The Fracture Risk Assessment Tool (FRAX®): applications in clinical practice

Osteoporosis is a serious health concern affecting millions of Americans, with many patients going undiagnosed and untreated. Fractures due to osteoporosis and fracture-related complications are the most clinically relevant and costly consequences of this disorder. The Fracture Risk Assessment Tool (FRAX?), released by the World Health Organization (WHO) in February 2008, is a major achievement in helping determine which patients may be candidates for pharmacological therapy for osteoporosis. This Web-based algorithm, which has been incorporated into some dual x-ray absorptiometry (DXA) reporting software, calculates the 10-year probability of major osteoporotic fracture (clinical vertebral, hip, forearm, or humerus) and the 10-year probability of hip fracture in men and women based on easily obtained clinical risk factors and bone mineral density (BMD) of the femoral neck (optional). The National Osteoporosis Foundation updated its U.S. guidelines in February 2008 to incorporate FRAX and recommends that all postmenopausal women and men aged ≥50 years with a hip or vertebral fracture, a T-score ≤-2.5 at the femoral neck or spine (excluding secondary causes), or low bone mass (T-score between -1.0 and -2.5) and a 10-year probability of hip fracture ≥3% or of major osteoporosis-related fracture ≥20% (based on FRAX) should be considered candidates for drug therapy. Despite its demonstrated clinical utility, FRAX has limitations and should not be used in all situations. Acceptance and clinical use of FRAX may help identify men and women at increased risk for osteoporotic fracture, but implementing the tool into clinical practice may be a challenge for busy physicians.     

Use of acid-suppressive drugs and risk of fracture: a meta-analysis of observational studies

PURPOSE Previous studies have reported inconsistent findings regarding the association between the use of acid-suppressive drugs such as proton pump inhibitors (PPIs) and histamine 2 receptor antagonists (H₂RAs) and fracture risk. We investigated this association using meta-analysis.METHODS We searched MEDLINE (PubMed), EMBASE, and the Cochrane Library from inception through December 2010 using common key words. We included case-control, nested case-control, and cohort studies. Two evaluators independently reviewed and selected articles. We determined pooled effect estimates by using random-effects meta-analysis, because of heterogeneity.RESULTS Of 1,809 articles meeting our initial inclusion criteria, 5 case-control studies, 3 nested case-control studies, and 3 cohort studies were included in the final analyses. The pooled odds ratio (OR) for fracture was 1.29 (95% confidence interval [CI], 1.18–1.41) with use of PPIs and 1.10 (95% CI, 0.99–1.23) with use of H₂RAs when compared with nonuse of the respective medications. Long-term use of PPIs increased the risk of any fracture (adjusted OR = 1.30; 95% CI, 1.15–1.48) and hip fracture risk (adjusted OR = 1.34; 95% CI, 1.09–1.66), whereas long-term H₂RA use was not significantly associated with fracture risk.CONCLUSIONS We found possible evidence linking PPI use to an increased risk of fracture, but no association between H₂RA use and fracture risk. Widespread use of PPIs with the potential risk of fracture is of great importance to public health. Clinicians should carefully consider their decision to prescribe PPIs for patients already having an elevated risk of fracture because of age or other factors.     

Dietary intakes of arachidonic acid and alpha-linolenic acid are associated with reduced risk of hip fracture in older adults

