FRAX (Aus) and falls risk: Association in men and women

PurposeThe WHO fracture risk prediction tool (FRAX®) utilises clinical risk factors to estimate the probability of fracture over a 10-year period. Although falls increase fracture risk, they have not been incorporated into FRAX. It is currently unclear if FRAX captures falls risk and whether addition of falls would improve fracture prediction. We aimed to investigate the association of falls risk and Australian-specific FRAX.MethodsClinical risk factors were documented for 735 men and 602 women (age 40–90 yr) assessed at follow-up (2006–2010 and 2000–2003, respectively) of the Geelong Osteoporosis Study. FRAX scores with and without BMD were calculated. A falls risk score was determined at the time of BMD assessment and self-reported incident falls were documented from questionnaires returned one year later. Multivariable analyses were performed to determine: (i) cross-sectional association between FRAX scores and falls risk score (Elderly Falls Screening Test, EFST) and (ii) prospective relationship between FRAX and time to a fall.ResultsThere was an association between FRAX (hip with BMD) and EFST scores (β = 0.07, p < 0.001). After adjustment for sex and age, the relationship became non-significant (β = 0.00, p = 0.79). The risk of incident falls increased with increasing FRAX (hip with BMD) score (unadjusted HR 1.04, 95% CI 1.02, 1.07). After adjustment for age and sex, the relationship became non-significant (1.01, 95% CI 0.97, 1.05).ConclusionsThere is a weak positive correlation between FRAX and falls risk score, that is likely explained by the inclusion of age and sex in the FRAX model. These data suggest that FRAX score may not be a robust surrogate for falls risk and that inclusion of falls in fracture risk assessment should be further explored.     

High-sensitivity C-reactive protein is an independent risk factor for non-vertebral fractures in women and men: The Tromsø Study

Low-grade inflammation is associated with fractures, while the relationship between inflammation and bone mineral density (BMD) is less clear. Moreover, any gender differences in the sensitivity to inflammation are still poorly elucidated. We therefore tested the hypothesis that high-sensitivity C-reactive protein (CRP) is an independent risk factor for low BMD and non-vertebral fractures, in both genders, and whether there are gender differences in these associations.CRP levels and BMD at the total hip and femoral neck were measured in 1902 women and 1648 men between 55 and 74 years of age, at baseline in the Tromsø Study, Norway, in 2001–2002. Non-vertebral fractures were registered from hospital X-ray archives during an average of 7.2 years follow-up. Linear regression analyses were used for CRP association with BMD and Cox proportional hazards model for fracture prediction by CRP.During 25 595 person-years follow-up, 366 (19%) women and 126 (8%) men suffered a non-vertebral fracture. There was no association between CRP and BMD in women, but an inverse association in men (p = 0.001) after adjustment for age and body mass index. Each standard deviation (SD) increase in log-CRP was associated with an increased risk for non-vertebral fracture by 13% in women and 22% in men (hazard ratios (HRs) 1.13, 95% confidence interval (CI) 1.02–1.26, p = 0.026 and 1.22, 95% CI = 1.00–1.48, p = 0.046, respectively). After adjustment for BMD and other risk factors, women with CRP in the upper tertile exhibited 39% higher risk for fracture than those in the lowest tertile of CRP (HR = 1.39, 95% CI = 1.06–1.83, p = 0.017), while men in the upper tertile exhibited 80% higher risk (HR = 1.80, 95% CI = 1.10–2.94, p = 0.019).In summary, CRP was not associated with BMD in women but inversely associated in men, and predicted fractures in both genders. We infer that inflammation influence fracture risk in both women and men, although the biological mechanisms may differ between the genders.     

