational, single-center study conducted in the Rheumatology Department of the Lille University Hospital Center between 2014 and 2018.In the study population (n=405), the frequency of surgery one year after hospitalization was 34.8%. Median time to surgery was 31 days. In multivariate analysis, working [odds ratio (OR) 2.3, 95% confidence interval (CI): 1.5; 3.6)], impulsive pain (OR 2.0, 95% CI: 1.3; 3.1), motor loss (OR 1.7; 95% CI: 1.2; 2.4) and number of infiltrations (OR 1.4, 95% CI: 1.2; 1.7) were predictive of surgery. A decrease in numeric pain-scale rating of the leg between the beginning and end of hospitalization was associated with fewer cases of surgery (OR 0.921, 95% CI: 0.861; 0.985).A proportion of 34.8% of the patients hospitalized for disc-related sciatica did undergo surgery within one year of our medical management protocol. Several predictive factors for surgery were found.

OBJECTIVE Little is known about body composition in patients with PsA. We compared body composition parameters in PsA patients and healthy controls, and then investigated the effects of ustekinumab (UST) on body composition in patients with PsA. METHODS At baseline, 30 PsA patients were compared cross-sectionnally with 60 non-PsA healthy controls matched for age, sex, menopausal status and body mass index. Thirty active PsA patients treated with UST were included in a 6-month open follow-up study. Body composition parameters were measured at baseline and 6 months of treatment. RESULTS Body composition parameters were different in PsA patients compared to healthy controls: in PsA patients, total and appendicular lean mass were lower (p=0.013 and p=0.010 respectively), whereas total fat mass was higher (p

Osteoporosis in older men is common and causes significant mortality and morbidity. Some data suggest that conditions leading to bone fragility, including osteoporosis, are under-identified and undertreated in men. Additionally, 50% of the causes of osteoporosis are secondary in men. The latest Endocrine Society and different Rheumatology Societies Guidelines recommend additional laboratory investigations in men with osteoporosis so as to treat them more efficiently.Our aim was to determine whether men managed in our geriatrics center, diagnosed with osteoporosis, underwent investigations to determine the aetiology of osteoporosis and other bone fragility conditions and what the secondary causes were.We conducted a monocentric, retrospective study including all men seen at the geriatric consult in 2016 diagnosed with osteoporosis. For each patient, we evaluated our clinical practice, whether common secondary causes were sought-after and what these aetiologies were.Among the 121 men with a diagnosis of osteoporosis seen at the geriatric consult at the Lille University Hospital in 2016, only 51 had undergone further investigations. Among the 3 major secondary causes were identified: 17.6% glucocorticoid induced, 13.7% treatment induced hypogonadism, 11.7% late onset hypogonadism.A more efficient etiological assessment of osteoporosis in older men could be achieved and would improve management for our patients. This can be achieved by a better knowledge of the recommendations for etiological assessment of bone fragility and osteoporosis and a dedicated consultation within the geriatric sector.

It is still debated whether differences in bone turnover markers (BTMs) exist between the 2 most popular bariatric surgery procedures (Roux-en-Y gastric bypass [RYGB] and sleeve gastrectomy [SG]).To compare changes in BTMs after RYGB and SG, and to investigate their association with predefined markers of interest.University hospital, Lille, France.An ancillary investigation of a prospective cohort was conducted. SG patients with severe obesity ≥40 years were matched one-to-one to RYGB patients for age, sex, body mass index (BMI), and menopausal status. BTMs, as well as predefined markers of interest, were measured at baseline, 12, and 24 months after bariatric surgery.Sixty-four patients (66% women) had a mean (standard deviation [SD]) age of 49.6 years (5.1) and a mean (SD) BMI of 45.0 kg/mRYGB was associated with a greater increase in BTMs than SG at 12 and 24 months.

Context Noninvasive assessment of proton density fat fraction (PDFF) by magnetic resonance imaging (MRI) may improve the prediction of fractures. Objective This work aimed to determine if an association exists between PDFF and fractures. Methods A case-control study was conducted at Lille University Hospital, Lille, France, with 2 groups of postmenopausal women: one with recent osteoporotic fractures, and the other with no fractures. Lumbar spine and proximal femur (femoral head, neck, and diaphysis) PDFF were determined using chemical shift-based water-fat separation MRI (WFI) and dual-energy x-ray absorptiometry scans of the lumbar spine and hip. Our primary objective was to determine the relationship between lumbar spine PDFF and osteoporotic fractures in postmenopausal women. Analysis of covariance was used to compare PDFF measurements between patient cases (overall and according to the type of fracture) and controls, after adjusting for age, Charlson comorbidity index (CCI) and BMD. Results In 199 participants, controls (n = 99) were significantly younger (P < .001) and had significantly higher BMD (P < 0.001 for all sites) than patient cases (n = 100). A total of 52 women with clinical vertebral fractures and 48 with nonvertebral fractures were included. When PDFFs in patient cases and controls were compared, after adjustment on age, CCI, and BMD, no statistically significant differences between the groups were found at the lumbar spine or proximal femur. When PDFFs in participants with clinical vertebral fractures (n = 52) and controls were compared, femoral neck PDFF and femoral diaphysis PDFF were detected to be lower in participants with clinical vertebral fractures than in controls (adjusted mean [SE] 79.3% [1.2] vs 83.0% [0.8]; P = 0.020, and 77.7% [1.4] vs 81.6% [0.9]; P = 0.029, respectively). Conclusion No difference in lumbar spine PDFF was found between those with osteoporotic fractures and controls. However, imaging-based proximal femur PDFF may discriminate between postmenopausal women with and without clinical vertebral fractures, independently of age, CCI, and BMD.

