Objective: To evaluate in patients with osteoporosis feasibility and effect of an online patient education program on self-care enablement, illness perception, as well as osteoporosis-specific knowledge and self-maintenance behaviors.

Material and methods: Thirty patients with osteoporosis (90% women, mean age 70, SD 6.4, 27% with previous vertebral fracture) were recruited to participate in an online patient education program. The program comprised 8 modules with osteoporosis-specific knowledge and behavioral activities (approximately 5 hours e-learning) that patients went through at own pace. Patients were assessed with questionnaires before and after 5 weeks. Outcome measures included the Patient Enablement Instrument (PEI), the Brief Illness Perception Questionnaire (BIPQ), and questions about osteoporosis-specific knowledge and self-maintenance behaviors relating to compliance with osteoporosis medicine, diet, exercises, fall prevention and ergonomic. Changes in outcomes were analyzed with paired samples tests. 

Results: All patients completed the online education program and reported they would recommend it to other (83% strongly recommend). They also scored very high both content and benefit of the program. A majority of the patients reported higher self-care enablement at follow-up scoring much better/better ability to understand the disease (90%), ability to cope with disease (77%), ability to maintain health (60%), ability to cope with life (62%), confidence with own health (57%), and ability to help one-self (70%). BIPQ score and patient-reported osteoporosis-specific knowledge improved (p< 0.001). Even compliance with osteoporosis-specific self-maintenance behaviors relating to practice of balance and weight-bearing exercises, and ergonomic adaptation in daily activities improved (p<0.01).  

Conclusions: Patients with osteoporosis who participated in an online patient education program reported higher self-care enablement, improved illness perception, as well as improvement in osteoporosis-specific knowledge and self-maintenance behaviors. Patients with osteoporosis are likely to benefit from participation in an online patient education program, and future studies should investigate long-term benefits on self-care enablement, as well as health-related quality of life for patients with osteoporosis.    

Objective: Vertebral fractures are significantly underdiagnosed in routine clinical practice.Opportunistic screening using CT scans could enhance detection rates. This study aims toimplement an MDR approved AI-screening tool (FLAMINGO, IB Lab) within a clinical FractureLiaison Service (FLS), thereby integrating radiology with clinical care.

Materials and Methods: In this prospective study, the AI-screening tool was incorporatedinto clinical care, linking radiology workflows to a FLS. All patients over 50 years of ageundergoing thoracic and/or abdominal CT scans for non-skeletal reasons (e.g. pneumonia,malignancy, kidney stones) at a medium-sized hospital, serving approximately 250,000inhabitants, were included.

Results: During the first month, a total of 1,249 CT scans (1,127 unique patients) werescreened using the AI algorithm, with 19% flagged as positive (238 CT scans [216 uniquepatients]). Radiologist confirmation indicated that 71% of these were true positives (169 CTscans [148 unique patients]). In the FLS triage, 74 of these 148 patients (50%) were referredfor further osteoporosis investigation and treatment. The remaining patients were alreadyknown and under correct treatment (30%) or were terminally ill or had deceased shortly(during 3 months) after the CT (20%). In total, 6.5% of all patients originally screened werefinally referred for a vertebral fracture that was new or had not been handled correctlybefore.

Conclusion: The implementation of the AI-screening tool (FLAMINGO, IB Lab) within theclinical FLS demonstrated significant potential to increase the detection of vertebral fracturesand to enhance subsequent investigation and treatment of osteoporosis.

