JBMR Plus

Bone metastasis (BM) are the most severe and prevalent consequences of prostate cancer (PC) affecting more than 80% of patients with advanced PC. PCBM generate pain, pathological fractures, and paralysis. As modern therapies increase survival, more patients are suffering from these catastrophic consequences of PCBM. Radiographically, PCBM are predominantly osteosclerotic, but the mechanisms of abnormal bone formation, and how this "more and new" bone is related to fractures is unclear. In this study, we conducted a comprehensive analysis on a cohort of 76 cadaveric PCBM samples and 12 from non-PC donors as control. We used -CT to determine three-dimensional organization and quantify bone characteristics, quantitative backscattering electron microscopy to characterize mineral content and details in bone structure, nano indentation to determine mechanical properties, and we finalize with histological and immunohistochemical analysis of bone structure and composition. We define 4 phenotypes of PCBM, osteolytic, mixed lytic-sclerotic, and two subgroups of osteosclerotic lesions, those with residual trabeculae, and others without residual trabeculae. The osteosclerotic lesions are characterized by the presence of abnormal bone within the trabeculae surfaces and intertrabecular spaces. This abnormal bone is characterized by higher lacunae density, abnormal lacunae morphology and orientation. However, we observed no significant difference between this irregular bone and residual trabeculae in terms of mineral content, hardness, and elastic modulus at micron-scale. The collagen matrix of this abnormal bone presents with irregular organization and is accompanied by increased proteoglycan and phosphorylated glycoprotein content. These characteristics suggests the presence of woven bone in PCBM. However, the lack of subsequent bone remodelling, absence of lamellar bone deposition on its surface, absence of markers of matrix vesicles but evidence of alkaline phosphatase dominated mineralization and collagen-III structure, set up differences from woven bone, while the role of PC cells in inducing this irregular bone phenotype remains unclear.

Combination treatment of Low-Intensity Vibration (LIV) with zoledronic acid (ZA) was hypothesized to preserve bone mass and muscle strength while reducing adipose tissue accrual associated with complete estrogen (E2)-deprivation in young and skeletally mature mice. Complete E2-deprivation (surgical-ovariectomy (OVX) and daily injection of aromatase inhibitor (AI) letrozole) were performed on 8-week-old C57BL/6 female mice for 4 weeks following commencement of LIV administration or control (no LIV), for 28 weeks. Additionally, 16-week-old C57BL/6 female E2-deprived mice were administered {+/-}LIV twice daily and supplemented with {+/-}ZA (2.5 ng/kg/week). By week 28, lean tissue mass quantified by dual-energy X-ray absorptiometry was increased in younger OVX/AI+LIV(y) mice, with increased myofiber cross-sectional area of quadratus femorii. Grip strength was greater in OVX/AI+LIV(y) mice than OVX/AI(y) mice. Fat mass remained lower in OVX/AI+LIV(y) mice throughout the experiment compared with OVX/AI(y) mice. OVX/AI+LIV(y) mice exhibited increased glucose tolerance and reduced leptin and free fatty acids than OVX/AI(y) mice. Trabecular bone volume fraction and connectivity density increased in the vertebrae of OVX/AI+LIV(y) mice compared to OVX/AI(y) mice; however, this effect was attenuated in the older cohort of E2-deprived mice, specifically in OVX/AI+ZA mice, requiring combined LIV with ZA to increase trabecular bone volume and strength. Similar improvements in cortical bone thickness and cross-sectional area of the femoral mid-diaphysis were observed in OVX/AI+LIV+ZA mice, resulting in greater fracture resistance. Our findings demonstrate that the combination of mechanical signals in the form of LIV and anti-resorptive therapy via ZA improve vertebral trabecular bone and femoral cortical bone, increase lean mass, and reduce adiposity in mice undergoing complete E2-deprivation. One Sentence Summary: Low-magnitude mechanical signals with zoledronic acid suppressed bone and muscle loss and adiposity in mice undergoing complete estrogen deprivation. Translational RelevancePostmenopausal patients with estrogen receptor-positive breast cancer treated with aromatase inhibitors to reduce tumor progression experience deleterious effects to bone and muscle subsequently develop muscle weakness, bone fragility, and adipose tissue accrual. Bisphosphonates (i.e., zoledronic acid) prescribed to inhibit osteoclast-mediated bone resorption are effective in preventing bone loss but may not address the non-skeletal effects of muscle weakness and fat accumulation that contribute to patient morbidity. Mechanical signals, typically delivered to the musculoskeletal system during exercise/physical activity, are integral for maintaining bone and muscle health; however, patients undergoing treatments for breast cancer often experience decreased physical activity which further accelerates musculoskeletal degeneration. Low-magnitude mechanical signals, in the form of low-intensity vibrations, generate dynamic loading forces similar to those derived from skeletal muscle contractility. As an adjuvant to existing treatment strategies, low-intensity vibrations may preserve or rescue diminished bone and muscle degraded by breast cancer treatment.