OBJECTIVESBone marrow adipose tissue (BMAT) represents >10% of total fat mass in healthy humans and further increases in diverse clinical conditions, but the impact of BMAT on human health and disease remains poorly understood. Magnetic resonance imaging (MRI) allows non-invasive measurement of the bone marrow fat fraction (BMFF), and human MRI studies have begun identifying associations between BMFF and skeletal or metabolic diseases. However, such studies have so far been limited to smaller cohorts: analysis of BMFF on a larger, population scale therefore has huge potential to reveal fundamental new knowledge of BMAT’s formation and pathophysiological functions. The UK Biobank (UKBB) is undertaking whole-body MRI of 100,000 participants, providing the ideal opportunity for such advances.MATERIALS AND METHODSHerein, we developed a deep learning pipeline for high-throughput BMFF analysis of these UKBB MRI data. Automatic bone marrow segmentation was achieved by designing new lightweight attention-based 3D U-Net convolutional neural networks that allowed more-accurate segmentation of small structures from large volumetric data. Using manual segmentations from 61-64 subjects, the models were trained against four bone marrow regions of interest: the spine, femoral head, total hip and femoral diaphysis. Models were validated using a further 10-12 datasets for each region and then used to segment datasets from a further 729 UKBB participants. BMFF was then determined and assessed for expected and new pathophysiological characteristics.RESULTSDice scores confirmed the accuracy of the models, which matched or exceeded that for conventional U-Net models. The BMFF measurements from the 729-subject cohort confirmed previously reported relationships between BMFF and age, sex and bone mineral density, while also identifying new site- and sex-specific BMFF characteristics.CONCLUSIONSWe have established a new deep learning method for accurate segmentation of small structures from large volumetric data. This method works well for accurate, large-scale BMFF analysis from UKBB MRI data and has the potential to reveal novel clinical insights. The application of our method across the full UKBB imaging cohort will therefore allow identification of the genetic and pathophysiological factors associated with altered BMAT. Together, our findings establish the utility of deep learning for population-level BMFF analysis and promise to help elucidate the full impact of BMAT on human health and disease.HighlightsWe establish a new deep learning method for image segmentation.Our method improves segmentation of small structures from large volumetric data.Using our method, we assess bone marrow fat fraction (BMFF) in UK Biobank MRI data.This is the first use of deep learning for large-scale, multi-site BMFF analysis.Our results highlight the potential of BMFF as a new clinical biomarker.

International audience; Introduction: This article presents the initial recommendations of the French Rheumatology Society (Société Française de Rhumatologie - SFR) and the Osteoporosis Research and Information Group (Groupe de Recherche et d'Informations sur les Ostéoporoses - GRIO) on the role of diet in the prevention and treatment of osteoporosis.Methods: The recommendations were produced by a working group composed of rheumatologists, physician nutrition specialists and a geriatrician. Fifteen (15) questions pertaining to "daily practices" were preselected by the working group. For the literature review, the working group focussed mainly on the effects of diet on bone mineral density (BMD) and fractures, and primarily on meta-analyses of longitudinal studies and dietary intervention studies.Results: A Mediterranean-type diet and the daily consumption of 2 to 3 dairy products are recommended. Together, these provide the calcium and "high quality" protein required to maintain a normal calcium-phosphorus balance and bone metabolism, and are associated with lower fracture risk. Conversely, unbalanced Western diets, vegan diets, weight-loss diets in non-overweight individuals, alcohol consumption and daily consumption of sodas are advised against. In terms of the beneficial effects on bone mineral density and fracture risk, current scientific data are either insufficient or too divergent to recommend increasing or restricting the consumption of tea or coffee, vitamins other than vitamin D, vitamin D-enriched or phytoestrogen-rich foods, calcium-enriched plant-based beverages, oral nutritional supplements, or dietary sources of prebiotics and probiotics.Conclusions: These are the first set of recommendations addressing the role of diet in the prevention and treatment of osteoporosis. More research is necessary to direct and support guidelines.

