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Introduction: Reports indicate that 22%–64% of travelers experience some illness when in a foreign country. To date, no prior study has reported the use of ambulances by travelers or the epidemiology of travel-related injury. Methods: In this retrospective study, we aimed to describe ambulance use by international travelers, including the rates of travel-related injury and illness. To do so, ambulance dispatch data from January 1, 2010 to December 31, 2018 was used. Results: Overall, of the 43201 cases of ambulance use during the study period, 524 (1.2%) were international travelers. Ambulance use by international travelers increased from 0.35% in 2010 (15/4311) to 2.54% in 2018 (125/4913), an average annual increase of 0.27%. Of the international travelers, 392 (74.8%) had minor complaints, 110 cases (21.0%) had moderate complaints, 280 (53.4%) had internal disease, and 223 cases (42.6%) had suffered trauma. Regarding location, 253 (48.3%) were from a hotel/lodge, 83 (15.8%) were from a road/parking, and 30 (5.7%) were in the forest/mountain. Conclusion: Most international travelers use ambulances for minor complaints, typically internal disease or trauma, and approximately half access the service from a hotel or lodge.

Purpose Denosumab reduces bone resorption and improves bone mineral density (BMD). Studies have analyzed subsequent treatment transitioning from bisphosphonates to denosumab based on dual-energy X-ray absorptiometry scanning (DXA). Quantitative computed tomography (QCT) can help assess cortical and trabecular bones separately in three dimensions without the interference of the surrounding osteophytes. In the present study, we analyzed the subsequent treatment transition from bisphosphonates to denosumab using QCT. Methods Thirty-two patients with postmenopausal osteoporosis to be treated with denosumab were recruited. The patients were divided into two groups (15 prior bisphosphonate and 17 naïve) based on their previous treatment. BMD of the lumbar spine and hip were evaluated by DXA and QCT at baseline and 12 months following denosumab treatment. Results The percentage change in volumetric BMD assessed by QCT at 12 months significantly improved in the naïve group compared with that in the prior bisphosphonate group. The region-specific assessment of femur at 12 months revealed that denosumab treatment was effective in both cortical and trabecular bones except the trabecular region of the prior bisphosphonate group. Conclusion Our study suggests that although denosumab treatment was useful in both treatment groups, BMD increase was significantly higher in the naïve group than in the prior-bisphosphonate group. Interestingly, in the prior-bisphosphonate group, denosumab treatment was more effective in the cortical region than the trabecular region. Our study offers insights into the subsequent treatment and permits greater confidence when switching to denosumab from bisphosphonates., Highlights • We analyzed the treatment transition from bisphosphonates to denosumab using QCT. • Percentage change in volumetric BMD at 12 months significantly improved in the naïve group. • Denosumab treatment was more effective on the cortical region than the trabecular region. • Our study offers insights into the subsequent treatment when switching to denosumab.

Summary We investigated the relationship between serum 25(OH)D levels, grip strength, and fall score in elderly osteoporotic women for fall risk assessment. Both low serum 25(OH)D and low grip strength were independently associated with increased fall risk. The serum 25(OH)D cutoff specific to increased fall risk was 14 mg/dL (35 nmol/L). Purpose This study aimed to establish a cutoff value of serum 25-hydroxyvitamin D (25(OH)D) for fall assessment and investigate the relationship between serum 25(OH)D, grip strength, and fall score adjusted for age in osteoporotic elderly Japanese women. Methods This is a cross-sectional study utilizing collected data of osteoporotic elderly (age ≥65 years) female patients. A questionnaire for fall risk assessment was used, in which a score ≥ 6 was determined as increased fall risk. Serum 25(OH)D levels and grip strength were measured, and the cutoff points were calculated by receiver operating curve (ROC) analysis. Logistic regression analysis with age adjustment was conducted for potential risk factors for fall. Results After applying eligibility criteria, finally, 349 patients were enrolled. The median patient age was 77.0 years, and the mean serum 25(OH)D level was 15.6 ng/mL (36 nmol/L). Based on the ROC analysis, we defined the cutoff values of serum 25(OH)D level and grip strength as 14 ng/mL (35 nmol/L) and 15 kg, respectively. A multivariate analysis adjusted for age was conducted. Low serum 25(OH)D level and grip strength were independent risk factors for ≥6 fall risk scores. Conclusion Both low serum 25(OH)D level and low grip strength were independently associated with increased fall risk score in osteoporotic elderly women. The appropriate serum 25(OH)D cutoff specific to the increased fall risk group in this population was 14 mg/dL (35 nmol/L). These findings might be used for the identification of patients with high fall risks. These results should be confirmed in other patient groups.