Ten-year risk of second hip fracture. A NOREPOS study

BackgroundSecond hip fracture risk is elevated after the first, however whether risk differs with age, by sex or over time is not well known.ObjectiveTo examine the risk of second hip fracture by sex, age and time after first hip fracture.DesignData on all hip fractures in subjects 50 years and older and treated in Norwegian hospitals during 1999–2008 were retrieved. Surgical procedure codes and additional diagnosis codes were used to define incident fractures. Survival analyses with and without adjustment for competing risk of death were used to estimate the risk of second hip fracture.ResultsAmong the 81,867 persons who sustained a first hip fracture, 6161 women and 1782 men suffered a second hip fracture during follow-up. The overall age-adjusted hazard ratio (HR) of a second hip fracture did not differ between the sexes (women versus men, HR = 1.03; 95% confidence interval (CI): 0.98–1.09). Taking competing risk of death into account, the corresponding age-adjusted HR of a second hip fracture was 1.40 (95% CI: 1.33–1.47) in women compared to men. The greater risk in women was due to a higher mortality in men. Based on competing risk analyses, we estimate that 15% of women and 11% of men will have suffered a second hip fracture within 10 years after the first hip fracture. The ten-year cumulative incidence was above 10% in all age-groups, except in men 90 years and older.ConclusionFracture preventive strategies have a large potential in both women and men who suffer their first hip fracture due to the high risk of another hip fracture.     

Cluster analysis of bone microarchitecture from high resolution peripheral quantitative computed tomography demonstrates two separate phenotypes associated with high fracture risk in men and women

Osteoporosis is a major healthcare problem which is conventionally assessed by dual energy X-ray absorptiometry (DXA). New technologies such as high resolution peripheral quantitative computed tomography (HRpQCT) also predict fracture risk. HRpQCT measures a number of bone characteristics that may inform specific patterns of bone deficits. We used cluster analysis to define different bone phenotypes and their relationships to fracture prevalence and areal bone mineral density (BMD). 177 men and 159 women, in whom fracture history was determined by self-report and vertebral fracture assessment, underwent HRpQCT of the distal radius and femoral neck DXA. Five clusters were derived with two clusters associated with elevated fracture risk. “Cluster 1” contained 26 women (50.0% fractured) and 30 men (50.0% fractured) with a lower mean cortical thickness and cortical volumetric BMD, and in men only, a mean total and trabecular area more than the sex-specific cohort mean. “Cluster 2” contained 20 women (50.0% fractured) and 14 men (35.7% fractured) with a lower mean trabecular density and trabecular number than the sex-specific cohort mean. Logistic regression showed fracture rates in these clusters to be significantly higher than the lowest fracture risk cluster [5] (p < 0.05). Mean femoral neck areal BMD was significantly lower than cluster 5 in women in cluster 1 and 2 (p < 0.001 for both), and in men, in cluster 2 (p < 0.001) but not 1 (p = 0.220). In conclusion, this study demonstrates two distinct high risk clusters in both men and women which may differ in etiology and response to treatment. As cluster 1 in men does not have low areal BMD, these men may not be identified as high risk by conventional DXA alone.     

Validation of FRAX without BMD: An age-related analysis of the Fifth Korean National Health and Nutrition Examination Survey (KNHANES V-1, 2010)

Although the Fracture Risk Assessment Tool (FRAX) is widely used to evaluate probabilities of fractures, there is no consensus regarding whether it is accurate when bone mineral density (BMD) is not included. This cross-sectional study aimed to compare the 10-year predicted fracture probabilities calculated using FRAX with and without BMD. Data were collected from the 2010 Fifth Korean National Health and Nutrition Examination Survey, and 2706 participants (1260 men and 1446 women) aged 50–90 years were analyzed. Ten-year predicted probabilities for major osteoporotic and hip fractures were calculated using the FRAX model. In men, the 10-year probabilities without BMD were 3.9 ± 1.8% and 1.3 ± 1.4% for major osteoporotic and hip fractures, respectively. In women, the 10-year probabilities without BMD were 7.7 ± 4.4% and 2.6 ± 2.9% for major osteoporotic and hip fractures, respectively. These probabilities were significantly correlated with the probabilities calculated using FRAX with BMD (all, p < 0.001). When participants were divided into 10-year age groups and compared with the 10-year predicted fracture probability with BMD, the 10-year predicted fracture probability without BMD was lower in men 50–59 years old, similar to men 60–69 years old, and higher in men ≥ 70 years old. The FRAX scores without BMD were generally lower for all women. The FRAX model without BMD appears to be a slightly lower fracture probability compared to that calculated with BMD, especially in younger participants. Although these results have important clinical implications for areas with limited ability to evaluate BMD, they must be confirmed by a large prospective study.     

