{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,23]],"date-time":"2026-03-23T11:04:30Z","timestamp":1774263870046,"version":"3.50.1"},"reference-count":33,"publisher":"MDPI AG","issue":"6","license":[{"start":{"date-parts":[[2026,3,23]],"date-time":"2026-03-23T00:00:00Z","timestamp":1774224000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: Cushing\u2019s syndrome (CS) causes excessive cortisol exposure, leading to significant skeletal complications. However, there is no validated, CS-specific model to predict osteoporosis and fracture risk. This study aimed to identify independent predictors and develop a practical clinical scoring system. Methods: A retrospective study was conducted on 139 patients with CS diagnosed between 2014 and 2025. Demographic, clinical, and biochemical data were analyzed. Osteoporosis was defined using dual-energy X-Ray absorptiometry criteria. Logistic regression analyses identified independent predictors, and the Cushing-Related Osteoporosis Risk Estimation (CORE) Score was constructed from normalized beta coefficients of significant variables. Results: Osteoporosis was present in 35.9% and fragility fractures in 13.4% of patients. Independent predictors included age \u2265 51 years, symptom duration \u2265 13.5 months, diabetes mellitus, late-night salivary cortisol \u2265 0.42 \u03bcg\/dL, and midnight serum cortisol \u2265 10.25 \u03bcg\/dL (all p &lt; 0.05). The CORE Score (0\u20136 points) showed strong diagnostic performance for osteoporosis (AUC 0.827; sensitivity 88%, specificity 72%) and fractures (AUC 0.866; sensitivity 84%, specificity 78%). Each one-point increase in the CORE Score elevates the risk of osteoporotic fracture by 3.13 times (p &lt; 0.001). Conclusions: The CORE Score represents a promising disease-specific tool for early identification of CS patients at increased risk of osteoporosis and fragility fractures, enabling more personalized management and follow-up strategies, such as prioritizing bone-protective interventions and closer skeletal monitoring. Early identification of high-risk individuals may also facilitate timely therapeutic interventions, potentially reducing future fracture risk.<\/jats:p>","DOI":"10.3390\/jcm15062442","type":"journal-article","created":{"date-parts":[[2026,3,23]],"date-time":"2026-03-23T09:48:42Z","timestamp":1774259322000},"page":"2442","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Identification of High-Risk Individuals for Osteoporosis and Fragility Fractures in Cushing\u2019s Syndrome: A Promising Predictive Approach"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6858-751X","authenticated-orcid":false,"given":"Enes","family":"Ucgul","sequence":"first","affiliation":[{"name":"Department of Endocrinology and Metabolism, Ankara Etlik City Hospital, 06170 Ankara, T\u00fcrkiye"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Burak","family":"Menekse","sequence":"additional","affiliation":[{"name":"Department of Endocrinology and Metabolism, Ankara Etlik City Hospital, 06170 Ankara, T\u00fcrkiye"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ogulcan","family":"Boz","sequence":"additional","affiliation":[{"name":"Department of Endocrinology and Metabolism, Ankara Etlik City Hospital, 06170 Ankara, T\u00fcrkiye"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Huseyin","family":"Demirci","sequence":"additional","affiliation":[{"name":"Department of Endocrinology and Metabolism, Ankara Etlik City Hospital, 06170 Ankara, T\u00fcrkiye"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Bekir","family":"Ucan","sequence":"additional","affiliation":[{"name":"Department of Endocrinology and Metabolism, Ankara Etlik City Hospital, 06170 Ankara, T\u00fcrkiye"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Erman","family":"Cakal","sequence":"additional","affiliation":[{"name":"Department of Endocrinology and Metabolism, Ankara Etlik City Hospital, 06170 Ankara, T\u00fcrkiye"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4451-1668","authenticated-orcid":false,"given":"Takako","family":"Araki","sequence":"additional","affiliation":[{"name":"Division of Diabetes, Endocrinology and Metabolism Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Muhammed","family":"Kizilgul","sequence":"additional","affiliation":[{"name":"Department of Endocrinology and Metabolism, Ankara Etlik City Hospital, 06170 Ankara, T\u00fcrkiye"},{"name":"Division of Diabetes, Endocrinology and Metabolism Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2026,3,23]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"4","DOI":"10.1038\/s41572-024-00588-w","article-title":"Cushing