Prevalent Vertebral Fractures in Black Women and White Women

Vertebral fractures are the most common osteoporotic fracture. Hip and clinical fractures are less common in black women, but there is little information on vertebral fractures. We studied 7860 white and 472 black women ≥65 yr of age enrolled in the Study of Osteoporotic Fractures. Prevalent vertebral fractures were identified from lateral spine radiographs using vertebral morphometry and defined if any vertebral height ratio was >3 SD below race‐specific means for each vertebral level. Information on risk factors was obtained by questionnaire or examination. Lumbar spine, total hip, and femoral neck BMD and BMC were measured by DXA. The prevalence of vertebral fractures was 10.6% in black and 19.1% in white women. In age‐adjusted logistic regression models, a 1 SD decrease in femoral neck BMD was associated with 47% increased odds of fracture in black women (OR = 1.47; 95% CI, 1.12–1.94) and 80% increased odds in white women (OR = 1.80; 95% CI, 1.68–1.94; interaction p = 0.14). The overall lower odds of fracture among black women compared with white women was independent of femoral neck BMD and other risk factors (OR = 0.51; 95% CI, 0.37–0.72). However, the prevalence of vertebral fractures increased with increasing number of risk factors in both groups. The prevalence of vertebral fractures is lower in black compared with white women but increases with age, low BMD, and number of risk factors.     

Achieving equity in dialysis care and outcomes: The role of policies

Socially disadvantaged persons, including racial and ethnic minorities, individuals with low incomes, homeless persons, and non-US citizens bear a disproportionate burden of end-stage kidney disease (ESKD). Inequities in nephrology referral, vascular access, use of home dialysis modalities, kidney transplantation, and mortality are prominent. Public policies, including the Patient Protection and Affordable Care Act, end-stage renal disease Quality Incentive Program, and the Prospective Payment System, were enacted to improve healthcare access and dialysis care. Here, we highlight inequities in dialysis care and outcomes, how current ESKD and other public policies may influence or exacerbate these inequities, and gaps in the literature needed to inform future policies toward achieving equity in ESKD. We give special attention to the 2019 Advancing American Kidney Health Executive Order, which has high potential to radically transform dialysis care.     

Race/ethnicity is associated with ABO‐nonidentical liver transplantation in the United States

United Network for Organ Sharing (UNOS) policies allow for ABO‐nonidentical liver transplantation (LT) in candidates with Model for End‐Stage Liver Disease (MELD) scores greater than 30. Previous studies showed ABO‐nonidentical LT resulted in an 18% and 55% net gain in livers for B and AB candidates. These results suggested that the current liver ABO allocation policies may need refinement. There are, however, strong associations between ABO blood groups and race/ethnicity. We hypothesized that race/ethnicity is associated with ABO‐nonidentical LT and that this is primarily influenced by recipient ABO status. We examined non‐status 1 adult candidates registered between July 1, 2013, and December 31, 2015. There were 27 835 candidates (70% non‐Hispanic White, 15% Hispanic, 9% Black, 4% Asian, 1% Other/Multiracial). A total of 11 369 underwent deceased donor LT: 93% ABO identical, 6% ABO compatible, and 1% ABO incompatible. Black and Asian race/ethnicity were associated with increased likelihoods of ABO‐nonidentical LT. Adjustment for disease etiology, listing MELD, transplant center volume, and UNOS region did not alter this association. Stepwise inclusion of recipient ABO status did eliminate this significant association of race/ethnicity with ABO‐nonidentical LT. Blacks and Asians may be advantaged by ABO‐nonidentical LT, and we suspect that changes to the existing policies may disproportionately impact these groups.     