SUMMARYZoledronic acid (ZA) prevents muscle weakness in mice with bone metastases; however, its role in muscle weakness in non-tumor-associated metabolic bone diseases and as an effective treatment modality for the prevention of muscle weakness associated with bone disorders, is unknown. We demonstrate the role of ZA-treatment on bone and muscle using a mouse model of accelerated bone remodeling, which represents the clinical manifestation of non-tumor associated metabolic bone disease. ZA increased bone mass and strength and rescued osteocyte lacunocanalicular organization. Short-term ZA treatment increased muscle mass, whereas prolonged, preventive treatment improved muscle mass and function. In these mice, muscle fiber-type shifted from oxidative to glycolytic and ZA restored normal muscle fiber distribution. By blocking TGF{beta} release from bone, ZA improved muscle function, promoted myoblast differentiation and stabilized Ryanodine Receptor-1 calcium channel. These data demonstrate the beneficial effects of ZA in maintaining bone health and preserving muscle mass and function in a model of metabolic bone disease. Context and significanceTGF{beta} is a bone regulatory molecule which is stored in bone matrix, released during bone remodeling, and must be maintained at an optimal level for the good health of the bone. Excess TGF{beta} causes several bone disorders and skeletal muscle weakness. Reducing excess TGF{beta} release from bone using zoledronic acid in mice not only improved bone volume and strength but also increased muscle mass, and muscle function. Progressive muscle weakness coexists with bone disorders, decreasing quality of life and increasing morbidity and mortality. Currently, there is a critical need for treatments improving muscle mass and function in patients with debilitating weakness. Zoledronic acids benefit extends beyond bone and could also be useful in treating muscle weakness associated with bone disorders.

The purpose of this explanatory retrospective case study was to report clinically significant increases in bone mineral density in a female and a male over 70 years of age with osteoporosis, following 16 weeks of hardstyle kettlebell training. Both case subjects were insufficiently active prior to participating in the BELL trial. Subjects trained five days a week accruing a large training load volume (calculated as kettlebell mass multiplied by repetitions performed) during structured group-based classes (74,872 kg and 110,132 kg, respectively). Regional dual-energy X-ray absorptiometry was used to assess BMD at the hip and lumbar spine. Increases in BMD of 12.7% and 5.9% at the femoral neck and lumbar spine (L2-L4) respectively were observed for the female, and 2.5% and 6.0% respectively for the male. Magnitude of change in BMD (g/cm2) at the lumbar spine was 2.0 and 1.9 times larger than the least significant change for the female and male respectively, and sufficient to advance the female subjects status from osteoporosis to osteopenia. Although these results do not show a definitive causal relationship between kettlebell training and increased BMD, further investigation of the effects of kettlebell training on BMD in older adults with osteoporosis and osteopenia is warranted.

BackgroundOsteoporosis is underdiagnosed and undertreated prompting the exploration of opportunistic screening using CT and artificial intelligence (AI). PurposeTo develop a reproducible deep learning-based convolutional neural network to automatically place a 3D region of interest (ROI) in trabecular bone, develop a correction method to normalize attenuation across different CT protocols or and scanner models, and to establish thresholds for osteoporosis in a large diverse population. MethodsA deep learning-based method was developed to automatically quantify trabecular attenuation using a 3D ROI of the thoracic and lumbar spine on chest, abdomen, or spine CTs, adjusted for different tube voltages and scanner models. Normative values, thresholds for osteoporosis of trabecular attenuation of the spine were established across a diverse population, stratified by age, sex, race, and ethnicity using reported prevalence of osteoporosis by the WHO. Results538,946 CT examinations from 283,499 patients (mean age 65 years{+/-}15, 51.2% women and 55.5% White), performed on 50 scanner models using six different tube voltages were analyzed. Hounsfield Units at 80 kVp versus 120 kVp differed by 23%, and different scanner models resulted in differences of values by < 10%. Automated ROI placement of 1496 vertebra was validated by manual radiologist review, demonstrating >99% agreement. Mean trabecular attenuation was higher in young women (<50 years) than young men (p<.001) and decreased with age, with a steeper decline in postmenopausal women. In patients older than 50 years, trabecular attention was higher in males than females (p<.001). Trabecular attenuation was highest in Blacks, followed by Asians and lowest in Whites (p<.001). The threshold for L1 in diagnosing osteoporosis was 80 HU. ConclusionDeep learning-based automated opportunistic osteoporosis screening can identify patients with low bone mineral density that undergo CT scans for clinical purposes on different scanners and protocols. Key Results 3 main results/conclusionsO_LIIn a study of 538,946 CT examinations performed in 283,499 patients using different scanner models and imaging protocols, an automated deep learning-based convolutional neural network was able to accurately place a three-dimensional regions of interest within thoracic and lumbar vertebra to measure trabecular attenuation. C_LIO_LITube voltage had a larger influence on attenuation values (23%) than scanner model (<10%). C_LIO_LIA threshold of 80 HU was identified for L1 to diagnose osteoporosis using an automated three-dimensional region of interest. C_LI