Change in estimated glomerular filtration rate and fracture risk in the Action to Control Cardiovascular Risk in Diabetes Trial

ObjectivePatients with type 2 diabetes (T2DM) are at increased risk of fracture. High prevalence of chronic kidney disease (CKD) in T2DM may contribute to bone fragility, but whether dynamic change in kidney function is associated with fracture risk is unclear.Research design and methodsTo evaluate the association of pre-randomization baseline estimated glomerular filtration (eGFR) and its change over time with subsequent fracture risk in the Bone substudy of Action to Control Cardiovascular Risk in Diabetes (ACCORD) Trial, we conducted an observational study of 2262 women and 4737 men with T2DM and with at least 2 eGFR values.ResultsDuring a mean follow-up of 4.40 ± 1.54 years, 235 women and 223 men sustained a new non-vertebral fracture. In multivariable adjusted sex-specific models, pre-randomization baseline eGFR was not a significant predictor of fracture risk in either men or women. However, a steeper decline in eGFR was associated with greater risk of fracture in women (hazard ratio [HR] per standard deviation [SD] decrement in eGFR slope, 1.30; 95%CI 1.17–1.44) but not men (HR per SD decrement in eGFR slope, 0.97; 95%CI 0.82–1.13). Accounting for competing risk of death modestly attenuated the association in women (HR per SD decrement in eGFR slope, 1.19; 95%CI 1.04–1.37), with the relationship in men remaining non-significant (HR per SD decrement in eGFR slope, 0.96; 95%CI 0.77–1.18).ConclusionsDeclining kidney function predicts fracture risk in women but not in men with T2DM. Future studies should investigate the mechanisms for these associations.     

Prevalence and risk factors of osteoporosis in Korea: A community-based cohort study with lumbar spine and hip bone mineral density

PurposeTo investigate bone mineral density (BMD) profiles, osteoporosis prevalence and risk factors in a community-based cohort in Korea.MethodsThe present study is a cross-sectional study. The study population consisted of 1,547 men and 1991 women aged 40 years and older with BMD measurements using central dual energy X-ray absorptiometry from a prospective community-based cohort. The data were compared with other ethnic groups. Risk factors related to osteoporosis were analyzed.ResultsCrude prevalence of osteoporosis in the whole subjects (40–79 years old) was 13.1% for men and 24.3% for women by WHO criteria, at any site among lumbar spine, femoral neck or total hip. Standardized prevalence of osteoporosis between age of 50 and 79 at lumbar spine, femoral neck and total hip was 12.9%, 1.3% and 0.7% in men and 24.0%, 5.7% and 5.6% in women, respectively. The mean BMD of studied female subjects after age of 50 was not significantly different from that of Chinese but significantly lower than that of Japanese, non-Hispanic whites, non-Hispanic blacks and Mexican Americans. Risk of osteoporosis was significantly associated with the presence of past fracture history (OR, 1.45; 95% CI, 1.08–1.94), smoking ≥ 1 pack/day (OR, 1.63; 95% CI, 1.01–2.62), menarche after age of 16 (OR, 1.46; 95% CI, 1.14–1.87), last delivery after age of 30 (OR, 1.58; 95% CI, 1.20–2.09), more than three offspring (OR, 1.42; 95% CI, 1.07–1.89), post-menopause status (OR, 7.32; 95% CI, 3.05–17.6), more than 17 years since menopause (OR, 1.53; 95% CI, 1.10–2.14), regular exercise of two to three times per week (OR, 0.40; 95% CI, 0.18–0.89), monthly income above 500,000 won per household (OR, 0.64; 95% CI, 0.45–0.92), college graduate (OR, 0.29; 95% CI, 0.13–0.63) and calcium intake ≥ 627.5 mg/day (OR, 0.65; 95% CI, 0.43–0.98) after adjusting for age and BMI.ConclusionThe BMD and osteoporosis prevalence of Koreans are presented. Risk of osteoporosis was significantly associated with fracture history, smoking, reproductive history, regular exercise, income level, education background and calcium intake.     