syndrome","volume":"11","author":"Nieman","year":"2025","journal-title":"Nat. Rev. Dis. Primers"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1070","DOI":"10.1001\/jama.2023.19100","article-title":"What Is Cushing Syndrome?","volume":"331","author":"Voelker","year":"2024","journal-title":"JAMA"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"2807","DOI":"10.1210\/jc.2015-1818","article-title":"Treatment of Cushing\u2019s Syndrome: An Endocrine Society Clinical Practice Guideline","volume":"100","author":"Nieman","year":"2015","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"379","DOI":"10.1016\/j.ecl.2011.01.006","article-title":"Cushing\u2019s Syndrome: All Variants, Detection, and Treatment","volume":"40","author":"Sharma","year":"2011","journal-title":"Endocrinol. Metab. Clin. N. Am."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"611","DOI":"10.1016\/S2213-8587(16)00086-3","article-title":"Complications of Cushing\u2019s syndrome: State of the art","volume":"4","author":"Pivonello","year":"2016","journal-title":"Lancet Diabetes Endocrinol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"315","DOI":"10.1007\/s40267-024-01079-4","article-title":"Glucocorticoid-induced osteoporosis\u2014From molecular mechanism to clinical practice","volume":"40","author":"Hsu","year":"2024","journal-title":"Drugs Ther. Perspect."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"54","DOI":"10.1016\/j.cytogfr.2023.03.002","article-title":"Pathogenic mechanisms of glucocorticoid-induced osteoporosis","volume":"70","author":"Chen","year":"2023","journal-title":"Cytokine Growth Factor Rev."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"647","DOI":"10.1016\/S2213-8587(18)30026-3","article-title":"The physiology of endocrine systems with ageing","volume":"6","author":"Kaufman","year":"2018","journal-title":"Lancet Diabetes Endocrinol."},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Radecka, A., and Lubkowska, A. (2023). The Significance of Dual-Energy X-ray Absorptiometry (DXA) Examination in Cushing\u2019s Syndrome\u2014A Systematic Review. Diagnostics, 13.","DOI":"10.3390\/diagnostics13091576"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"837","DOI":"10.1007\/s11102-024-01427-7","article-title":"Cushing\u2019s disease and bone","volume":"27","author":"Stachowska","year":"2024","journal-title":"Pituitary"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"15","DOI":"10.36553\/wm.155","article-title":"Bone metabolism disorders in endogenous Cushing syndrome","volume":"5","author":"Maria","year":"2023","journal-title":"Wiedza Medyczna"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1632","DOI":"10.1038\/s41440-022-00939-8","article-title":"Urinary free cortisol excretion is associated with lumbar bone density in patients with adrenal Cushing\u2019s syndrome","volume":"45","author":"Morimoto","year":"2022","journal-title":"Hypertens. Res."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Stachowska, B., Halupczok-\u017by\u0142a, J., Kuliczkowska-P\u0142aksej, J., Syrycka, J., and Bolanowski, M. (2021). Decreased Trabecular Bone Score in Patients With Active Endogenous Cushing\u2019s Syndrome. Front. Endocrinol., 11.","DOI":"10.3389\/fendo.2020.593173"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"847","DOI":"10.1016\/S2213-8587(21)00235-7","article-title":"Consensus on diagnosis and management of Cushing\u2019s disease: A guideline update","volume":"9","author":"Fleseriu","year":"2021","journal-title":"Lancet Diabetes Endocrinol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"364","DOI":"10.1016\/S0140-6736(18)32112-3","article-title":"Osteoporosis","volume":"393","author":"Compston","year":"2019","journal-title":"Lancet"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"766","DOI":"10.4103\/ijem.IJEM_160_18","article-title":"Bone Health in Patients with Cushing\u2019s Syndrome","volume":"22","author":"Rahaman","year":"2018","journal-title":"Indian J. Endocrinol. Metab."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1507\/endocrj.50.1","article-title":"Osteoporosis is more prevalent in adrenal than in pituitary Cushing\u2019s syndrome","volume":"50","author":"Ohmori","year":"2003","journal-title":"Endocr. J."