PUFA are hypothesized to influence bone health, but longitudinal studies on hip fracture risk are lacking. We examined associations between intakes of PUFA and fish, and hip fracture risk among older adults (n = 904) in the Framingham Osteoporosis Study. Participants (mean age ~75 y at baseline) were followed for incident hip fracture from the time they completed the baseline exam (1988-1989) until December 31, 2005. HR and 95% CI were estimated for energy-adjusted dietary fatty acid exposure variables [(n-3) fatty acids: α-linolenic acid (ALA), EPA, DHA, EPA+DHA; (n-6) fatty acids: linoleic acid, arachidonic acid (AA); and the (n-6):(n-3) ratio] and fish intake categories, adjusting for potential confounders and covariates. Protective associations were observed between intakes of ALA (P-trend = 0.02) and hip fracture risk in a combined sample of women and men and between intakes of AA (P-trend = 0.05) and hip fracture risk in men only. Participants in the highest quartile of ALA intake had a 54% lower risk of hip fracture than those in the lowest quartile (Q4 vs. Q1: HR = 0.46; 95% CI = 0.26-0.83). Men in the highest quartile of AA intake had an 80% lower risk of hip fracture than those in the lowest quartile (Q4 vs. Q1: HR = 0.20; 95% CI = 0.04-0.96). No significant associations were observed among intakes of EPA, DHA, EPA+DHA, or fish. These findings suggest dietary ALA may reduce hip fracture risk in women and men and dietary AA may reduce hip fracture risk in men.     

Peer Reviewed: Smoking Status as a Predictor of Hip Fracture Risk in Postmenopausal Women of Northwest Texas

Introduction

The purpose of this study was to determine the effect of cigarette smoking on the risk of hip fracture for postmenopausal women living in rural and urban areas of Northwest Texas.

Methods

Using an unmatched case-control design, we compared postmenopausal women who had recently experienced osteoporotic hip fracture with women who had not. Both study groups completed a questionnaire on demographic, clinical, and behavioral risk factors for osteoporotic hip fracture. We categorized smoking status as never smoked, former smoker, and current smoker. Covariates included age, weight, age at menopause, physical activity, estrogen replacement, calcium supplementation, and rurality. We used univariate and multivariate logistic regressions to test the associations between hip fracture and the independent variables of interest.

Results

We found an increased risk of hip fracture for former smokers (adjusted odds ratio [OR], 2.27; 95% confidence interval [CI], 1.22–4.21) and current smokers (adjusted OR, 3.72; 95% CI, 1.59–8.70). Residence in a rural county (population <100,000) also was associated with increased risk (adjusted OR, 2.71; 95% CI, 1.48–4.95).

Conclusion

Former and current smoking increased the risk of hip fracture in this population of postmenopausal women.     

The relation between hip fracture and alzheimer's disease in the canadian national population health survey health institutions data, 1994-1995. A cross-sectional study

PURPOSE: The purpose of this study is to examine the relation between hip fractures and Alzheimer's disease in institutionalized men and women who participated in the 1994-1995 Canadian National Population Health Survey (NPHS).METHODS: Participants in the institutional component of NPHS were randomly chosen from selected health care institutions from all provinces in Canada. A questionnaire, which assessed health, demographic and socio-economic status, risk factors, medication use, and falls, was administered by an interviewer. Proxy respondents were sought for residents who were ill or incapacitated. Logistic regression was used to examine the association between hip fractures and Alzheimer's disease in 408 men and 1105 women >/=65 years. Models were examined with either hip fracture or Alzheimer's disease as the dependent variable. Covariates that were assessed included osteoporosis, age group, sex, medications, reported falls and comorbid conditions.RESULTS: All hip fractures reported in this survey were the result of a fall, however only 3.7% of falls resulted in a hip fracture. Those who had sustained a hip fracture were more likely to have Alzheimer's disease (OR 2.0, 95% CI 1.1-3.5), osteoporosis (OR 4.3, 95% CI 2.5-7.4) and heart disease (OR 2.4, 95% CI 1.1-5.0). Respondents who had Alzheimer's disease were more likely to have sustained a hip fracture (OR 2.1 95% CI 1.2-3.6), to have osteoporosis (OR 1.9, 95% CI 1.5-2.5), and to have fallen (OR 1.4, 95% CI 1.1-1.8) and were less likely to be taking anti-psychotic medication (OR 0.4, 95% CI 0.3-0.6) than those with no diagnosis of Alzheimer's disease.CONCLUSIONS: There is an association between Alzheimer's disease and hip fractures that is independent of other covariates in this representative sample of institutionalized elderly Canadians.     