Although body mass index is positively associated with bone mineral density, suggesting obesity is protective against fracture, elderly obese individuals experience greater fracture risk at certain sites than non-obese peers, suggesting bone structural or material changes contribute to fragility. Diet-induced obesity rodent studies have reported detrimental changes to bone microstructure and some apparent-level material properties, but tissue-level material changes are not well understood. Because adipose tissue is highly vascularized, and bone remodeling depends critically on functional vascular supply, concurrent effects on osteovascular perfusion and structure may provide insight about obesity-related bone fragility. This study aimed to determine the effects of obesity on both tissue-level bone properties and osteovascular properties that could negatively impact bone strength. Five-week-old male C57Bl/6J mice were fed either high fat diet (HFD) or control fat diet (CFD) for 17 weeks and received daily treadmill exercise or remained sedentary for eight weeks at ages 14-22 weeks. HFD negatively affected femur bending strength, with 18% lower yield load than CFD. Although HFD negatively altered cancellous microstructure in the distal femur, with 32% lower bone volume fraction than CFD, it did not affect cortical bone geometry in the femoral metaphysis or diaphysis. HFD caused increased carbonate substitution but had no effect on other composition metrics or apparent- or tissue-level material properties in the femoral diaphysis. Exercise did not affect bone strength or microstructure but increased endosteal mineralizing surface in the tibial diaphysis, mineral crystallinity and mineral-to-matrix ratio in the femur, and blood supply to the proximal tibial metaphysis. HFD did not affect blood supply in the tibia or 2D osteovascular structure in the distal femoral metaphysis, indicating that HFD negatively affects cancellous bone without affecting osteovasculature. This study reveals that HFD negatively affected cancellous microstructure without affecting osteovascular structure, and whole-bone strength without altering cortical geometry or material properties.

Vitamin K has been implicated in skeletal health because vitamin K-dependent proteins are present in bone. While there are multiple forms of vitamin K, most research has focused on phylloquinone, which is found mainly in plant-based foods, and its metabolite menaquinone-4 (MK4). However, there are additional forms of vitamin K that are bacterially produced that appear to influence bone health but have not yet been studied extensively. Herein, we evaluated the effects of menaquinone-9 (MK9), a bacterially produced form of vitamin K on bone tissue quality and density in young mice. Four-week-old male (n=32) and female (n=32) C57BL/6 mice were supplemented with 0.06 mg/kg diet or 2.1 mg/kg diet of MK9 for 12 weeks. During week 11, a sub-group of mice (n=7/sex/group) received daily deuterium-labeled MK9 to trace its metabolic fate in bone. Liver MK4 and MK9 were significantly higher in mice fed 2.1 mg MK9/kg compared to those receiving 0.06 mg MK9/kg, regardless of sex (all p [&le;] 0.017). MK4 was the only vitamin K form detected in bone, with 63-67% of skeletal MK4 in mice fed 2.1 mg MK9/kg derived from deuterium-labeled MK9. Femoral tissue strength, maximum bending moment, section modulus, and bone mineral density did not differ significantly across diet groups in either sex (all p[&ge;]0.083). Cross-sectional area (p=0.003) and moment of inertia (p=0.001) were lower in female mice receiving 2.1 mg MK9/kg compared to those receiving 0.06 mg MK9/kg, but no differences were found in male mice. Higher bone MK4 concentrations did not correlate with higher bone tissue quality or density. Despite dietary MK9 being a dietary precursor to MK4 in bone, dietary MK9 supplementation did not affect bone tissue quality or bone mineral density. Lay summaryMost research about vitamin K and bone health has focused on phylloquinone, the plant-based vitamin K form, and its metabolite menaquinone-4. Because interest in bacterially produced forms of vitamin K, which are abundant in the intestinal microbiome, is growing, we evaluated the effect of menaquinone-9 (a bacterially-produced form of vitamin K) on skeletal health. We supplemented mice with low and high doses of menaquinone-9 and also used stable-isotope labeled menaquinone-9 to trace its conversion to menaquinone-4 in bone. We found menaquinone-9 served as a precursor to menaquinone-4 in bone, but menaquinone-9 supplementation did not improve bone health.