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"51","DOI":"10.1530\/eje.0.1460051","article-title":"Increased risk of osteoporotic fractures in patients with Cushing\u2019s syndrome","volume":"146","author":"Vestergaard","year":"2002","journal-title":"Eur. J. Endocrinol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"403","DOI":"10.1111\/cen.12299","article-title":"Diagnosis and complications of Cushing\u2019s disease: Gender-related differences","volume":"80","author":"Zilio","year":"2014","journal-title":"Clin. Endocrinol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"2457","DOI":"10.1016\/j.clnu.2023.10.013","article-title":"The effect of overweight or obesity on osteoporosis: A systematic review and meta-analysis","volume":"42","author":"Liu","year":"2023","journal-title":"Clin. Nutr."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"28","DOI":"10.3390\/healthcare13010028","article-title":"Associations of Body Mass Index and Percent Body Fat with Osteoporosis, Sarcopenia, and Osteosarcopenia: A Retrospective Study Based on Postmenopausal Women in China","volume":"13","author":"Zhao","year":"2025","journal-title":"Healthcare"},{"key":"ref_22","unstructured":"EUROSTAT, and Europ\u00e9enne UeC (2012). Active Ageing and Solidarity Between Generations: A Statistical Portrait of the European Union 2012, Publications office of the European Union."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"419","DOI":"10.3109\/13697137.2010.507886","article-title":"Age of menopause and impact of climacteric symptoms by geographical region","volume":"13","author":"Palacios","year":"2010","journal-title":"Climacteric"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"395","DOI":"10.1093\/ejendo\/lvad008","article-title":"Cushing\u2019s syndrome in the elderly: Data from the European Registry on Cushing\u2019s syndrome","volume":"188","author":"Amodru","year":"2023","journal-title":"Eur. J. Endocrinol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1779","DOI":"10.1210\/jc.2005-0582","article-title":"Bone demineralization and vertebral fractures in endogenous cortisol excess: Role of disease etiology and gonadal status","volume":"91","author":"Pivonello","year":"2006","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1016\/S2213-8587(21)00347-8","article-title":"Bone fragility in diabetes: Novel concepts and clinical implications","volume":"10","author":"Hofbauer","year":"2022","journal-title":"Lancet Diabetes Endocrinol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"913","DOI":"10.1007\/s00198-013-2520-5","article-title":"Bone complications in patients with Cushing\u2019s syndrome: Looking for clinical, biochemical, and genetic determinants","volume":"25","author":"Trementino","year":"2014","journal-title":"Osteoporos. Int."},{"key":"ref_28","first-page":"2681","article-title":"Late-night salivary cortisol as a screening test for Cushing\u2019s syndrome","volume":"83","author":"Raff","year":"1998","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1296","DOI":"10.1016\/j.amjmed.2025.04.035","article-title":"The Combination of Afternoon and Midnight Salivary Cortisol Improves the Diagnosis of Cushing Syndrome","volume":"138","author":"Lionetto","year":"2025","journal-title":"Am. J. Med."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"315","DOI":"10.1530\/EJE-12-0685","article-title":"Usefulness of salivary cortisol in the diagnosis of hypercortisolism: Comparison with serum and urinary cortisol","volume":"168","author":"Manetti","year":"2013","journal-title":"Eur. J. Endocrinol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1046","DOI":"10.1093\/ije\/dyy276","article-title":"Cohort Profile: The OsteoLaus study","volume":"48","author":"Shevroja","year":"2018","journal-title":"Int. J. Epidemiol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"117109","DOI":"10.1016\/j.bone.2024.117109","article-title":"Trabecular bone score (TBS) in Cushing\u2019s disease: TBS gain after hypercortisolism normalization","volume":"184","author":"Tan","year":"2024","journal-title":"Bone"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"86","DOI":"10.1093\/ejendo\/lvae004","article-title":"Evaluation of bone-related mechanical properties in female patients with long-term remission of Cushing\u2019s syndrome using quantitative computed tomography-based finite element analysis","volume":"190","author":"Giuliodori","year":"2024","journal-title":"Eur. J. Endocrinol."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/6\/2442\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,23]],"date-time":"2026-03-23T10:14:48Z","timestamp":1774260888000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/6\/2442"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,3,23]]},"references-count":33,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2026,3]]}},"alternative-id":["jcm15062442"],"URL":"https:\/\/doi.org\/10.3390\/jcm15062442","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,3,23]]}}}