International audience; Background: In response to the gradual decline in the number of prescriptions for anti-osteoporosis medication (AOM) following fragility fractures, Fracture Liaison Services (FLSs) have been set up around the world with the aim of filling this treatment gap. Several studies have already reported the benefits of such organizations, particularly in reducing fracture risk, mortality rates and health-care costs, and literature on FLSs has increased at a steady pace over time.Methods: A narrative review was conducted on the latest available findings on the effectiveness of FLSs. Various approaches to implementing an effective FLS program are discussed.Results: FLS programs have enhanced the management of osteoporosis-related fractures. However, several studies have highlighted that not all FLSs are necessarily effective in reducing subsequent fracture risk and mortality. Long-term AOM persistence and monitoring are another critical issue in FLS programs. A few studies have reported that FLSs are associated with an improvement in AOM persistence, regardless of the type of AOM. Practitioners in the FLS setting need to be aware of the impact of recency of fracture and fracture recurrence rates, and the need for timely interventions. The administration of zoledronic acid in an in-patient setting may improve AOM treatment rates in patients, who often encounter obstacles to out-patient follow-up. Introducing 'vertebral fracture identification services' in FLS programs is also an option. However, doing so leads to an increase in workload and this would need to be considered by any FLS that is considering introducing such a service. Evidence suggests that digital technologies can support (i) multidisciplinary teams in providing the best possible patient care based on current evidence, and (ii) patient self-management. However, as the methodological quality of many of the studies evaluating these technologies was poor, their validity of their results is limited.Conclusion: Further research should focus on the optimal implementation of post-fracture care using automated systems, and standardized reporting of patient's characteristics and outcome measures using key performance indicators.

International audience; Osteoporosis carries a high medical, economic, and societal burden principally because of the risk of severe fractures. The objective of this cost-of-illness study was to describe health resource utilization and associated costs in all patients aged ≥50 years hospitalized for a severe osteoporotic fracture over a 6-year period (2009 to 2014) in France. Data were extracted from the French national healthcare database (SNDS) on all health care resource utilization between the index date (date of hospitalization for first fracture during the enrollment period) and study end (December 31, 2016) or until the patient died. Costing was restricted to direct costs and determined from the payer perspective. Variables related to costs were identified through multivariate logistic regression analysis. A total of 356,895 patients were included (median follow-up 39.1 months). In the year after the index fracture, 36,622 patients (10.5%) were rehospitalized for a fracture-related reason. Only 18,474 (5.3%) underwent bone densitometry and 58,220 (16.7%) received a specific treatment. The total annual per capita osteoporosis-related cost in the year after the index severe osteoporotic fracture was €18,040 (from €8598 for multiple ribs to €21,085 for hip fracture) of which €17,905 was incurred by fracture-related costs. The cost incurred by management of osteoporosis was €135. Over years 2 to 5, the mean annual per capita costs of fracture treatment (€806, mostly attributable to the treatment of refractures) continued to dominate those of osteoporosis management (€99). Total annual cost of care was €1260 million (year 2014). Variables associated with higher cost were older age, male sex, site of fracture, a history of prior osteoporotic fracture, and the number of refracture events. The 5-year cost of severe osteoporotic fractures to the French health care system is high and mostly attributable to the treatment of refractures. Improved fracture prevention measures in patients with osteoporosis is crucial to reduce the economic burden of the disease. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Resume L’activite physique est un facteur de risque modifiable en cas d’osteoporose chez l’adulte. La majorite des etudes cliniques sur l’activite physique et la sante osseuse ont ete menees aupres de femmes menopausees. Les etudes observationnelles prospectives menees chez des adultes d’au moins 40 ans suggerent une association entre l’activite physique et la reduction du risque de fracture entre 11-40 % mais ces etudes comportent de nombreuses limites. Il n’existe pas d’essai randomise controle specifiquement dedie a l’impact de l’activite physique sur la reduction du risque de fracture. En revanche, la reduction des chutes grâce a l’activite physique permettrait de reduire le taux de fractures. En cas d’osteoporose, le benefice de l’activite physique ne se resume pas a son impact sur le tissu osseux. L’activite physique doit combiner un programme d’entrainement (i) postural (permet une prise de conscience du positionnement corporel et de la posture), (ii) d’equilibre (permet de renforcer l’equilibre et de reduire le risque de chute), (iii) en charge (marche, course a pieds, danse…) et (iv) de force (travail de renforcement musculaire progressif en force) pour permettre de reduire le risque de chute, de realiser un renforcement musculaire et d’ameliorer la resistance osseuse par le biais d’une augmentation modeste de la densite minerale osseuse. Ce programme doit etre d’intensite moderee a elevee afin d’obtenir une efficacite optimale. L’assiduite est un element cle de la reussite. L’âge ne doit pas etre un facteur limitant et le caractere progressif et supervise est essentiel. Bien entendu, le programme d’activite physique doit etre adapte a chaque patient. Le message cle est le suivant : « il faut se tenir droit, etre stable et etre fort ! »