Postoperative Protocol in the Prevention of Fragility Fractures in Patients with Osteoporosis-Related Fractures

Osteoporosis is a multifactorial disorder that requires advanced diagnostic evaluation tools. It should not be considered to be an inevitable disease entity or as a logical consequence of the physiological ageing process. Osteoporosis can be diagnosed and – more importantly – properly treated. It is therefore incomprehensible that most of the patients with diagnosed osteoporosis do not receive a specific pharmacotherapeutic treatment. Since orthopedic trauma surgeons most often see a patient with an osteoporosis-associated fracture on a first-hand basis, they, after providing adequate treatment of the fracture, must play a key role in initiating the primary diagnostics and therapy according to national or international guidelines for patients with previous osteoporotic fractures. Treatment should be closely coordinated with general practitioners so that a continuation of the therapy initiated in the hospital can be guaranteed. Basic measures for fracture prevention, including dietary supplements of calcium and vitamin D, should be recommended and implemented for all patients, whereas only those patients with the diagnosis of a manifest osteoporosis should receive a specific pharmacotherapy. Antiresorptive and anabolic drugs that are licensed for the treatment of men or postmenopausal women with osteoporosis have been shown to effectively reduce the incidence of vertebral and non-vertebral fractures. An evaluation of the treatment efficiency should also be performed, such as routine clinical re-evaluation and the measuring of the bone mineral density by dual X-ray absortiometry, every 18–24 months after the initiation of the pharmacotherapy. S. Seitz and T. F. Beil have contributed equally to this work.     

Official Positions for FRAX Clinical Regarding International Differences: From Joint Official Positions Development Conference of the International Society for Clinical Densitometry and International Osteoporosis Foundation on FRAX

Osteoporosis is a serious worldwide epidemic. Increased risk of fractures is the hallmark of the disease and is associated with increased morbidity, mortality and economic burden.FRAX^® is a web-based tool developed by the Sheffield WHO Collaborating Center team, that integrates clinical risk factors, femoral neck BMD, country specific mortality and fracture data and calculates the 10 year fracture probability in order to help health care professionals identify patients who need treatment. However, only 31 countries have a FRAX^® calculator at the time paper was accepted for publication. In the absence of a FRAX^® model for a particular country, it has been suggested to use a surrogate country for which the epidemiology of osteoporosis most closely approximates the index country. More specific recommendations for clinicians in these countries are not available.In North America, concerns have also been raised regarding the assumptions used to construct the US ethnic specific FRAX^® calculators with respect to the correction factors applied to derive fracture probabilities in Blacks, Asians and Hispanics in comparison to Whites. In addition, questions were raised about calculating fracture risk in other ethnic groups e.g., Native Americans and First Canadians.In order to provide additional guidance to clinicians, a FRAX^® International Task Force was formed to address specific questions raised by physicians in countries without FRAX^® calculators and seeking to integrate FRAX^® into their clinical practice. The main questions that the task force tried to answer were the following:

• 1. 

  What is the evidence supporting ethnic and sex specific adjustments for fracture incidence rates in Blacks, Hispanics and Asians?

• 2. 

  What data exist for other groups, e.g., Native Americans, First Nations Canadians?

• 3. 

  Are there secular changes in fracture rates?

• 4. 

  What are the requirements for the construction of a FRAX® calculator? And what are the desirable/optimal characteristics of the data?

• 5. 

  What do I do if my country does not have a FRAX® calculator?

The Task Force members conducted appropriate literature reviews and developed preliminary statements that were discussed and graded by a panel of experts at the ISCD-IOF joint conference. The statements approved by the panel of experts are discussed in the current paper.     