The effect of including quantitative heel ultrasound in models for estimation of 10-year absolute risk of fracture

The role of quantitative ultrasound (QUS) in clinical practice is debatable. An unanswered question is that whether combining QUS and BMD measurements could improve the prediction of fracture risk. We examined this in a sample of men and women in the European Prospective Investigation into Cancer (EPIC)-Norfolk who had both heel QUS and hip DXA between 1995 and 1997 and were followed for any incident fracture up to 2007. From 1455 participants (703 men) aged 65–76 years at baseline, 79 developed a fracture over 10.3 ± 1.4 years of follow-up. Two separate sex-stratified Cox proportional-hazard models were used including clinical risk factors and total hip BMD. Heel broadband ultrasound attenuation (BUA) was also included in the second model. Global measures of model fit, area under ROC curve, and the Hosmer–Lemeshow statistic showed relative superiority of the model including BUA. Using each model, we calculated 10-year absolute risk of fracture for all participants and categorized them in groups of < 5%, 5% to < 15%, and ≥ 15%. Comparison of groupings showed a total re-classification of 16.6% of participants after inclusion of BUA with the greatest re-classification (30.7%) among the group with intermediate risk. Adding a QUS measurement to models based on clinical risk factors and BMD improves the predictive power of models and suggests that further attention should be paid to QUS as a clinical tool for fracture risk assessment.     

Ten-year incident osteoporosis-related fractures in the population-based Canadian Multicentre Osteoporosis Study — Comparing site and age-specific risks in women and men

BackgroundPopulation-based incident fracture data aid fracture prevention and therapy decisions. Our purpose was to describe 10-year site-specific cumulative fracture incidence by sex, age at baseline, and degree of trauma with/without consideration of competing mortality in the Canadian Multicentre Osteoporosis Study adult cohort.MethodsIncident fractures and mortality were identified by annual postal questionnaires to the participant or proxy respondent. Date, site and circumstance of fracture were gathered from structured interviews and medical records. Fracture analyses were stratified by sex and age at baseline and used both Kaplan–Meier and competing mortality methods.ResultsThe baseline (1995–97) cohort included 6314 women and 2789 men (aged 25–84 years; mean ± SD 62 ± 12 and 59 ± 14, respectively), with 4322 (68%) women and 1732 (62%) men followed to year-10. At least one incident fracture occurred for 930 women (14%) and 247 men (9%). Competing mortality exceeded fracture risk for men aged 65 + years at baseline. Age was a strong predictor of incident fractures especially fragility fractures, with higher age gradients for women vs. men. Major osteoporotic fracture (MOF) (hip, clinical spine, forearm, humerus) accounted for 41–74% of fracture risk by sex/age strata; in women all MOF sites showed age-related increases but in men only hip was clearly age-related. The most common fractures were the forearm for women and the ribs for men. Hip fracture incidence was the highest for the 75–84 year baseline age-group with no significant difference between women 7.0% (95% CI 5.3, 8.9) and men 7.0% (95% CI 4.4, 10.3).InterpretationThere are sex differences in the predominant sites and age-gradients of fracture. In older men, competing mortality exceeds cumulative fracture risk.     