Osteoporosis and ischemic heart disease (IHD) represent important public health problems. Existing research suggests an association between the two conditions beyond that attributable to shared risk factors, with a potentially causal relationship. In this study, we tested the association of bone speed of sound (SOS) from quantitative heel ultrasound with (i) measures of arterial compliance from cardiovascular magnetic resonance (aortic distensibility [AD]); (ii) finger photoplethysmography (arterial stiffness index [ASI]); and (iii) incident myocardial infarction and IHD mortality in the UK Biobank cohort. We considered the potential mediating effect of a range of blood biomarkers and cardiometabolic morbidities and evaluated differential relationships by sex, menopause status, smoking, diabetes, and obesity. Furthermore, we considered whether associations with arterial compliance explained association of SOS with ischemic cardiovascular outcomes. Higher SOS was associated with lower arterial compliance by both ASI and AD for both men and women. The relationship was most consistent with ASI, likely relating to larger sample size available for this variable (n = 159,542 versus n = 18,229). There was no clear evidence of differential relationship by menopause, smoking, diabetes, or body mass index (BMI). Blood biomarkers appeared important in mediating the association for both men and women, but with different directions of effect and did not fully explain the observed effects. In fully adjusted models, higher SOS was associated with significantly lower IHD mortality in men, but less robustly in women. The association of SOS with ASI did not explain this observation. In conclusion, our findings support a positive association between bone and vascular health with consistent patterns of association in men and women. The underlying mechanisms are complex and appear to vary by sex. © 2020 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Introduction: We aimed to evaluate the utility of FDG-PET/CT in diagnosing polymyalgia rheumatica (PMR) and associated large-vessel vasculitis (LVV). Methods: We analyzed FDG-PET/CT completed between 2015 and 2019 on patients diagnosed with PMR. For comparisons, patients with PMR were matched 1:1 to controls based on age and gender. FDG-PET/CT had been completed on the controls over the same period. The FDG uptake was scored visually for 17 articular or periarticular sites and 13 vascular sites using a semi-quantitative scoring system (score of 0–3). Results: Eighty-one patients with PMR and eighty-one controls were included (mean age 70.7 (9.8) years; 44.4% women). Significant differences between the PMR and control groups were found at all articular and periarticular sites for the following: (i) the FDG uptake score (p < 0.001 for all locations); (ii) the number of patients per site with significant FDG uptake (score ≥ 2); (iii) the global FDG articular uptake scores (31 [IQR, 21 to 37] versus 6 [IQR, 3 to 10], p < 0.001); and (iv) the number of sites with significant FDG uptake (score ≥ 2) (scores of 0–17) (11 [IQR, 7 to 13] versus 1 [IQR, 0 to 2], p < 0.001). No significant differences in the global FDG vascular uptake scores were found between the patients who were considered isolated PMR and the control groups. Conclusions: The FDG uptake score and the number of sites with significant FDG uptake could be pertinent criteria for the diagnosis of PMR. Unlike others, we did not confirm the presence of vascular involvement in patients with isolated PMR.

Sclerostin is a Wnt signaling pathway inhibitor that negatively regulates bone formation. Bone-marrow-derived stromal cell (BMSC) differentiation is influenced by the Wnt pathway, leading to the hypothesis that higher levels of sclerostin might be associated with an increase in bone marrow adiposity (BMA). The main purpose of this study was to determine whether a relationship exists between circulating sclerostin and BMA in post-menopausal women with and without fragility fractures. The relationships between circulating sclerostin and body composition parameters were then examined. The outcomes measures included vertebral and hip proton density fat fraction (PDFF) using the water fat imaging (WFI) MRI method; DXA scans; and laboratory measurements, including serum sclerostin. In 199 participants, no significant correlations were found between serum sclerostin and PDFF. In both groups, serum sclerostin was correlated positively with bone mineral density (R = 0.27 to 0.56) and negatively with renal function (R = −0.22 to −0.29). Serum sclerostin correlated negatively with visceral adiposity in both groups (R = −0.24 to −0.32). Serum sclerostin correlated negatively with total body fat (R = −0.47) and appendicular lean mass (R = −0.26) in the fracture group, but not in the controls. No evidence of a relationship between serum sclerostin and BMA was found. However, serum sclerostin was negatively correlated with body composition components, such as visceral adiposity, total body fat and appendicular lean mass.