Regional Variation in the Denial of Reimbursement for Bone Mineral Density Testing Among US Medicare Beneficiaries

Although the Bone Mass Measurement Act outlines the indications for central dual-energy X-ray absorptiometry (DXA) testing for US Medicare beneficiaries, the specifics regarding the appropriate ICD-9 codes to use for covered indications have not been specified by Medicare and are sometimes ambiguous. We describe the extent to which DXA reimbursement was denied by gender and age of beneficiary, ICD-9 code submitted, time since previous DXA, whether the scan was performed in the physician's office and local Medicare carrier. Using Medicare administrative claims data from 1999 to 2005, we studied a 5% national sample of beneficiaries age ≥65 yr with part A + B coverage who were not health maintenance organization enrollees. We identified central DXA claims and evaluated the relationship between the factors listed above and reimbursement for central DXA (CPT code 76075). Multivariable logistic regression was used to evaluate the independent relationship between DXA reimbursement, ICD-9 diagnosis code, and Medicare carrier. For persons who had no DXA in 1999 or 2000 and who had 1 in 2001 or 2002, the proportion of DXA claims denied was 5.3% for women and 9.1% for men. For repeat DXAs performed within 23 mo, the proportion denied was approximately 19% and did not differ by sex. Reimbursement varied by more than 6-fold according to the ICD-9 diagnosis code submitted. For repeat DXAs performed at <23 mo, the proportion of claims denied ranged from 2% to 43%, depending on Medicare carrier. Denial of Medicare reimbursement for DXA varies significantly by sex, time since previous DXA, ICD-9 diagnosis code submitted, place of service (office vs facility), and local Medicare carrier. Greater guidance and transparency in coding policies are needed to ensure that DXA as a covered service is reimbursed for Medicare beneficiaries with the appropriate indications.     

Clinical Guidelines for the Diagnosis and Treatment of Fragility Fractures of the Pelvis

Background

Fragility fractures of the pelvis (FFPs) are osteoporotic pelvic fractures or insufficiency pelvic fractures caused by the low energy injury or stress fracture in daily livings in the elderly more than 60 years, which the incidence is increasing with the aging population in our country. FFPs result in considerable morbidity and mortality and as well as massive financial burden on the already strained health systems throughout the world.

Methods

This clinical guideline was initiated by the Trauma Orthopedic Branch of Chinese Orthopedic Association; the External Fixation and Limb Reconstruction Branch of Chinese Orthopedic Association; the National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation; Senior Department of Orthopedics of Chinese PLA general hospital; the Third Hospital of Hebei Medical University. The grading of recommendations assessment, development and evaluation (GRADE) approach and the reporting items for practice guidelines in healthcare (RIGHT) checklist were adopted.

Results

22 evidence based recommendations were formulated based on 22 most concerned clinical problems among orthopedic surgeons in China.

Conclusion

Understanding these trends through this guideline will facilitate better clinical care of FFP patients by medical providers and better allocation of resources by policy makers.     

Dialysis facility referral and start of evaluation for kidney transplantation among patients treated with dialysis in the Southeastern United States

Variability in transplant access exists, but barriers to referral and evaluation are underexplored due to lack of national surveillance data. We examined referral for kidney transplantation evaluation and start of the evaluation among 34 857 incident, adult (18‐79 years) end‐stage kidney disease patients from 690 dialysis facilities in the United States Renal Data System from January 1, 2012 through August 31, 2016, followed through February 2018 and linked data to referral and evaluation data from nine transplant centers in Georgia, North Carolina, and South Carolina. Multivariable‐adjusted competing risk analysis examined each outcome. The median within‐facility cumulative percentage of patients referred for kidney transplantation within 1 year of dialysis at the 690 dialysis facilities in Network 6 was 33.7% (interquartile range [IQR]: 25.3%‐43.1%). Only 48.3% of referred patients started the transplant evaluation within 6 months of referral. In multivariable analyses, factors associated with referral vs evaluation start among those referred at any time differed. For example, black, non‐Hispanic patients had a higher rate of referral (hazard ratio [HR]: 1.22; 95% confidence interval [CI]: 1.18‐1.27), but lower evaluation start among those referred (HR: 0.93; 95% CI: 0.88‐0.98), vs white non‐Hispanic patients. Barriers to transplant varied by step, and national surveillance data should be collected on early transplant steps to improve transplant access.     