Identifying low muscle mass in patients with hip fracture: Validation of bioelectrical impedance analysis and anthropometry compared to dual energy X-ray absorptiometry

Background

Older hip fracture patients often have reduced muscle mass, which is associated with adverse outcomes. Dual energy X-ray absorptiometry (DXA) can determine muscle mass, but is not practical in the acute phase. We investigated bioelectrical impedance analysis (BIA) and anthropometry compared against DXA for detecting low muscle mass in hip fracture patients.

Methods

This was a cross-sectional validation study at two Norwegian hospitals on 162 hip fracture patients aged ≥ 65 years. Appendicular lean mass (ALM) was determined by DXA, BIA and anthropometry 3 months after hip fracture. ALM by BIA was calculated by the Kyle, Janssen, Tengvall and Sergi equations, and ALM by anthropometry by the Heymsfield and Villani equations. The area under the receiver operating characteristic curve (AUC) was used to compare BIA and anthropometry for determining low ALM (≤5.67 kg/m² for women and ≤7.25kg/m² for men).

Results

Mean age was 79 years (SD 7.9), 74% were female. Mean ALM by DXA was 14.8 kg (SD 2.3) for women and 20.8 kg (SD 4.2) for men and 45% of women and 60% of men had low ALM. BIA (Kyle) in women (AUC 0.81, 95% confidence interval 0.72–0.89) and BIA (Sergi) in men (AUC 0.89, 95% CI 0.80–0.98) were best able to discriminate between low and normal ALM. Anthropometry (Heymsfield) was less accurate than BIA in women (AUC 0.64, 95% CI 0.54–0.75), and equal to BIA in men (AUC 0.72, 95% CI 0.72 0.56–0.87).

Conclusion

BIA (Sergi, Kyle and Tengvall) and anthropometry (Heymsfield) can identify low muscle mass in hip fracture patients.

     

Bone Density Testing: An Under-Utilised and Under-Researched Health Education Tool for Osteoporosis Prevention?

Feedback of fracture risk based on bone mineral density (BMD) is an under-explored potential osteoporosis education intervention. We performed a randomised controlled trial of either an osteoporosis information leaflet or small group education (the Osteoporosis Prevention and Self-Management Course (OPSMC)), combined with individualised fracture risk feedback in premenopausal women over two years. Women with a mean T-score at spine and hip of <0 were informed they were at higher risk of fracture in later life and those with T-score ≥ 0 were informed they were not. Women receiving feedback of high fracture risk had a greater increase in femoral neck, but not lumbar spine, BMD compared to the low risk group (1.6% p.a. vs. 0.7% p.a., p = 0.0001). Participation in the OPSMC had no greater effect on BMD than receiving the leaflet. Femoral neck BMD change was associated with starting calcium supplements (1.3% p.a., 95% CI +0.49, +2.17) and self-reported physical activity change (0.7% p.a., 95% CI +0.22, +1.22). Mother's report of increasing their children's calcium intake was associated with receiving the OPSMC (OR 2.3, 95% CI 1.4, 3.8) and feedback of high fracture risk (OR 2.0, 95% CI 1.2, 3.3). Fracture risk feedback based on BMD could potentially make an important contribution to osteoporosis prevention but confirmation of long-term benefits and cost effectiveness is needed before implementation can be recommended.     

Stroke among male professional drivers in Denmark, 1994-2003

Objectives

(1) To estimate the relative risk of stroke among various groups of professional drivers; (2) to determine if any excess risk should be attributed to infarction or haemorrhage; (3) to estimate the relative risk ratio for stroke among professional drivers living in Greater Copenhagen compared to those living outside the metropolis.