Risk factors for falls in a longitudinal population-based cohort study of Japanese men and women: The ROAD Study

The objective of this study was to clarify the associations of physical performance and bone and joint diseases with single and multiple falls in Japanese men and women using a population-based longitudinal cohort study known as Research on Osteoarthritis/osteoporosis Against Disability (ROAD). A total of 452 men and 896 women were analyzed in the present study (mean age, 63.9 years). A questionnaire was used to assess the number of falls during the 3-year follow-up. Grip strength, 6-m walking time, and chair stand time were measured at baseline. Knee osteoarthritis (OA) and lumbar spondylosis were defined as Kellgren Lawrence = 2, 3 or 4. Vertebral fracture (VFx) was assessed with the Japanese Society of Bone and Mineral Research criteria. Osteoporosis was defined by bone mineral density using dual energy X-ray absorptiometry based on World Health Organization criteria. Knee and lower back pain were estimated by an interview. During a 3-year follow-up, 79 (17.4%) men and 216 (24.1%) women reported at least one fall, and 54 (11.9%) men and 111 (12.4%) women reported multiple falls. Knee pain was a risk factor for multiple falls in women, but not in men. VFx tended to be associated with multiple falls in women, but not in men. A longer 6-m walking time was a risk factor for multiple falls in women, whereas a longer chair stand time was a risk factor for multiple falls in men. We found gender differences in risk factors for falls.     

Systematic vertebral fracture assessment in asymptomatic postmenopausal women

IntroductionRecognition of vertebral fractures (VFs) changes the patient's diagnostic classification, estimation of fracture risk, and threshold for pharmacological intervention. Vertebral fracture assessment (VFA) enables the detection of VFs in the same session as bone mineral density (BMD) testing.ObjectiveTo study prevalence and risk factors of VFs using VFA in asymptomatic women and measure its effect on treatment recommendations.MethodsWe enrolled 908 postmenopausal women (mean age, weight and BMI of 60.9 ± 7.7 (50–91) years, 73.2 ± 13.2 (35–150) kg and 29.8 ± 5.3 (14.5–50.8) kg/m², respectively. Lateral VFA images and scans of the lumbar spine and proximal femur were obtained using a GE Healthcare Lunar Prodigy densitometer. VFs were defined using a combination of Genant semiquantitative (SQ) approach and morphometry.ResultsVFs were identified in 382 patients (42.0%): 203 (22.3%) had grade 1 and 179 (19.7%) had grade 2 or 3. The prevalence of VFA-detected fractures globally increased significantly with age and as BMI and BMD declined. A fracture was identified on VFA in 63 (28.3%) women with normal BMD (8.5% had grade 2/3 VFs) and in 145 (38.5%) with osteopenia (15.7% had grade 2/3 VFs). Stepwise regression analysis showed that presence of VFs was independently related to age, BMI, number of parity, history of peripheral fracture and lumbar spine BMD.ConclusionA high proportion of women with asymptomatic VFs would not receive treatment if screening were based only on BMD evaluation. Our results support the recommendation to enlarge the indications of VFA in the presence of risk factors such as age over 60, multiparity, history of peripheral traumatic fractures and low BMI.     

Application of FRAX Model to Sri Lankan Postmenopausal Women

The FRAX software developed by the World Health Organization provides a method to estimate fracture probability of old men and women based on their bone mineral density (BMD) and clinical risk factors (CRFs). The validity of 4 selected ethnic-specific FRAX tools in determining prevalent fracture or treatment decisions in a group of postmenopausal women from Sri Lanka was examined. Women with a history of fragility fracture/s and those who were detected to have femoral neck T-score < 2.5 were considered eligible for specific osteoporosis treatment. Ten-year all osteoporotic fracture (vertebral and nonvertebral) probability (10y-AOFP) of 481 postmenopausal women were estimated on US Caucasian, US Asian, Japanese, and Chinese FRAX tools, first using CRFs alone and then combining with femoral neck T-scores. At 20% 10y-AOFP, Chinese tool showed a very low sensitivity in detecting prevalent fracture or detecting women needing intervention (1.3%). Sensitivities observed with US Asian and Japanese tools ranged from 33% to 42%, showing their limitations in predicting prevalent fracture in this group of women. The US Caucasian tool, either with CRFs alone or with BMD incorporated, showed a relatively higher sensitivity in detecting fractures or identifying those needing interventions (71% and 76%, respectively). Furthermore, the US Caucasian tool showed a relatively high specificity (ranging from 70% to 87%). In conclusion, this analysis showed the limitations of the current FRAX tools in predicting fractures when applied to a different ethnic group. Until a separate FRAX tool is developed, the US Caucasian tool can be used to predict fractures in Sri Lankan postmenopausal women.     