Osteoblastic bone metastasis, in which disseminated tumor cells drive net bone formation, is a clinically distinct and mechanistically underexplored form of skeletal disease that is enriched in hormone receptor-positive breast cancers. Preclinical models of bone metastasis from breast cancer predominantly rely on immunodeficient hosts inoculated with osteolytic human breast cancer cell lines, limiting the study of immune-dependent mechanisms of bone remodeling. Here we describe the development and characterization of an immunocompetent, syngeneic osteoblastic bone metastasis model using intratibial injection of PyMT-CK(OB), a luciferase-expressing derivative of the MMTV-PyMT mammary carcinoma cell line, in FVB/N mice. PyMT-CK(OB) cells produced detectable bioluminescent signal after intratibial injection, enabling longitudinal monitoring of tumor progression. Micro-computed tomography (microCT) revealed significant increases in trabecular bone volume fraction and trabecular number at three and four weeks post-injection, consistent with osteoblastic remodeling. Histological analysis confirmed dense bone lesion formation in tumor-bearing bones. Critically, this osteoblastic phenotype was entirely absent in immunodeficient NOD SCID hosts, despite robust tumor growth, supporting a role for immune competence in tumor-induced bone formation. Loss of bioluminescent signal in immunocompetent mice reflected either immune pressure on reporter gene expression or limited space for cancer cell expansion in the bone, rather than tumor regression or hypoxia, as confirmed by hypoxia imaging and histological endpoint analysis. In contrast, a second PyMT cell subline, PyMT-CF, maintained sustained bioluminescent signal and produced predominantly osteolytic lesions, providing a complementary syngeneic model of osteolytic disease from the same parental background. In vitro hydrogel coculture experiments and protein array analysis of conditioned media revealed that the PyMT sublines have differing impact on MC3T3 osteoblast mineralization, identifying candidate mediators of divergent bone remodeling phenotypes. R7 mammary carcinoma cells derived from MMTV-RON transgenic mouse mammary tumors did not induce measurable bone remodeling under equivalent experimental conditions. Together, these models provide a validated, immunologically intact framework for studying the mechanistic basis of osteoblastic bone metastasis and evaluating therapeutic interventions targeting the tumor-bone microenvironment.

ObjectivesStudies documented the association of melanoregulin (MREG), a cargo-sorting protein, with its binding partner, the autophagic protein, microtubule-associated protein 1 light chain 3B (LC3B) in macrophages which could affect bone physiology due to the importance of autophagy in osteoclast function. Herein we propose to test the hypothesis that MREG modulates bone remodeling. Therefore, we analyzed the Mregdsu/dsu mutant mice for bone mass, growth plate microarchitecture, and bone marrow-derived osteoclast function to understand how lack of MREG affects bone and mass at two different time points. MethodsMice femurs from wild type and MREG-/- male mice (on C57BL6)/J background) were harvested at 4 and 10 months and imaged by microcomputed tomography to assess bone mass parameters. Femurs were processed for histology by H&E and TRAP staining for assessment of osteoclast numbers. Primary bone marrow-derived macrophages from 3-week-old mice were harvested to assess osteoclast differentiation and function via TRAP, resorptive assay and Western Blot for osteoclast differentiation markers. In addition, a separate cohort of mice were analyzed via EchoMRI to characterize total lean vs. fat whole body mass. ResultsThere was a statistically significant difference in bone volume of 10-month old mice in wild type vs. MREG-/- with MREG mutation suggesting a preservative effect on phenotypical bone parameters as the mice age. A reduction in adipose tissue but an increase in osteoclast numbers was found histologically in MREG mutant femurs. Bone marrow-derived cells, however, showed reduced osteoclastic function in MREG-/-. The mutant mice presented a total lean mass significantly increased compared to wild type per EchoMRI. ConclusionsMREG deficiency seems to impact osteoclast numbers in vivo but not in vitro, although in vitro function was reduced. MREG deficiency favors lean mass preservation over fat accumulation in bones and body composition as mice age. This study provides the foundation for a more in-depth investigation of MREGs role in bone and systemic metabolism. It is possible that MREG can be a future target for new therapeutic modalities in inflammatory and metabolic bone diseases.

Bone strength is an important factor for determining fracture risk that is dependent on bone mass and bone architecture as well as bone material properties. Bone material properties are defined, in part, by the heterogeneity and degree of bone mineralization, parameters that can be assessed with a bone mineral density distribution (BMDD) from 2D-histological sections of bone using backscatter electron microscopy (BSEM). Here we perform a comprehensive examination of a 3D-CT-based BMDD to assess its utility in bone research. Analysis of cortical bone CT scans from preclinical studies using anabolic treatments, pro-resorptive conditions, and genetically heterogeneous mouse lines extend and confirm published findings from BSEM-based BMDD. Principal Component Analysis identified features of the BMDD (e.g. skewness, variance, mean degree of mineralized bone or MDMB) that are distinct from the traditional bone phenotyping measures of bone mineral density, bone mineral content, and cortical bone thickness. In addition, BMDD parameters (e.g. MDMB) correlated to indices of bone material properties from Reference Point Indentation (RPI, US 1st, stiffness) and 4-point bending (toughness). These BMDD parameters also increased the predictive value of a multiple linear regression model for US 1st from RPI (from r2=0.26 for traditional bone phenotypes to r2=0.41 for the full model). Thus, CT-based BMDD reveals unique phenotypes related to bone material properties that complement existing bone phenotyping tools thereby increasing our ability to draw biological inferences about the nature of bone and the processes controlling bone mineralization.