The purpose of this study was to evaluate the implementation of the European Calcified Tissue Society (ECTS) 2022 recommendations on the prevention and treatment of osteoporosis secondary to bariatric surgery. The ECTS 2022 recommendations were applied in a retrospective cohort of postmenopausal women and men aged 50 years and older who were undergoing or had already undergone bariatric surgery. Osteoporosis medication was indicated if any of the following criteria were met: (i) history of recent (within 2 years) fragility fracture after the age of 40 years, (ii) BMD T score ≤ −2 at any of the sites of measurement, and (iii) FRAX® ≥ 20% for major osteoporotic fractures and/or ≥3% for hip fractures. Of the 170 patients (144 women, mean age 59 (55 to 63) years) included between February 2019 and March 2022, 33 were eligible for osteoporosis medication based on the ECTS 2022 recommendations, i.e., a prevalence of 19.6% [CI95%: 13.9%; 26.5%]. Most patients met the BMD T score ≤ −2 criterion (n = 25/170, 14.7% [CI95%: 9.7%; 20.9%]) and/or the history of recent fragility fracture criterion (n = 12/170, 7.1% [CI95%: 3.7%; 12.0%]). In this study, a fifth of our population was found to be eligible for osteoporosis medication after the application of the ECTS 2022 recommendations.

Purpose of Review: This review focuses on the recent findings regarding bone marrow adipose tissue (BMAT) concerning bone health. We summarize the variations in BMAT in relation to age, sex, and skeletal sites, and provide an update on noninvasive imaging techniques to quantify human BMAT. Next, we discuss the role of BMAT in patients with osteoporosis and interventions that affect BMAT. Recent Findings: There are wide individual variations with region-specific fluctuation and age- and gender-specific differences in BMAT content and composition. The Bone Marrow Adiposity Society (BMAS) recommendations aim to standardize imaging protocols to increase comparability across studies and sites. Water-fat imaging (WFI) seems an accurate and efficient alternative for spectroscopy (1H-MRS). Most studies indicate that greater BMAT is associated with lower bone mineral density (BMD) and a higher prevalence of vertebral fractures. The proton density fat fraction (PDFF) and changes in lipid composition have been associated with an increased risk of fractures independently of BMD. Therefore, PDFF and lipid composition could potentially be future imaging biomarkers for assessing fracture risk. Evidence of the inhibitory effect of osteoporosis treatments on BMAT is still limited to a few randomized controlled trials. Moreover, results from the FRAME biopsy sub-study highlight contradictory findings on the effect of the sclerostin antibody romosozumab on BMAT. Summary: Further understanding of the role(s) of BMAT will provide insight into the pathogenesis of osteoporosis and may lead to targeted preventive and therapeutic strategies.

Context Numerous studies have demonstrated detrimental skeletal consequences following bariatric surgery. Methods A working group of the European Calcified Tissue Society (ECTS) performed an updated review of existing literature on changes of bone turnover markers (BTMs), bone mineral density (BMD), and fracture risk following bariatric surgery and provided advice on management based on expert opinion. Literature review Based on observational studies, bariatric surgery is associated with a 21–44% higher risk of all fractures. Fracture risk is time-dependent and increases approximately 3 years after bariatric surgery. The bariatric procedures that have a malabsorptive component (including Roux-en-Y Gastric bypass (RYGB) and biliopancreatic diversion (BPD)) have clearly been associated with the highest risk of fracture. The extent of high-turnover bone loss suggests a severe skeletal insult. This is associated with diminished bone strength and compromised microarchitecture. RYGB was the most performed bariatric procedure worldwide until very recently, when sleeve gastrectomy (SG) became more prominent. There is growing evidence that RYGB is associated with greater reduction in BMD, greater increase in BTMs, and higher risk of fractures compared with SG but RCTs on optimal management are still lacking. Expert opinion In all patients, it is mandatory to treat vitamin D deficiency, to achieve adequate daily calcium and protein intake and to promote physical activity before and following bariatric surgery. In post-menopausal women and men older than 50 years, osteoporosis treatment would be reasonable in the presence of any of the following criteria: i) history of recent fragility fracture after 40 years of age, ii) BMD T-score ≤ −2 at hip or spine, iii) FRAX score with femoral neck BMD exceeding 20% for the 10-year major osteoporotic fracture probability or exceeding 3% for hip fracture. Zoledronate as first choice should be preferred due to intolerance of oral formulations and malabsorption. Zoledronate should be used with caution due to hypocemia risk. It is recommended to ensure adequate 25-OH vitamin D level and calcium supplementation before administering zoledronate. Conclusions The bariatric procedures that have a malabsorptive component have been associated with the highest turnover bone loss and risk of fracture. There is a knowledge gap on osteoporosis treatment in patients undergoing bariatric surgery. More research is necessary to direct and support guidelines.