Racial/ethnic disparities in waitlisting for deceased donor kidney transplantation 1 year after implementation of the new national kidney allocation system

The impact of a new national kidney allocation system (KAS) on access to the national deceased‐donor waiting list (waitlisting) and racial/ethnic disparities in waitlisting among US end‐stage renal disease (ESRD) patients is unknown. We examined waitlisting pre‐ and post‐KAS among incident (N = 1 253 100) and prevalent (N = 1 556 954) ESRD patients from the United States Renal Data System database (2005‐2015) using multivariable time‐dependent Cox and interrupted time‐series models. The adjusted waitlisting rate among incident patients was 9% lower post‐KAS (hazard ratio [HR]: 0.91; 95% confidence interval [CI], 0.90‐0.93), although preemptive waitlisting increased from 30.2% to 35.1% (P < .0001). The waitlisting decrease is largely due to a decline in inactively waitlisted patients. Pre‐KAS, blacks had a 19% lower waitlisting rate vs whites (HR: 0.81; 95% CI, 0.80‐0.82); following KAS, disparity declined to 12% (HR: 0.88; 95% CI, 0.85‐0.90). In adjusted time‐series analyses of prevalent patients, waitlisting rates declined by 3.45/10 000 per month post‐KAS (P < .001), resulting in ≈146 fewer waitlisting events/month. Shorter dialysis vintage was associated with greater decreases in waitlisting post‐KAS (P < .001). Racial disparity reduction was due in part to a steeper decline in inactive waitlisting among minorities and a greater proportion of actively waitlisted minority patients. Waitlisting and racial disparity in waitlisting declined post‐KAS; however, disparity remains.     

Assessing population risk for postmenopausal osteoporosis: a new strategy using data from the Behavioral Risk Factor Surveillance System (BRFSS).

Osteoporosis public health measures are hindered by the inability to easily identify subclinical disease. We have now estimated state-specific osteoporosis prevalences using a simple formula (OST Index) to analyze age and weight of 62,882 older women; the prevalences determined are similar to those based on BMD. This new method has potential use for guiding implementation of osteoporosis prevention/treatment programs. INTRODUCTION: Although osteoporosis-related fractures are a major U.S. public health issue, population-based prevention programs have not yet been developed. One contributing factor has been lack of a suitable screening test to detect asymptomatic high-risk individuals. MATERIALS AND METHODS: We estimated state-specific prevalences of postmenopausal osteoporosis using the Osteoporosis Self-Assessment Tool Index (OST Index; [self-reported weight in kg - age] x 0.2) to analyze data from 62,882 women >or=50 yr of age who participated in the 2002 Behavioral Risk Factor Surveillance System (BRFSS). The OST Index, designed to assess an individual's risk of disease, has previously been shown to have modest positive and high negative predictive value for osteoporosis defined by BMD criteria. Based on this index, women from each state were distributed among high-, moderate-, and low-risk OST categories. Calculated percentages for each category were weighted to U.S. Census Bureau population projections for 2002. By adjusting results to reflect previously validated percentages of women with osteoporosis in each risk category, we estimated the prevalence of postmenopausal osteoporosis in each state. RESULTS: Our calculated weighted prevalence estimates agreed closely with those of the National Osteoporosis Foundation derived from actual femoral neck BMD measurements obtained in the third National Health and Nutrition Examination Survey (1988-1994) and projected to U.S. census state population predictions for 2002. Comparison of unweighted BRFSS-OST results and NHANES BMD data revealed similar percentages of osteoporosis among all women >or=50 yr of age (BRFSS, 18.5%; NHANES, 18.0%; p = 0.47) and also among white women (BRFSS, 19.0%; NHANES, 20.0%; p = 0.28). However, the percentages of osteoporosis among blacks and Hispanics did not correspond, at least partly because of the lack of race-specific reference standards for BMD measurements and OST index ranges. CONCLUSIONS: Analysis of readily available BRFSS data with the OST index formula is a simple, no-cost technique that provides state prevalence estimates of postmenopausal osteoporosis that could be used to guide allocation of resources to statewide osteoporosis prevention programs.     