Dedicator of Cytokinesis 7 (DOCK7) has recently emerged as a regulator of skeletal homeostasis, but existing Dock7 mutant models harbor only global mutations and are incompatible with tissue-specific deletion studies. We previously generated a Dock7-floxed allele in which exons 3-4 are flanked by LoxP sites. To validate the utility of this allele for future conditional strategies, we globally deleted exons 3-4 to generate Dock7em2/em2mice and characterized their skeletal phenotype. Dock7em2/em2mice exhibited a diluted coat color and white belly spot, consistent with spontaneous Dock7 mutations. Bone microarchitecture was assessed in 21-week-old males and females. Global deletion of Dock7 exons 3-4 resulted in a 30-37% reduction in trabecular bone volume in the distal femur and L5 vertebrae. Cortical bone thickness was unchanged in both sexes; however, male Dock7em2/em2mice displayed reduced total femoral area, whereas females showed increased medullary area. These data suggest altered appositional bone growth with mutation of Dock7. To assess osteoblast function, bone marrow stromal cells (BMSCs) were differentiated in vitro. Dock7em2/em2 BMSCs exhibited reduced mineralization and decreased Bglap expression, indicating attenuated osteoblast differentiation. These findings demonstrate that Dock7 exons 3-4 are required for normal trabecular bone acquisition and osteoblast function. Loss of these exons disrupts DOCK7 activity, supporting the Dock7em2/em2 line as a valid loss-of-function model. The Dock7em2/em2 mouse provides a foundation for future tissue-specific deletion studies to define the cellular roles of DOCK7 in regulating bone formation and trabecular architecture.

Three-dimensional dual-energy X-ray absorptiometry (3D-DXA) reconstructs proximal femur models from standard scans to estimate cortical and trabecular bone parameters. The aim of this study was to evaluate 3D-DXA against quantitative computed tomography (QCT) across independent international cohorts. The study included 537 subjects from four cohorts: an adult population from Spain, a postmenopausal female population from the United States, an osteoarthrosis population and a young population, both from Japan. Subjects underwent both 3D-DXA and QCT imaging. Accuracy was assessed using linear regression and Bland-Altman analysis to evaluate systematic and random errors. 3D-DXA parameters strongly correlated with QCT across all datasets, with correlation coefficients between 0.82 and 0.97. Random errors were consistent across cohorts and ranged between 16.55 and 19.91 mg/cm3 for integral volumetric bone mineral density (vBMD), between 13.52 and 18.47 mg/cm3 for trabecular vBMD, and between 9.13 and 11.37 mg/cm2 for cortical surface bone mineral density (sBMD). Systematic errors ranged between -14.84 and 4.50 mg/cm3 for integral vBMD, between -8.31 and 14.41 mg/cm3 for trabecular vBMD, and between -5.58 and 3.21 mg/cm2 for cortical sBMD. The variations in systematic errors were likely attributable to differences in QCT acquisition protocols. Overall, these results demonstrate consistent agreement between 3D-DXA and QCT across sex, age, ethnicity, geographic regions, and clinical profiles. Taken together, these findings support the use of 3D-DXA as an accurate, non-invasive, and clinically accessible technology for advanced assessment of the cortical and trabecular compartments of the proximal femur.

Teriparatide (PTH 1-34) is an anabolic agent used to treat osteoporosis, yet clinical response varies widely among patients. To investigate genetic and sex-specific determinants of skeletal response, we administered intermittent PTH to male and female mice from eight genetically diverse inbred strains. Mice were treated for four weeks, and bone phenotypes were assessed via DXA, microCT, and mechanical testing. Response to PTH was highly strain- and sex-dependent, with some strains responding at the femur but not the spine, and vice versa. Heritability estimates for PTH-induced changes in bone mineral density (BMD), cortical area, breaking strength, and trabecular bone volume fraction (BV/TV) ranged from moderate to high, with BV/TV showing the strongest genetic influence. Cortical bone response mechanisms differed by sex: males exhibited periosteal expansion, while females showed endosteal remodeling. These findings mirror clinical observations where hip non-response is more prevalent than spine non-response and suggest that genetic background and sex significantly influence therapeutic outcomes. Our data support the use of genetically diverse mouse models to elucidate the genetic architecture of PTH response and highlight the potential for personalized approaches in osteoporosis treatment. Future genome-wide association studies in outbred mice may identify specific loci mediating skeletal responsiveness to PTH, advancing precision medicine strategies for bone anabolic therapies. LAY SUMMARYTeriparatide, a drug used to treat osteoporosis, consists of the active portion of parathyroid hormone (PTH). Information from clinical studies suggests that not all patients will respond to this medication. We used eight strains of inbred mice to study the impact of genetic background and sex on the response to PTH. We learned that response to PTH is driven by both genetics and sex. Some strains responded at the femur, but not the spine and vice versa. These results may explain why a failure to respond at the hip in humans is more common than at the spine.