International audience; The purpose of this multicentric study was to evaluate the prevalence and causes of Elevated Bone Mass (EBM) in patients who underwent DXA scanning over a 10-year period. The prevalence of EBM was 1 in 100. The main causes of EBM were degenerative spine disorders and renal osteodystrophy. Introduction Reports of elevated bone mass (EBM) on routine dual energy X-Ray absorptiometry (DXA) scanning are not infrequent. However, epidemiological studies of EBM are few and definition thresholds are variable. The purpose of this French multicentric study was to evaluate the prevalence and causes of EBM in adult patients who underwent DXA scanning over a 10-year period. Methods This multicentric, retrospective study was conducted in six French regional bone centres. DXA databases were initially searched for individuals with a bone mineral density (BMD) Z-score >= +4 at any site in the lumbar spine or hip from April 1st, 2008 to April 30st, 2018. Results In all, 72,225 patients with at least one DXA scan were identified. Of these, 909 (322 men and 587 women) had a Z-score >= + 4, i.e. a prevalence of 1.26% [1.18-1.34%]. The DXA scan reports and imagery and medical records of the 909 EBM patients were reviewed and 936 causes were found. In 42 patients (4%), no cause could be determined due to unavailability of data. Artefactual causes of EBM were found in 752 patients (80%), in whom the predominant cause was degenerative disease of the spine (613 patients, 65%). Acquired causes of focal EBM-including Paget's disease (n = 7)-were found in 12 patients (1%), and acquired causes of generalized EBM-including renal osteodystrophy (n = 32), haematological disorders (n = 20) and hypoparathyroidism (n = 15)-in 84 patients (9%). Other causes were rare hereditary diseases and unknown EBM in 19 (2%) and 27 (3%) cases respectively. Conclusions The prevalence of EBM was approximately 1 in 100. These findings suggest that degenerative disease of the spine is the main cause of EBM, but that acquired or hereditary diseases are also causal factors.

International audience; With intermittent vitamin D supplementation, serum 25-hydroxyvitamin D (25OHD) levels may remain stable only if the dosing interval is shorter than 3 months, the ideal perhaps being about 1 month. Recent data support moderate daily vitamin D doses instead of high intermittent doses, notably in elderly patients prone to falls. The level of evidence is low, however, with no head-to-head comparisons of clinical outcomes such as fractures and falls in groups given identical dosages daily versus intermittently. A challenge to daily vitamin D supplementation in France is the absence of a suitable pharmaceutical formulation. In addition, daily dosing carries a high risk of poor adherence. Until suitable vitamin D3 formulations such as tablets or soft capsules each containing 1000 or 1500 IU become available, we suggest intermittent supplementation according to 2011 GRIO guidelines. Among the available dosages, the lowest should be preferred, with the shortest possible interval, e.g., 50,000 IU monthly rather than 100,000 every two months.

Standard adjuvant therapies for breast cancer such as chemotherapy or aromatase inhibitor and LH-RH agonist hormone therapy are associated with significant survival gains but also induce bone loss by aggravating the estrogen deprivation. The bone loss may be substantial, notably during early treatment, and occurs regardless of the baseline bone mineral density values. The objective of developing these recommendations was to achieve a practical consensus among various scientific societies, based on literature review, about osteoporosis prevention and treatment in these patients. The following scientific societies contributed to the work: Société Française de Rhumatologie (SFR), Groupe de Recherche et d'Information sur les Ostéoporoses (GRIO), Groupe Européen d'Etudes des Métastases Osseuses (GEMO), Association Francophone pour les Soins Oncologiques de Support (AFSOS), Société Française de Sénologie et de Pathologie Mammaire (SFSPM), Société Française de Radiothérapie Oncologique (SFRO). Drug prescription and reimbursement modalities in France were taken into account. These recommendations apply to postmenopausal women taking systemic chemotherapy and/or aromatase inhibitor therapy, non-postmenopausal women taking LH-RH agonist therapy, and non-postmenopausal women with persistent amenorrhea 1 year after chemotherapy completion. All women in these three categories should undergo an evaluation of bone health and receive interventions to combat risk factors for bone loss. Patients with a history of severe osteoporotic fracture and/or a T-score value-2.5 should receive osteoporosis drug therapy. The FRAX® score should be used to guide treatment decisions in patients whose T-score is between -1 and -2.5. General osteoporosis prevention measures should be applied in patients without criteria for osteoporosis drug therapy, who should undergo bone mineral density measurements 18-24 months later if the baseline T-score is-1 and 3-5 years later if the baseline T-score is-1. The anti-tumor effect of bisphosphonates and denosumab was not considered when establishing these recommendations.