There is growing interest in "osteosarcopenia" as the coexistence of osteoporosis and sarcopenia exacerbates negative outcomes. However, limited information is available regarding the risk factors of osteosarcopenia development in patients with osteoporosis. Therefore, we retrospectively reviewed 276 consecutive patients with postmenopausal osteoporosis who regularly visited Showa University Hospital. Patients were eligible for the study if they were ≥65 years of age and underwent dual-energy X-ray absorptiometry, blood sampling, and physical performance assessment. Patients were divided into the osteosarcopenia and osteoporosis alone groups according to the diagnostic criteria of the Asian Working Group for Sarcopenia. Of the 276 patients with osteoporosis, 54 patients (19.6%) had osteosarcopenia. Patients in the osteosarcopenia group had a greater risk of frailty than did those in the osteoporosis alone group (odds ratio 2.33; 95% confidence interval, 1.13-4.80, P = 0.028). Low body mass index seemed to be the strongest factor related to the development of osteosarcopenia, and none of the patients in the osteosarcopenia group were obese (BMI ≥27.5 kg/m2). Multiple logistic analyses revealed that patients aged 65-74 years who had comorbidities such as kidney dysfunction and high levels of HbA1c were at risk of developing osteosarcopenia. Thus, we strongly recommend the assessment of the key components of the diagnosis of osteosarcopenia in an osteoporosis clinic for patients with low body mass index. Furthermore, appropriate assessments, including comorbidities, will help in identifying patients at greater risk of developing osteosarcopenia.

Prospective feasibility study on consecutive patients.The aim of this study was to investigate the ability of regional BMD around the pedicle screw to predict the screw fixation.Pedicle screw fixation is the gold standard technique for spinal fusion. Despite the advantage of biomechanical stability, screw loosening is a common complication. In previous studies, pullout strength and screw insertional torque were correlated, and most importantly, affected by bone mineral density (BMD). Although the density and structure of the vertebral body are not homogeneous, no study has yet evaluated the relationship between screw insertional torque and regional BMD around the pedicle screw in vivo.Consecutive 50 patients, scheduled for transpedicular fixation, were evaluated preoperatively for BMD measured by dual-energy absorptiometry (DXA) and quantitative computed tomography (QCT). Regional volumetric BMD around the pedicle screw (PS-vBMD) using the novel QCT technique was also evaluated. Among all patients, 190 screws (diameter, 7.5 to 8.5 mm; length, 40 to 45 mm, inserted from L1 to L5) were eligible for this study and were analyzed to identify factors contributing to insertional torque. The following factors were investigated: age, body mass index, laboratory data, pedicle diameter, screw diameter, screw length, and 5 types of bone mineral density measures [DXA: spine-areal BMD (aBMD), total hip-aBMD, femoral neck-aBMD, QCT: central-vBMD, PS-vBMD].Insertional torque was significantly correlated with each BMD measurement and strongest with PS-vBMD (r=0.61, P0.001). Multiple regression analysis showed PS-vBMD was most strongly correlated with screw insertional torque (stdβ=0.494; P0.001). A model containing the following 5 predictors was significantly associated with screw insertional torque: age, pedicle diameter, screw diameter, screw length, and PS-vBMD.The preoperative measurement of PS-vBMD was technically feasible and reliably predictive of screw insertional torque during transpedicular fixation in a clinical setting.

Discontinuation of denosumab during osteoporosis treatment leads to rapid loss of bone mineral density and induces a bone turnover rebound effect. Previous studies have reported analysis based on dual-energy X-ray absorptiometry scanning (DXA). Here, we report the first case involving analysis of three-dimensional bone mineral density and bone strength, measured by quantitative computed tomography (QCT) after discontinuation of denosumab. An 82-year-old woman who discontinued denosumab because of patient’s wish was administered the fifth dose after a gap of 14 months. Her bone mineral density evaluated by DXA and QCT, bone strength, and bone turnover marker levels showed significant rebound phenomenon. The levels of the cortical parameters of the hip were also decreased indicating an increased risk of femoral fractures after denosumab interruption. Our case highlights the increased risk of fractures after discontinuation of denosumab. Therefore, denosumab must be used judiciously without interruption in the dosage schedule.

Denosumab is a fully human monoclonal antibody against the receptor activator of nuclear factor-κB ligand (RANKL) that is used for the treatment of osteoporosis. Denosumab-induced hypocalcemia is a rare but important adverse event, which is usually asymptomatic in patients with osteoporosis. It is also known that hypocalcemia is common in patients with bone metastases and severe renal impairment. Here we report a case of symptomatic hypocalcemia following administration of 60 mg of denosumab in a patient with high bone turnover and no renal impairment (estimated glomerular filtration rate [eGFR], 71 mL/min), despite prophylactic oral vitamin D administration. This report supports our observation that there is a risk of protracted and marked denosumab-induced hypocalcemia in patients with high bone turnover, irrespective of their degree of renal impairment.