Increased physical loading of the skeleton activates new bone formation ensuring its ability to meet mechanical demands over time; however, the capacity of bone to respond to mechanical stimulation diminishes with age. Osteocytes, the cells embedded and dispersed throughout mineralized bone matrix, are master regulators of mechanoadaptation through recruitment of new bone-forming cells, the osteoblasts, via signaling to osteoprogenitors located on bone surfaces. We previously demonstrated that in vivo and in vitro mechanical stimulation significantly upregulated the chemokine C-X-C Motif Chemokine Ligand 12 (CXCL12) and its receptor, CXCR4, in osteocytes and bone lining cells, and that CXCR4 antagonism with AMD3100 attenuated in vivo load-induced bone formation. Here, we extended this work by showing that ablation of CXCL12+ cells and deletion of cxcl12 in late-stage osteoblasts and osteocytes significantly attenuated in vivo load-induced bone formation in the mouse tibia. This bone loading phenotype was rescued by treatment with recombinant CXCL12. To address mechanism, we showed that in vitro deletion of cxcl12 and cxcr4, separately, in bone marrow stromal cells resulted in significantly reduced osteogenic differentiation. Furthermore, CXCL12 treatment enhanced GSK-3b phosphorylation and {beta}-catenin translocation to the nucleus, the former of which was partially blocked by AMD3100. Finally, CXCL12 synergized Wnt signaling leading to significantly increased total {beta}-catenin protein and Axin2 expression, a Wnt signaling target gene. These findings together demonstrate that CXCL12 expression in late-stage osteoblasts and osteocytes is essential for load-induced bone formation, in part, by regulating osteogenic differentiation through activation of the Wnt signaling pathway. SignificanceSkeletal adaptation to mechanical loading is contingent on the recruitment of new osteoblasts to bone surfaces. CXCL12, a chemokine expressed by osteolineage cells, targets effector cells expressing its receptor CXCR4, including osteoprogenitors. Exogenous mechanical loading of mouse hind limbs upregulates CXCL12 in osteocytes, bone lining cells and marrow cells, while antagonizing CXCR4 led to significantly attenuated load-induced bone formation. Here, we show that CXCL12 expression in late-stage osteoblasts and osteocytes is required for load-induced bone formation. Treatment with recombinant CXCL12 rescued the bone loading phenotype suggesting that the CXCL12/CXCR4 signaling pathway may be a feasible drug target for promoting load-induced bone formation when exercise alone is insufficient to counteract low bone mass and osteoporosis.

ObjectiveTo compare and rank different exercise interventions on bone mineral density (BMD) in postmenopausal women. Data Sources and Study SelectionMEDLINE, EMBASE, CINAHL, AMED, the Cochrane Central Register of Controlled Trials (CENTRAL), Scopus and Web of Science were searched from database inception to January 2021 of randomized controlled studies investigating the effect of exercise more than six months on BMD in postmenopausal women. Data Extraction and SynthesisData at baseline and post intervention (or the change from baseline) were extracted. A Bayesian random-effects network meta-analysis was performed. Main Outcomes and MeasuresThe primary outcome was the change of BMD (at lumbar spine, femoral neck, and total hip) from baseline values. Effect size measures were mean differences with 95% credible intervals (CrIs). ResultsWe identified 3324 citations and included 66 studies with a total number of 4336 participants. Associated with BMD at lumbar spine (LS) improve were found for multicomponent exercise, resistance training, mind body exercise, lower impact exercise, high impact exercise, and whole body vibration. With regard to femoral neck (FN), only multicomponent exercise, whole body vibration, and mind body exercise were effective. As for total hip (TH), only multicomponent exercise, resistance training, and flexibility exercise were found to be beneficial. Moreover, no matter the age of postmenopausal women, and the duration of intervention (range between 6 to 18 months), some certain kinds of exercise could be performed to improve BMD at LS and FN. Conclusions and RelevanceThis NMA confirms that exercise therapy has clear benefits on bone mineral density in postmenopausal women. It also shows that the magnitude of effect varies depending on the outcome of interest, the age of participants, and the duration of intervention. Clinicians might consult the ranking of the exercise intervention presented in this study, when designating an optimal, individualized exercise prescription to improve BMD.

BackgroundRecent reassessment of the safety of aspartame has prompted increased evaluation of its effect on the health of a range of tissues. The gut microbiome is altered by oral aspartame. One prior study suggested that changes in the microbiome caused by aspartame could influence the strength of bone in young skeletally developing mice. Here we ask how aspartame influences bone in mice of different age and sex. ObjectiveThe objective of this study was to determine the effect of aspartame on the bone strength and gut microbiota of young and aged mice. MethodsMale and female C57Bl/6J mice were untreated or treated with a high dose of aspartame in their drinking water from 1 month of age until 4 (young cohort; n = 80) or 22 months (aged cohort; n = 52). ResultsIn aged males, mice treated with aspartame had greater body mass, whole bone strength, and femoral geometry relative to untreated. Specifically, in aged males, aspartame led to 9% increase in body mass (p < 0.001), 22% increase in whole bone strength (p = 0.006), and 17% increase in section modulus (p < 0.001) relative to untreated mice. Aged males and females receiving aspartame had a different microbiota than untreated mice and a decreased abundance of Odoribacter. No differences in body mass, whole bone strength, or femoral geometry were associated with aspartame dosing in young males or young or aged females. ConclusionsAspartame treated aged males had greater whole bone strength and the effect appeared to be explained by greater body mass. Aspartame treatment did not alter whole bone strength in young males or young or aged females despite the aspartame having a similar effect on the microbiota of both aged males and females.