Resume Les traitements adjuvants standards du cancer du sein comme la chimiotherapie et les hormonotherapies par inhibiteurs de l’aromatase et/ou analogues de la LH-RH sont associes a un gain significatif de survie des patientes mais sont responsables d’une perte osseuse parfois importante surtout en debut de traitement. Cette perte osseuse est due a la carence estrogenique supplementaire induite par ces traitements et s’observe quel que soit le niveau densitometrique initial des patientes. L’objectif de ces recommandations est de proposer, a la suite d’une revue de la litterature, une attitude consensuelle pratique pour la prevention et le traitement de l’osteoporose chez ces patientes, entre les differentes societes savantes qui ont participe a ce travail : Societe francaise de rhumatologie (SFR), Groupe de recherche et d’Information sur les osteoporoses (GRIO), Groupe europeen d’etudes des metastases osseuses (GEMO), Association francophone pour les soins oncologiques de Support (AFSOS), Societe francaise de senologie et de pathologie mammaire (SFSPM), Societe francaise de radiotherapie oncologique (SFRO), en tenant compte des modalites de prescription et de remboursement des traitements en France. Ces recommandations concernent les femmes menopausees recevant un traitement systemique par chimiotherapie et/ou inhibiteur d’aromatase, les femmes non menopausees recevant un agoniste de LH-RH et les femmes non-menopausees presentant une amenorrhee persistante 1 an apres l’arret de la chimiotherapie. Il est recommande que toutes ces femmes aient une evaluation osseuse et une prevention des facteurs de risque de perte osseuse. Il est recommande que les patientes aux antecedents de fracture osteoporotique severe et/ou ayant un T-score −1. Ces recommandations n’abordent pas l’action anti-tumorale des bisphosphonates ou du denosumab.

International audience; Both type 1 and type 2 diabetes mellitus are associated with bone disorders, albeit via different mechanisms. Early studies in patients with type 1 diabetes suggested a 10-fold increase in the hip fracture risk compared to nondiabetic controls. Metaanalyses published more recently indicate a somewhat smaller risk increase, with odds ratios of 6 to 7. Diminished bone mineral density is among the contributors to the increased fracture risk.Both types of diabetes are associated with decreased bone strength related to low bone turnover. The multiple and interconnected pathophysiological mechanisms underlying the bone disorders seen in type 1 diabetes include insulin deficiency, accumulation of advanced glycation end products, bone microarchitecture alterations, changes in bone marrow fat content, low-grade inflammation, and osteocyte dysfunction. The bone alterations are less severe in type 2 diabetes. Odds ratios for hip fractures have ranged across studies from 1.2 to 1.7, and bone mineral density is higher than in nondiabetic controls. The odds ratio is about 1.2 for all bone fragility fractures combined. The pathophysiological mechanisms are complex, particularly as obesity is very common in patients with type 2 diabetes and is itself associated with an increased risk of fractures at specific sites (humerus, tibia, and ankle). The main mechanisms underlying the bone fragility are an increase in the risk of falls, sarcopenia, disorders of carbohydratemetabolism, vitamin D deficiency, and alterations in cortical bone microarchitecture and bone matrix.The medications used to treat both types of diabetes do not seem to play a major role. Nevertheless, thiazolidinediones and, to a lesser extent, sodium-glucose cotransporter inhibitors may have adverse effects on bone, whereas metformin may have beneficial effects. For the most part, the standard management of bone fragility applies to patients with diabetes. However, emphasis should be placed on preventing falls, which are particularlycommon in this population. Finally, there is some evidence to suggest that anti-fracture treatments are similarly effective in patients with and without diabetes.

Resume La castration chirurgicale ou chimique, en particulier avec les analogues de la LH-RH utilises lors du cancer de la prostate est responsable d’une perte osseuse importante et rapide. Cette perte osseuse est due a la diminution de la testosteronemie, et peut-etre a l’origine d’une augmentation du risque de fractures. L’objectif de ces recommandations est de proposer, a la suite d’une revue de la litterature, une attitude consensuelle pratique pour la prevention et le traitement de l’osteoporose chez ces patients, entre les differentes societes savantes qui ont participe a ce travail : Societe francaise de rhumatologie (SFR), Groupe de recherche et d’information sur les osteoporoses (GRIO), Groupe europeen d’etudes des metastases osseuses (GEMO), Association francophone pour les soins de support (AFSOS), Association francaise d’urologie (AFU), Societe francaise de radiotherapie oncologique (SFRO), en tenant compte des modalites de prescription et de remboursement des traitements en France. Il est recommande que tous ces patients aient une evaluation du risque de fracture et une prevention des facteurs de risque de perte osseuse. Il est recommande que les patients aux antecedents de fracture osteoporotique severe et/ou ayant un T-score