Proportion of osteoporotic women remaining at risk for fracture despite adherence to oral bisphosphonates

BackgroundAdherence to oral bisphosphonates is often low, but even adherent patients may remain at elevated fracture risk. The goal of this study was to estimate the proportion of bisphosphonate-adherent women remaining at high risk of fracture.MethodsA retrospective cohort of women aged 50 years and older, adherent to oral bisphosphonates for at least two years was identified, and data were extracted from a multi-system health information exchange. Adherence was defined as having a dispensed medication possession ratio ≥ 0.8. The primary outcome was clinical occurrence of: low trauma fracture (months 7–36), persistent T-score ≤ − 2.5 (months 13–36), decrease in bone mineral density (BMD) at any skeletal site ≥ 5%, or the composite of any one of these outcomes.ResultsOf 7435 adherent women, 3110 had either pre- or post-adherent DXA data. In the full cohort, 7% had an incident osteoporotic fracture. In 601 women having both pre- and post-adherent DXA to evaluate BMD change, 6% had fractures, 22% had a post-treatment T-score ≤ − 2.5, and 16% had BMD decrease by ≥ 5%. The composite outcomes occurred in 35%. Incident fracture was predicted by age, previous fracture, and a variety of co-morbidities, but not by race, glucocorticoid treatment or type of bisphosphonate.ConclusionDespite bisphosphonate adherence, 7% had incident osteoporotic fractures and 35% had either fracture, decreases in BMD, or persistent osteoporotic BMD, representing a substantial proportion of treated patients in clinical practices remaining at risk for future fractures. Further studies are required to determine the best achievable goals for osteoporosis therapy, and which patients would benefit from alternate therapies.     

Higher serum carcinoembryonic antigen levels associate with more frequent development of incident fractures in Korean women: A longitudinal study using the national health insurance claim data

BackgroundPro-inflammatory cytokines play important roles in bone metabolism and several studies have shown that carcinoembryonic antigen (CEA) may promote inflammation. We investigated the association of serum CEA levels with the risk of osteoporosis and incident fracture.MethodsWe performed a small cross-sectional study with 302 Korean women and a large, longitudinal study with 7192 Korean women in an average 3-year follow-up period. For the cross-sectional study, bone mineral density (BMD) and bone turnover markers (BTMs) were measured. For the longitudinal study, incident fractures in the follow-up period were identified by using the selected International Classification of Diseases, 10th revision (ICD-10) codes and the nationwide claims database of the Health Insurance Review and Assessment Service of Korea.ResultsIn the cross-sectional study, serum CEA levels correlated negatively with BMD at the lumbar spine (γ = − 0.023; P = 0.029) and positively with BTMs (γ = 0.122 to 0.138, P = 0.002 to P < 0.001) after adjustment for confounding variables. In the longitudinal study, 254 (3.5%) women developed incident fractures in the follow-up period (2.8 ± 1.3 years). After adjustment for potential confounders, the hazard ratio (HR) per 1 ng/mL increment of the baseline CEA level for the development of incident fracture was 1.22 [95% confidence interval (CI): 1.05–1.42]. The HR was markedly higher in subjects in the highest CEA quartile category compared with those in the lowest CEA quartile category (HR = 1.54, 95% CI: 1.04–2.28).ConclusionTherefore, serum CEA may be a biomarker of the risk of incident fracture in postmenopausal Korean women.     