IntroductionPatient education in combination with physical activity has been proposed as a way of increasing health-related quality of life and functional capacity in patients with osteoporosis. A randomised pilot study called the School of Osteoporosis in Linkoping (SOL) was conducted in 2018 for persons aged &gt;= 60 years with established spinal osteoporosis. The SOL was scheduled for ten weeks with once-weekly theory education with or without additional supervised physical group training. The purpose of the present study was to explore the experiences of having participated in an osteoporosis school in persons with established spinal osteoporosis.Materials and methodsTen participants who had completed the SOL with patient education and supervised physical group training were invited to individual interviews, while six persons were accepted to participate. Qualitative content analysis was conducted with an inductive approach.FindingsThree main categories were identified from the interviews: The structure of the osteoporosis school; Gained knowledge related to the education in the osteoporosis school; and Experiences of health status one-year post-intervention. Seven associated subcategories were identified. Increased knowledge and perceptions of improved health acquired by the interventions were emphasised. However, continued supervised group training was requested and there were also concerns about worsened health at the one-year post-intervention follow-up.ConclusionThe tailored content and the group aspects of the structured osteoporosis school were experienced as the most important factors for successful results.

Summary: We assessed the prevalence of hypocalcemia after denosumab injections in a real-world cohort routinely monitored for calcium during up to 7.5 years of treatment. Among 1096 injections in 242 patients, 6.3% resulted in hypocalcemia, and was independent of the injection number. Severe hypocalcemia was rare (1%).

Purpose: To assess the prevalence of and risk factors for hypocalcemia after administration of denosumab in a patient cohort routinely monitored for ionized calcium after each dose.

Methods: In this retrospective observational study, we analyzed denosumab-induced hypocalcemia in a real-world cohort who were routinely followed up with ionized calcium pre- and post-injection (within 31 days after injection) during the period 2011 to 2020.

Results: In total, we included data from 1096 denosumab injections in 242 individuals (1–15 injections per patient). The mean age for the first injection was 74 ± 10 years, and 88% were female. Post-injection hypocalcemia occurred after 6.3% of all injections (4.6% mild, 0.6% moderate, and 1.1% severe) and was independent of the number of injections (rate of hypocalcemia varied from 3–8%). Risk factors for hypocalcemia were male sex, severe renal failure, pre-injection hypocalcemia, hypomagnesemia, hypophosphatemia, and vitamin D insufficiency. Furthermore, older age was not associated with an increased hypocalcemia risk.

Conclusions: Denosumab-induced hypocalcemia is a prevalent adverse event, which occurs independently of the number of injections. However, severe hypocalcemia is a rare occurrence, and severe renal failure and nutritional status appear to be important predictive factors. Magnesium and phosphate might add value in the pre-injection risk assessment; however, this observation needs to be confirmed in larger cohorts.

Fragility fractures, in particular vertebral fractures, are associated with high morbidity, including chronic pain and reduced health-related quality of life. We aimed to investigate the short- and long-term effects of patient education, including interdisciplinary themes, with or without physical training or mindfulness/medical yoga for patients with established spinal osteoporosis in primary care. Osteoporotic persons aged sixty years or older with one or more vertebral fractures were randomized to theory only, theory and physical exercise, or theory and mindfulness/medical yoga and were scheduled to once a week for ten weeks. Participants were followed up by clinical tests and questionnaires. Twenty-one participants completed the interventions and the one-year follow-up. Adherence to interventions was 90%. Pooled data from all participants showed significant improvements after intervention on pain during the last week and worst pain, and reduced painkiller use (any painkillers at baseline 70% [opioids 25%] vs. post-intervention 52% [opioids 14%]). Significant improvements were seen regarding RAND-36 social function, Qualeffo-41 social function, balance, tandem walking backwards, and theoretical knowledge. These changes were maintained at the 1-year follow-up. Patient group education combined with supervised training seems to have positive effects on pain, and physical function in persons with established spinal osteoporosis. The improved quality of life was maintained at the 1-year follow-up.