Modest rates and wide variation in timely access to repeat kidney transplantation in the United States

Success of transplantation is not limited to initial receipt of a donor organ. Many kidney transplant recipients experience graft loss following initial transplantation and the benefits of expedited placement on the waiting list and retransplantation extend to this population. Factors associated with access to repeat transplantation may be unique given experience with the transplant process and prior viability as a candidate. We examined the incidence, risk factors, secular changes, and center‐level variation of preemptive relisting or transplantation (PRLT) for kidney transplant recipients in the United States with graft failure (not due to death) using Scientific Registry of Transplant Recipients data from 2007 to 2018 (n = 39 557). Overall incidence of PRLT was 15% and rates of relisting declined over time. Significantly lower PRLT was evident among patients who were African American and Hispanic, males, older, obese, publicly insured, had lower educational attainment, were diabetic, had longer dialysis time prior to initial transplant, shorter graft survival, longer distance to transplant center, and resided in distressed communities. There was significant variation in PRLT by center, median = 13%, 10th percentile = 6%, 90th percentile = 24%. Cumulatively, results indicate that despite prior access to transplantation, incidence of PRLT is modest with pronounced clinical, social, and center‐level sources of variation suggesting opportunities to improve preemptive care among patients with failing grafts.     

Prevalence and trends in low femur bone density among older US adults: NHANES 2005–2006 compared with NHANES III

Hip fracture incidence appears to be declining in the United States, but changes in bone mineral density (BMD) of the population have not been evaluated. We used femur BMD data from the National Health and Nutrition Examination Survey (NHANES) 2005–2006 to estimate the prevalence of low femoral BMD in adults age 50 years and older and compared it with estimates from NHANES III (1988–1994). Dual‐energy X‐ray absorptiometry systems (pencil‐beam geometry in NHANES III, fan‐beam geometry in NHANES 2005–2006) were used to measure femur BMD, and World Health Organization (WHO) definitions of low BMD were used to categorize skeletal status. In 2005–2006, 49% of older US women had osteopenia and 10% had osteoporosis at the femur neck. In men, 30% had femur neck osteopenia and 2% had femur neck osteoporosis. An estimated 5.3 million older men and women had osteoporosis at the femur neck, and 34.5 million more had osteopenia in 2005–2006. When compared with NHANES III, the age‐adjusted prevalence of femur neck osteoporosis in NHANES 2005–2006 was lower in men (by 3 percentage units) and women (by 7 percentage units) overall and among non‐Hispanic whites. Changes in body mass index or osteoporosis medication use between surveys did not fully explain the decline in osteoporosis. Owing to the increase in the number of older adults in the US population, however, more older adults had low femur neck BMD (osteoporosis + osteopenia) in 2005–2006 than in 1988–1994. Thus, despite the decline in prevalence, the estimated number of affected older adults in 2005–2006 remained high. Copyright © 2010 American Society for Bone and Mineral Research     

Subtrochanteric and Diaphyseal Femur Fractures in Patients Treated With Alendronate: A Register‐Based National Cohort Study

Alendronate (aln) is a potent bisphosphonate with a prolonged duration of action. Recent reports have found long‐term aln use to be common in patients with subtrochanteric or proximal diaphyseal femur fracture, raising concerns that these fractures could be a consequence of excessive suppression of bone turnover. Two national observational register‐based studies were performed: (1) cross‐sectional study (N = 11,944) comparing age distribution, exposure, and trauma mechanisms between different types of proximal femur fractures and (2) matched cohort study in patients with prior nonhip fractures (N = 5187 + 10,374), testing the hypothesis that the increase in the risk of subsequent atypical femur fractures exceeded the increase in typical hip fractures. We also sought evidence of a dose‐response relationship, where high adherence to or long‐term use of aln led to more atypical femur fractures. We found that 7% of patients with atypical fractures were aln exposed, and the same was found for typical hip fractures. In the cohort study, the HR for subtrochanteric/diaphyseal fracture with aln was 1.46 (0.91–2.35, p = 0·12) compared with 1.45 (1.21–1.74, p < 0·001) for hip fracture after adjustment for comorbidity and co‐medications. The risk was reduced by high adherence, and the ratio between hip and subtrochanteric/diaphyseal femur fractures was identical in aln‐treated patients and the control cohort even in the limited number of patients who received long‐term treatment. Subtrochanteric/diaphyseal femur fractures share the epidemiology and treatment response of classical hip fractures and are best classified as osteoporotic fractures.     