Risk of second hip fracture persists for years after initial trauma

BackgroundSecondary prevention often targets women who suffer from higher rates of second hip fracture than men, especially in the early years after first fracture. Yet, the occurrence of second hip fracture by certain times also depends on the death rate, which is higher in men than women. We compared the risk of sustaining second hip fracture by a certain time between women and men remaining alive at that time.MethodsWe retrieved 38,383 hospitalization records of patients aged 60 years or older, who were discharged alive after admission for hip fracture surgery between 1990 and 2005 in British Columbia, Canada. The outcome variable was the time to a subsequent hip fracture.ResultsDuring ten years of follow-up, 2,902 (8%) patients sustained a second hip fracture, and 21,428 (56%) died before sustaining a second hip fracture. The risk of second hip fracture in the surviving post-fracture patients was higher in women than in men: 2% vs 2%, 5% vs 4%, 9% vs 7%, 15% vs 13%, and 35% vs 30% at 1, 2, 3, 5, and 10 years after initial trauma, respectively, crude OR = 1.25 (95% CI: 1.13–1.39). However, the risk did not differ between women and men after adjustment, OR = 1.09 (95% CI: 0.98–1.21).ConclusionsThe risk of second hip fracture persists for at least ten years among hip fracture survivors, and therefore secondary prevention should continue beyond an early post-fracture period. Women and men have similar risks of second hip fracture and both should be considered for secondary prevention.     

Age-Related Trends in Phalangeal Bone Mineral Density in Sri Lankan Men and Women Aged 20 Years or More

To establish normative reference values and to study the age-related trends in phalangeal bone mineral density (BMD), 4504 male and 5215 female volunteers aged 20 yr or more were recruited from 7 provinces from October 2004 to October 2005. Subjects suffering from diseases and those who were taking medications, which could affect BMD were excluded from the analysis (n = 530). Phalangeal BMD was measured in the nondominant hand using an AccuDXA. Men and women were categorized to age groups of 20–29 (1087 men and 1079 women), 30–39 (1122 men and 1146 women), 40–49 (1148 men and 1455 women), 50–59 (810 men and 1111 women), 60–69 (250 men and 335 women), and 70 yr or more (87 men and 94 women). Mean BMDs (SD) of men in above categories were 0.595 (0.057), 0.603 (0.061), 0.591 (0.066), 0.576 (0.069), 0.558 (0.077), and 0.522 (0.079) g/cm², respectively. The corresponding BMDs (SD) in women were 0.495 (0.057), 0.506 (0.062), 0.502 (0.064), 0.462 (0.072), 0.406 (0.072), and 0.340 (0.055) g/cm², respectively. Peak BMD was seen in 30–39-age category in both sexes. Women after 50 yr lost BMD at a rate of 0.006 (standard error 0.0003) g/cm²/yr, whereas the corresponding value in men was 0.002 (standard error 0.0001) g/cm²/yr. These data provide normative reference data for the calculation of T-score and Z-score for phalangeal BMD in Sri Lankan men and women aged more than 20 yr.     

Procollagen type 1 amino-terminal propeptide (P1NP) and risk of hip fractures in elderly Norwegian men and women. A NOREPOS study

The current study aimed to assess a possible association between the bone turnover marker procollagen type 1 amino-terminal propeptide (P1NP) and future hip fractures in elderly Norwegian men and women and to elucidate the relation between P1NP, bone mineral density and 25-hydroxyvitamin D (25(OH)D). Men and women aged 71 to 77 from two population based health studies in Norway (1999–2001) were followed for a median period of 7.3 years with respect to hip fractures. The study was designed as a case-cohort study. P1NP and 25(OH)D were analysed in frozen serum samples obtained at baseline in hip fracture patients (n = 340) and in randomly selected sex stratified sub-cohorts. Bone mineral density was measured by dual-energy X-ray absorptiometry (DXA) in a subset of participants. Cox proportional hazards regression with inverse probability weighting and robust variance was performed. No significant correlation between 25(OH)D and P1NP was found. A negative correlation between P1NP and BMD was observed in women (Rho = − 0.36, p = 0.001). A similar trend was observed in men. No association between quartiles of P1NP and rate of subsequent hip fractures was found. Spline analyses suggested a higher rate of hip fracture at P1NP levels above 60 μg/L in both men and women. A higher hip fracture rate, which was independent of BMD, was also indicated in women with very low levels of P1NP.     