Objective: Patient education is part of fracture liaison services in many organizations and has been shown to have positive effects on several important patient outcomes. The present study aimed to assess the patients’ preferences when seeking disease specific information on osteoporosis. Methods: Patients with denosumab (Den) or zoledronic acid (ZA) treatment administrated at our endocrinology clinic July 2017 – December 2017 were sent a postal questionnaire with questions on preferences on how to obtain information about osteoporosis. One reminder was sent to nonresponders. Participants were mainly patients followed by primary healthcare, but with help from specialized hospital care to administrate injections/infusions. No osteoporosis school was arranged by the health organization in the catchment area. Results: A total number of 155 patients (84% females, mean age±SD 75±9 y) participated in the study. Dropout rate was 26%. A total of 67% of patients actively searched for disease specific information on osteoporosis. No difference in search behavior was seen regarding type of treatment (Den or ZA) or age. More women than men searched for information as did patients experiencing any adverse event (both p<0.01). The most used source of information was brochure (46%), internet sites from healthcare providers (27%), internet in general (15%) and weekly magazines (8%). In total, 57% of participants stated they would like to attend a school for osteoporosis. Of these 44% preferred general lectures, 39% group education with physical meet-ups, 23% internet (general information) and 13% internet osteoporosis schools. Conclusion: Disease specific information is prompted by a majority of osteoporosis patients. Type of education and sources varies. Internet sources, preferentially from the healthcare organization, was used by a third of patients. The study was done pre-pandemic and it is possible that the use of internet resources might have changed.

Objectives:Fracture liaison services are designed to identify patients needing osteoporosis treatment after a fracture. Some fracture liaison service designs involve a prescreening step, for example, fracture risk assessment tool (FRAX®). Another possible prescreening tools are bone mass density assessment in the acute setting. The aim of this study was to assess the effectiveness of prescreening tools.Methods:In the present prospective cohort study, women aged >55 years with a radius fracture were included. Patients were recruited at the emergency department after experiencing their fracture. All patients performed fracture risk assessment by fracture risk assessment tool, and bone mass density assessment by digital X-ray radiogrammetry and dual-energy X-ray absorptiometry (prescreening steps) as well as full routine evaluation at the osteoporosis unit (endpoint). The main outcome measures were sensitivity, specificity, predictive values, and area under the curve.Results:Forty-one women were recruited (mean age: 70 ± 8 years). Of these, 54% fulfilled the treatment indication criteria of osteoporosis after a full examination. Fracture risk assessment tool without bone mass density (cutoff ⩾ 15%) for prescreening patients had a high sensitivity (90%) but a low area under the curve (0.50) and specificity (16%). The highest area under the curve (0.73) was found prescreening with bone mass density assessment (dual-energy X-ray absorptiometry or digital X-ray radiogrammetry) having a sensitivity of 59%–86% and specificity of 61%–90%.Conclusion:This study, though small, raises questions regarding the effectiveness of using a prescreening step in fracture liaison services for high-risk individuals. In this cohort, FRAX® without bone mass density had a low precision, with a risk of both underestimating and overestimating patients requiring treatment. Bone mass density assessment in the acute setting could improve the precision of prescreening. Further investigations on the effectiveness and health economics of prescreening steps in fracture liaison services are needed.

Background: We aimed to compare two volumetric bone mineral density (vBMD) analysis programs, regarding (I) agreement of vBMD values based on monoand dual-energy computed tomography (MECT and DECT) scans and (II) suitability for analyzing DECT data obtained at different energies. Methods: We retrospectively analyzed two abdominal CT datasets: one performed in a MECT scan (vertebrae L1-L3) and one in a DECT scan (vertebrae L1-L4). Each dataset included different individuals [MECT 15 patients (45 vertebrae) and DECT 12 patients (48 vertebrae), respectively]. vBMD analysis was conducted using Philips IntelliSpace (IP) and Mindways qCT Pro (MW). Regarding the DECT scans, vBMD analysis was done at three different energies: 80, 150 and synthetic 120 kVp and for MECT scan at 120 kVp. For comparison of vBMD results between different software (aim 1) MECT 120 kVp and DECT synthetic 120 kVp data was used. For analyzing suitability of using different DECT energies for vBMD assessment (aim 2) all three DECT energies were used and results from each software was analyzed separately. Results: vBMD assessed with MW and IP, respectively correlated significantly for both the MECT (r=0.876; P&lt;0.001) and DECT (r=0.837; P&lt;0.001) scans, but the vBMD values were lower in using IP for vBMD assessment (8% and 14% lower for MECT and DECT, respectively; P=0.001). Regarding the different DECT energies, using MW for vBMD assessment showed significant correlations in vBMD results between 120 kVp and the two other energies (r=0.988 and r=0.939) and no significant differences in absolute vBMD values (P 0.05). The IP analysis as well showed significant correlation between 120 kVp and the other energies (r=0.769 and r=0.713, respectively), but differences in absolute vBMD values between the energies (P &lt;= 0.001). Conclusions: We show that the correlations between the vBMD derived from the two investigated software solutions were generally good but that absolute vBMD value did differ and might impact the clinical diagnosis of osteoporosis. Though small, our study data indicate that vBMD might be assessed in energies other than 120 kVp when using MW but not when using IP.