During peri-puberty, bone growth and the attainment peak bone mass is driven predominantly by sex steroids. This is important when treating transgender and gender diverse youth, who have become increasingly present at pediatric clinics. Analogues of gonadotropin-releasing hormone (GnRH) are commonly prescribed to transgender and gender diverse youth prior to starting gender-affirming hormone therapy (GAHT). However, the impact of GnRH agonists on long bones with the addition of GAHT is relatively unknown. To explore this, we developed a trans-masculine model by introducing either GnRHa or vehicle treatment to female-born mice at a pre-pubertal age. This treatment was followed by male GAHT (testosterone, T) or control treatment three weeks later. Six weeks after T therapy, bone quality was compared between four treatment groups: Control (vehicle only), GnRHa-only, GnRHa + T, and T-only. Bone length/size, bone shape, mechanical properties, and trabecular morphology were modulated by GAHT. Independent of GnRHa administration, mice treated with T had shorter femurs, larger trabecular volume and increased trabecular number, higher trabecular bone mineral density, and wider superstructures on the surface of bone (e.g., third trochanters) when compared to control or GnRHa-only mice. In conclusion, prolonged treatment of GnRHa with subsequent GAHT treatment directly affect the composition, parameters, and morphology of the developing long bone. These findings provide insight to help guide clinical approaches to care for transgender and gender diverse youth.

Recent studies in mice have indicated that the gut microbiome can regulate bone tissue strength. However, prior work involved modifications to the gut microbiome in growing animals and it is unclear if the same changes in the microbiome, applied later in life, would change matrix strength. Here we changed the composition of the gut microbiome before and/or after skeletal maturity (16 weeks of age) using oral antibiotics (ampicillin + neomycin). Male and female mice (n=143 total, n=12-17/group/sex) were allocated into five study groups:1) Unaltered, 2) Continuous (dosing 4-24 weeks of age), 3) Delayed (dosing only 16-24 weeks of age), 4) Initial (dosing 4-16 weeks of age, suspended at 16 weeks), and 5) Reconstituted (dosing from 4-16 weeks following by fecal microbiota transplant from Unaltered donors). Animals were euthanized at 24 weeks of age. In males, bone matrix strength in the femur was 25-35% less than expected from geometry in mice from the Continuous (p= 0.001), Delayed (p= 0.005), and Initial (p=0.040) groups as compared to Unaltered. Reconstitution of the gut microbiota, however, led to a bone matrix strength similar to Unaltered animals (p=0.929). In females, microbiome-induced changes in bone matrix strength followed the same trend as males but were not significantly different, demonstrating sex-related differences in the response of bone matrix to the gut microbiota. Minor differences in chemical composition of bone matrix were observed (Raman spectroscopy). Our findings indicate that microbiome-induced impairment of bone matrix in males can be initiated and/or reversed after skeletal maturity. The portion of the femoral cortical bone formed after skeletal maturity (16 weeks) is small; however, this suggests that microbiome-induced changes in bone matrix occur without osteoblast/osteoclast turnover using an, as of yet unidentified mechanism. These findings add to evidence that the mechanical properties of bone matrix can be altered in the adult skeleton.

Pseudoxanthoma elasticum is a rare inherited disorder marked by abnormal calcium phosphate deposition in soft connective tissues, particularly the skin, arteries, and eyes. It is caused by inactivating mutations in the ABCC6 gene, which encodes a hepatic efflux transporter. Loss of ABCC6 function leads to reduced plasma levels of pyrophosphate, a key inhibitor of calcification, thereby promoting ectopic mineralization. Oral pyrophosphate therapy has emerged as a potential treatment, but its effectiveness is uncertain. Most ingested pyrophosphate is hydrolyzed in the gut to inorganic phosphate, which may worsen calcification. Moreover, its impact on mineralized tissues remains largely unexplored. Abcc6-/- mice closely mimic human pseudoxanthoma elasticum and are widely used in preclinical studies. Although patients are most concerned about ocular complications, eye calcification is rarely assessed in translational studies using Abcc6-/- mice. Using microcomputed tomography we found that ectopic calcification at the ciliary margin is a reliable marker of ocular disease progression in these mice. Administering pyrophosphate in drinking water at concentrations up to 90 mM did not increase calcification in skin or eyes. However, only very high doses effectively prevented ectopic calcification - doses that would equate to an impractical 2.5 g/kg/day of disodium pyrophosphate in humans. These high doses also led to pyrophosphate accumulation in bone and negatively affected bone structure and strength. In summary, only supraphysiological doses of orally administered pyrophosphate inhibited ectopic calcification in Abcc6-/- mice, but these doses are not feasible for human use and may compromise bone function. These data are especially important considering the currently ongoing clinical trial evaluating the safety and efficacy of oral pyrophosphate administration as a treatment for pseudoxanthoma elasticum. LAY SUMMARYPseudoxanthoma elasticum (PXE) is a rare inherited mineralization disorder caused by the absence of functional ABCC6, a liver-expressed protein. This deficiency leads to reduced plasma levels of pyrophosphate, a key inhibitor of mineralization, resulting in abnormal calcium phosphate deposition in the skin, eyes, and blood vessels. Oral pyrophosphate has been proposed as a therapeutic strategy for PXE, and a clinical trial evaluating its efficacy recently began in France. In a PXE mouse model, we show that only very high oral doses of pyrophosphate are effective, but these doses impair bone quality and are not suitable for human use.