Severe osteoporotic fractures (hip, proximal humerus, pelvic, vertebral and multiple rib fractures) carry an increased risk of mortality. This retrospective cohort study in the French national healthcare database aimed to estimate refracture and mortality rates after severe osteoporotic fractures at different sites, and to identify mortality‐related variables. A total of 356,895 patients hospitalized for severe osteoporotic fracture between 2009 and 2014 inclusive were analyzed. The cohort was followed for 2 to 8 years up to the study end or until the patient died. Data were extracted on subsequent hospitalizations, refracture events, treatments, comorbidities of interest and survival. Time to refracture and survival were described using Kaplan‐Meier analysis by site of fracture and overall. Mortality risk factors were identified using a Cox model. Hip fractures accounted for 60.4% of the sample (N = 215,672). In the 12 months following fracture, 58,220 patients (16.7%) received a specific osteoporosis treatment, of whom 21,228 were previously treatment‐naïve. The 12‐month refracture rate was 6.3% (95% confidence interval [CI], 6.2%–6.3%), ranging from 4.0% (95% CI, 3.7%–4.3%) for multiple rib fractures to 7.8% (95% CI, 7.5%–8.1%) for pelvic fractures. Twelve‐month all‐cause mortality was 12.8% (95% CI, 12.7%–12.9%), ranging from 5.0% (95% CI, 4.7%–5.2%) for vertebral fractures to 16.6% (95% CI, 16.4%–16.7%) for hip fractures. Osteoporosis‐related mortality risk factors included fracture site, previous osteoporotic fracture (hazard ratio 1.21; 95% CI, 1.18–1.23), hip refracture (1.74; 95% CI, 1.71–1.77), and no prior osteoporosis treatment (1.24; 95% CI, 1.22–1.26). Comorbid cancer (3.15; 95% CI, 3.09–3.21) and liver disease (2.54; 95% CI, 2.40–2.68) were also strongly associated with mortality. In conclusion, severe osteoporotic fractures, including certain non‐hip nonvertebral fractures, carry a high burden in terms of mortality and refracture risk. However, most patients received no anti‐osteoporotic treatment. The findings emphasize the importance of better management of patients with severe fractures, and of developing effective strategies to reduce fracture risk in patients with osteoporosis. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Summary: Vertebral fractures are independent risk factors for vertebral and nonvertebral fractures. Since vertebral fractures are often missed, the relatively new introduction of vertebral fracture assessment (VFA) for imaging of the lateral spine during DXA-measurement of the spine and hips may contribute to detect vertebral fractures. We advocate performing a VFA in all patients with a recent fracture visiting a fracture liaison service (FLS). Fracture liaison services (FLS) are important service models for delivering secondary fracture prevention for older adults presenting with a fragility fracture. While commonly age, clinical risk factors (including fracture site and number of prior fracture) and BMD play a crucial role in determining fracture risk and indications for treatment with antiosteoporosis medications, prevalent vertebral fractures usually remain undetected. However, vertebral fractures are important independent risk factors for future vertebral and nonvertebral fractures. A development of the DXA technology, vertebral fracture assessment (VFA), allows for assessment of the lateral spine during the regular DXA bone mineral density measurement of the lumbar spine and hips. Recent approaches to the stratification of antiosteoporosis medication type according to baseline fracture risk, and differences by age in the indication for treatment by prior fracture mean that additional information from VFA may influence initiation and type of treatment. Furthermore, knowledge of baseline vertebral fractures allows reliable definition of incident vertebral fracture events during treatment, which may modify the approach to therapy. In this manuscript, we will discuss the epidemiology and clinical significance of vertebral fractures, the different methods of detecting vertebral fractures, and the rationale for, and implications of, use of VFA routinely in FLS. Summary points: • Vertebral fracture assessment is a tool available on modern DXA instruments and has proven ability to detect vertebral fractures, the majority of which occur without a fall and without the signs and symptoms of an acute fracture. • Most osteoporosis guidelines internationally suggest that treatment with antiosteoporosis medications should be considered for older individuals (e.g., 65 years +) with a recent low trauma fracture without the need for DXA. • Younger individuals postfracture may be risk-assessed on the basis of FRAX® probability including DXA and associated treatment thresholds. • Future fracture risk is markedly influenced by both site, number, severity, and recency of prior fracture; awareness of baseline vertebral fractures facilitates definition of true incident vertebral fracture events occurring during antiosteoporosis treatment. • Detection of previously clinically silent vertebral fractures, defining site of prior fracture, might alter treatment decisions in younger or older FLS patients, consistent with recent IOF-ESCEO guidance on baseline-risk-stratified therapy, and provides a reliable baseline from which to define new, potentially therapy-altering, vertebral fracture events.