Adverse adult experiences and health outcomes: Racial and ethnic differences in a low-income sample

Extending research on adverse childhood experiences (ACEs), this study aimed to investigate whether the prevalence of and outcomes associated with adverse adult experiences vary among racial and ethnic subgroups. Survey data were collected from 1566 low-income women in Wisconsin using the Adult Experiences Survey (AES). Ten major adult adversities were assessed, including items that reference an intimate partner or household member (e.g., physical or emotional abuse, substance use) along with other social and economic stressors such as homelessness and discrimination. Adverse adult experiences were highly prevalent overall, but even more so among non-Hispanic Whites than their Black and Hispanic counterparts. The results reinforce prior research on ACEs in low-income populations. Lending further credence to these findings, tests of measurement invariance indicated that the AES demonstrated acceptable configural and scalar invariance across racial and ethnic groups. As expected, greater exposure to adult adversity was significantly related to poorer physical and mental health. These associations manifested cross-sectionally and longitudinally for observed and latent measures of adult adversity—even after controlling for ACEs. Associations between adult adversity and health were not moderated by race/ethnicity. In sum, adverse adult experiences were unequally distributed across racial/ethnic groups, but the consequences associated with adversity appeared to be evenly dispersed.     

Osteomalacia in Fractures of the Proximal Femur

The occurrence of osteomalacia was studied in 58 hip fracture patients who were admitted to the University Central Hospital of Kuopio for operative treatment. Findings indicating osteomalacia were frequent in the series. Hypocalcaemia was found in 70 per cent and an increase in serum alkaline phosphatase in 22 per cent of the patients. Urinary calcium excretion was decreased in 45 per cent and urinary hydroxyproline excretion was increased in 70 per cent of the cases. The serum levels of 25-hydroxyvitamin D and 24,25-dihydroxyvitamin D were significantly decreased in the patients compared with the controls. Histomorphometric analysis revealed no difference in the amount of trabecular bone in the patients compared with the controls, but the amount of osteoid and resorption surfaces was increased in the patients. Histological osteomalacia was found in 12 out of 50 patients (24 per cent). In 10 of these 12 cases the diagnosis of osteomalacia was supported by biochemical changes.

There was only one patient, a 29-year-old man with glutein enteropathy who had an evident reason for osteomalacia. The most obvious cause of osteomalacia was the lack of vitamin D due to a deficient diet and lack of exposure to sunlight. The conclusion drawn was that osteoporosis was the main cause and osteomalacia was an important aggravating factor in the bone fragility in these hip fracture patients.     

Osteomalacia in Fractures of the Proximal Femur

The occurrence of osteomalacia was studied in 58 hip fracture patients who were admitted to the University Central Hospital of Kuopio for operative treatment. Findings indicating osteomalacia were frequent in the series. Hypocalcaemia was found in 70 per cent and an increase in serum alkaline phosphatase in 22 per cent of the patients. Urinary calcium excretion was decreased in 45 per cent and urinary hydroxyproline excretion was increased in 70 per cent of the cases. The serum levels of 25-hydroxyvitamin D and 24,25-dihydroxyvitamin D were significantly decreased in the patients compared with the controls. Histomorphometric analysis revealed no difference in the amount of trabecular bone in the patients compared with the controls, but the amount of osteoid and resorption surfaces was increased in the patients. Histological osteomalacia was found in 12 out of 50 patients (24 per cent). In 10 of these 12 cases the diagnosis of osteomalacia was supported by biochemical changes.