Abdominal aortic calcification and risk of fracture among older women — The SOF study

Data concerning the link between severity of abdominal aortic calcification (AAC) and fracture risk in postmenopausal women are discordant. This association may vary by skeletal site and duration of follow-up. Our aim was to assess the association between the AAC severity and fracture risk in older women over the short- and long term. This is a case–cohort study nested in a large multicenter prospective cohort study. The association between AAC and fracture was assessed using Odds Ratios (OR) and 95% confidence intervals (95%CI) for vertebral fractures and using Hazard Risks (HR) and 95%CI for non-vertebral and hip fractures. AAC severity was evaluated from lateral spine radiographs using Kauppila's semiquantitative score. Severe AAC (AAC score 5 +) was associated with higher risk of vertebral fracture during 4 years of follow-up, after adjustment for confounders (age, BMI, walking, smoking, hip bone mineral density, prevalent vertebral fracture, systolic blood pressure, hormone replacement therapy) (OR = 2.31, 95%CI: 1.24–4.30, p < 0.01). In a similar model, severe AAC was associated with an increase in the hip fracture risk (HR = 2.88, 95%CI: 1.00–8.36, p = 0.05). AAC was not associated with the risk of any non-vertebral fracture. AAC was not associated with the fracture risk after 15 years of follow-up. In elderly women, severe AAC is associated with higher short-term risk of vertebral and hip fractures, but not with the long-term risk of these fractures. There is no association between AAC and risk of non-vertebral-non-hip fracture in older women. Our findings lend further support to the hypothesis that AAC and skeletal fragility are related.     

Underestimated Fracture Probability in Patients With Unilateral Hip Osteoarthritis as Calculated by FRAX

Osteoporosis (OP) and osteoarthritis (OA) are age-related diseases often considered to be mutually exclusive. We previously found that 25% of women with advanced OA had occult OP and that femoral neck (FN) bone mineral density (BMD) T-scores were significantly higher for osteoarthritic vs contralateral hips. The FRAX calculator incorporates clinical risk factors and FN BMD T-score to estimate 10-yr total fracture probability and hip fracture probability. In 35 women and men aged 41 yr or older with unilateral hip OA scheduled for hip replacement, we tested whether FRAX fracture probability is underestimated when using data for the OA rather than the contralateral hip. There were between-hip differences for FN BMD T-score (p < 0.0001), total fracture probability (p = 0.0004), and hip fracture probability (p = 0.0009). Use of FN BMD T-scores resulted in OP treatment recommendations for 0% and 11% of subjects compared with 11% and 17% for total fracture probability and hip fracture probability, respectively. In 6–11% of subjects in this series, the FRAX calculator underestimated fracture probability with data for the OA hip. With the increased use of FRAX in clinical use, these data suggest that measurement of BMD at the contralateral hip may yield higher calculated FRAX total and hip fracture probabilities.     

Effects of lead and cadmium co-exposure on bone mineral density in a Chinese population

It has been indicated that both cadmium (Cd) and lead (Pb) may have adverse effects on the bone. However, most studies have only focused on a single factor. The primary and main and interactive effects of Cd and Pb on bone mineral density (BMD) in a Chinese population were observed in this study. A total of 321 individuals (202 women and 119 men), aged 27 years and older, living in control and polluted areas, were recruited to participate in this study. The BMD was measured through dual energy X-ray absorptiometry (DXA) at the proximal radius and ulna. The samples of urine and blood were collected to determine the levels of Cd and Pb in the urine (UCd and UPb) and blood (BCd and BPb). The Cd and Pb levels of people living in the polluted area were significantly higher than those living in the control area (p < 0.05). The BMD of women living in polluted area was significantly lower than that of women living in the control area (p < 0.05). Furthermore, the BMD decreased with increasing of BCd (p < 0.05), BPb and UPb in women. The likelihood of low BMD was associated with higher BCd in women (OR = 2.5, 95% CI: 1.11–5.43) and BPb in men (OR = 4.49, 95% CI: 1.37–14.6). The relative extra risk index of low BMD for female and male subjects with both high levels of BCd and BPb was 0.45 and 1.16, respectively. This study strengthens previous evidence that cadmium and lead may influence the bone and also demonstrates that cadmium and lead may have interactive effects on BMD.