Objective: To investigate the effect of the COVID-19 pandemic on denosumab persistence. Methods: All patients who initiated denosumab treatment at our outpatient care (osteoporosis/endocrinology unit) between 2016-2019 were included and date of injections were recorded from case records. Persistence was analyzed regarding 2-y persistence and 1-y persistence. Persistence was defined as a maximum interval of either 1) 8 months (m) [6+2m], or 2) 9m [6+3m]. Results: In total 171 patients were included. Mean age was 74.3+10.2 y (range 35-93 y) and 87% were women. Age and gender distribution did not differ significantly between the year of denosumab initiation. The 2-y persistence rate (8-m interval permitted) was lower in patients starting denosumab 2019 than those starting 2016-1018, i.e., 69% vs. 83%, p=0.044. No significant difference was seen analyzing 1-y persistence in the same groups (87 vs. 91%, p=0.410). When using a more liberal persistence definition, i.e., 9+m interval permitted, no difference was seen between 2 y persistence, 77 vs. 83%, p=0.341. Conclusion: The present study indicates that a higher number of patients got their injection later than recommended during the pandemic, but despite high pressure on our healthcare system and health concerns in the general population, no significant influence on denosumab persistence using a more liberal interval allowance was seen in this outpatient osteoporosis group. 

Purpose: To compare health-related quality of life (HRQOL) in type 1 diabetes and non-diabetic controls and possible links to upper extremity impairments (UEIs). Prevalence of sick-leave and causes were investigated.

Materials and methods: This Swedish population-based case-control study included type 1 diabetes patients <67 years old and with a diabetes duration ≥20 years. Participants completed a postal questionnaire including Short Form 36, and questions regarding UEIs, and sick-leave.

Results: In total, 773 patients, aged 50 ± 10 years (diabetes duration 35 ± 10 years), and 708 non-diabetic controls, aged 54 ± 9 years, completed the study. Patients reported significantly lower HRQOL compared with controls. The difference was greatest for general health, vitality, and bodily pain. Patients with shoulder or hand but not finger impairments scored significantly lower than asymptomatic patients. The prevalence of sick leave was higher in patients vs. controls (23% vs. 9%, p < 0.001), and nearly half cited impairments from back, muscles, or joints as the main reason.

Conclusions: Health-related quality of life is lower in type 1 diabetes than controls and in patients with shoulder and hand impairments than in asymptomatic. Musculoskeletal impairments (back/muscle/joints) have impact on work ability. Identification of UEIs is important for initiating preventative-, therapeutic-, and rehabilitative interventions.

Implications for rehabilitation

• Upper extremity impairments (UEIs) that are common in type 1 diabetes, and associated with reduced health-related quality of life, should preferably be screened for on a regular basis along with other known diabetes complications.

• Early identification of UEIs is important to improve health by initiating preventive as well as therapeutic multi-professional rehabilitative interventions.

• Sick leave is higher in type 1 diabetes than in controls. Musculoskeletal impairments, including the back, muscles, and joints, are a common cause for sick leave warranting further studies.