There was only one patient, a 29-year-old man with glutein enteropathy who had an evident reason for osteomalacia. The most obvious cause of osteomalacia was the lack of vitamin D due to a deficient diet and lack of exposure to sunlight. The conclusion drawn was that osteoporosis was the main cause and osteomalacia was an important aggravating factor in the bone fragility in these hip fracture patients.     

Bone Fragility Contributes to the Risk of Fracture in Children,Even After Moderate and Severe Trauma

We prospectively examined whether the relationship between skeletal fragility and fracture risk in children 9.9 ± 0.3 (SD) yr is affected by trauma level. Bone size relative to body size and humeral vBMD showed similar inverse relationships with fracture risk, irrespective of whether fractures followed slight or moderate/severe trauma. Introduction: Fracture risk in childhood is related to underlying skeletal fragility. However, whether this relationship is confined to low‐trauma fractures or whether skeletal fragility also contributes to the risk of fracture caused by higher levels of trauma is currently unknown. Materials and Methods: Total body DXA scan results obtained at 9.9 yr of age were linked to reported fractures over the following 2 yr in children from the Avon Longitudinal Study of Parents and Children. DXA scan results that were subsequently derived included total body less head (TBLH) bone size relative to body size (calculated from TBLH area adjusted for height and weight) and humeral volumetric BMD (vBMD; derived from subregional analysis at this site). Trauma level was assigned using the Landin classification based on a questionnaire asking about precipitating causes. Results: Of the 6204 children with available data, 549 (8.9%) reported at least one fracture over the follow‐up period, and trauma level was assigned in 280 as follows: slight trauma, 56.1%; moderate trauma, 41.0%; severe trauma, 2.9%. Compared with children without fractures, after adjustment for age, sex, socioeconomic status, and ethnicity, children with fractures from both slight and moderate/severe trauma had a reduced bone size relative to body size (1133 cm² in nonfractured children versus 1112 cm² for slight trauma fractures, p < 0.001; 1112 cm² for moderate/severe trauma fractures, p = 0.001) and reduced humeral vBMD (0.494 g/cm³ in nonfractured children versus 0.484 g/cm³ for slight trauma fractures, p = 0.036; and 0.482g/cm³ for moderate/severe trauma fractures, p = 0.016). Conclusions: Skeletal fragility contributes to fracture risk in children, not only in fractures caused by slight trauma but also in those that result from moderate or severe trauma.     

The risk of prostate cancer amongst South Asian men in southern England: the PROCESS cohort study

OBJECTIVE

To reinvestigate whether South Asian men in the UK are at lower risk of being diagnosed with prostate cancer in a UK‐based retrospective cohort study and to examine possible reasons that may explain this.

PATIENTS AND METHODS

The catchment areas were predefined in four areas of southern England, and age‐ and race‐specific populations for those areas taken from census data. Cases were ascertained through review of multiple hospital sources, while race, other demographic factors, and medical history were determined using questionnaires sent to the men, hospital records review and death certificates. The South Asian group included men of Indian, Bangladeshi and Pakistani origin.

RESULTS

There was modest evidence of lower prostate cancer rates in South Asian men compared with their White neighbours (age‐adjusted rate ratio 0.81; 95% confidence interval 0.65–1.00). This difference did not reflect less use of prostate‐specific antigen (PSA) testing or differences in clinical features at presentation.

CONCLUSION

This study provides evidence of a lower incidence of prostate cancer amongst South Asian men living in England, in comparison with their White counterparts. If anything, South Asian men presented with clinical features of earlier disease suggesting that the reduced risk is unlikely to be an artefact of poorer access to health care.