BackgroundOsteoporosis is prevalent in elderly women, which causes fragility fracture and hence increased mortality and morbidity. Predicting osteoporotic fracture risk is both clinically-beneficial and cost-effective. However, traditional tools using clinical factors and bone mineral density (BMD) fail to reflect bone microstructure. Here we aim to use high-resolution peripheral quantitative CT (HR-pQCT) images to construct deep-learning models which predict fragility fracture history in elderly Chinese women. MethodsWe used ChiVOS, a community-based national cohort of 2,664 Chinese elderly women. Demographic data, BMD, and HR-pQCT from 216 patients were used to construct three groups of models: BMD, pQCT-index, and DeepQCT. For DeepQCT, we used ResNet34 as classifier, and logistic regression for late fusion. Models were developed using 6-fold cross-validation in development set (90%, N=195), and tested in internal test set (10%, N=21). We applied unsupervised clustering on HR-pQCT indices to derive patient subgroups. FindingsDeepQCT (best model AUC 0.86-0.94) was superior or similar to pQCT-index (best model AUC 0.8-0.93), which both outperformed BMD (best model AUC 0.54-0.78). Surprisingly, DeepQCT built from non-weight-bearing bones performed similarly to weight-bearing bones. Furthermore, two distinct patient groups were classified using HR-pQCT indices. The one with higher DeepQCT risk score showed lower volumetric BMD, bone more microarchitectural abnormalities, and had higher probability of osteoporosis and fragility fracture history. InterpretationDeepQCT scores and HR-pQCT-index permit early recognition of patients with high risk of fragility fracture. This established framework can be easily adapted for other diagnostic tasks using HR-pQCT scans, which promotes bone health management via digital medicine. FundingThis research was supported by the National Natural Science Foundation of China (LC, 82100946; WX, 82270938), CAMS Innovation Fund for Medical Sciences (WX, 2021-I2M-1-002), National Key R&D Program of China (WX, 2021YFC2501700), National High Level Hospital Clinical Research Funding (WX, 2022-PUMCH-D-006), the Non-profit Central Research Institute Fund of Chinese Academy of Medical Sciences (LC, 2023-PT320-10), and Young Elite Scientists Sponsorship Program by BAST (LC, No.BYESS2023171). Part of the study was supported by Merck Sharp & Dohme China, Hangzhou, China. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSBone mineral density (BMD) from dual X-ray absorptiometry was firstly used to predict fragility fracture, but had low sensitivity. Tools like FRAX, QFracture, and Garvan, which also incorporated clinical factors into prediction models, showed improved performance. Models containing standard HR-pQCT indices (FRAC) further surpassed most clinical tools. Nevertheless, direct learning from original HR-pQCT images is always desired to reduce labor and bias. Deep learning being the most common method for image-based learning, we searched PubMed for articles published up to Mar 25, 2024, using keywords "( fragility fracture OR osteoporotic fracture) and ( prediction model) and ( HR-pQCT or High-resolution peripheral quantitative CT) and ( deep-learning OR deep learning)". Results showed that no study has built deep learning models from HR-pQCT for fragility fracture prediction. Added value of this studyWe developed DeepQCT from HR-pQCT of 216 elderly Chinese women from a national cohort (ChiVOS), which calculated risk scores using individual bone images and clinical features. BMD and pQCT-index models were compared to DeepQCT. We found both DeepQCT (best model AUC 0.86-0.94) and pQCT-index (best model AUC 0.8-0.93) outperformed BMD (best model AUC 0.54-0.78). DeepQCT using non-weight-bearing bones (ulna, fibula) performed similarly to weight-bearing bones (tibia, radius). Specifically, HR-pQCT revealed one patient subgroup with higher DeepQCT risk scores, which showed lower BMD and multiple bone microarchitectural abnormalities, associated with osteoporosis and fragility fracture history. Implications of all the available evidenceDeepQCT is the first method which uses deep-learning to predict fragility fracture directly from HR-pQCT images. It is also the first to use single bones individually in prediction models, including non-weight-bearing bones, which are excluded in HR-pQCT-index computation. Of note, DeepQCT risk score is highly clinically relevant, as showed in bone density or microarchitectural features differences between patient subgroups. The non-inferior performance of DeepQCT compared to the manual annotation-dependent pQCT-index, supported its application to reduce labor and enhance efficiency. Performance of non-weight-bearing bones also challenges traditional perception of using load-bearing bones only in predicting osteoporotic conditions. Most importantly, the DeepQCT framework can be easily adapted for other tasks using HR-pQCT scans, which greatly expands application of digital medicine in bone mineral disease diagnosis or management.