Methods

A cohort of 6285 bus drivers, 4204 car, taxi, and van drivers, and 25 879 heavy truck and lorry drivers were followed up for hospital admission due to stroke and sub‐diagnoses in the period 1994–2003. Using hospital admission for all economically active men as the standard, the standardised hospitalisation ratios (SHR) were calculated, taking age and county into consideration.

Results

There was a high SHR for stroke among all groups of professional drivers (SHR = 132; 95% CI 121–141). Among car, taxi, and van drivers the SHR was 157 (95% CI 132–189), among bus drivers it was 139 (95% CI 119–163), and among heavy truck and lorry drivers it was 124 (95% CI 113–136). The excess risk for all groups of professional drivers was highest for cerebrovascular infarction (SHR = 139; 95% CI 124–155) and lowest for non‐traumatic intracranial haemorrhage (SHR = 113; 95% CI 96–133). The excess risks for all groups were significantly higher for cerebrovascular infarction than for non‐traumatic intracranial haemorrhage (relative risk ratio (RRR) 1.23; 95% CI 1.01–1.51). The RRR of stroke among drivers in the metropolitan area compared to rural areas was 1.13 (95% CI 0.94–1.36). The RRR for stroke among car, taxi, and van drivers compared to drivers of heavy trucks and of lorries was 1.28 (95% CI 1.03–1.57).

Conclusion

All groups of professional drivers are at increased risk of stroke. The excess risk is more due to cerebral infarctions than to non‐traumatic intracranial haemorrhage. The risk of stroke is higher among drivers carrying passengers than among drivers carrying goods.     

Greater Consumption of Total and Individual Lignans and Dietary Fibers Were Significantly Associated with Lowered Risk of Hip Fracture—A 1:1 Matched Case–Control Study among Chinese Elderly Men and Women

The study aims to examine the association of dietary intake of lignans with the risk of hip fractures in Chinese older adults. This was a 1:1 age- and gender- matched case–control study. Dietary survey was conducted by face-to-face interviews using a 79-item validated food frequency questionnaire. Habitual intake of total and individual lignans (matairesinol, secoisolariciresinol, pinoresinol, and lariciresinol) was estimated based on the available lignans databases. Conditional logistic regression was used to examine the relationship of dietary total and individual lignans, lignan-rich foods (vegetables, fruits, nuts, and cereals) and dietary fibers with the risk of hip fracture. A total of 1070 pairs of hip fracture incident cases and controls were recruited. Compared with the lowest quartile, the highest quartile group showed a reduced hip fracture risk by 76.3% (0.237, 95% CI: 0.103–0.544, P_trend < 0.001) for total lignans, and 62.5% (0.375, 95% CI: 0.194–0.724, P_trend = 0.001) for dietary fibers. Similar findings were observed for individual lignans, the estimated enterolactone level, as well as lignans from vegetables and nuts. We concluded that greater consumption of total and individual lignans, and lignan-rich foods were significantly associated with decreased risk of hip fracture.     

Urinary cadmium and osteoporosis in U.S. Women >or= 50 years of age: NHANES 1988-1994 and 1999-2004

Background

Urinary cadmium (U-Cd) has been associated with decreased peripheral bone mineral density (BMD) and osteoporosis. This association, however, has not been confirmed using femoral BMD, the international standard for diagnosing osteoporosis, at levels < 1.0 μg Cd/g creatinine.

Objectives

Our goal was to investigate the statistical association between U-Cd, at levels ≤ 1 μg/g creatinine, and osteoporosis, as indicated by hip BMD and self-report in a population-based sample of U.S. women ≥ 50 years of age.

Methods

We drew data from the National Health and Nutrition Examination Surveys for 1988–1994 (n = 3,207) and 1999–2004 (n = 1,051). Osteoporosis was indicated by hip BMD cutoffs based on the international standard and self-report of physician diagnosis. We analyzed U-Cd levels for association with osteoporosis using multiple logistic regression.

Results

Women ≥ 50 years of age with U-Cd levels between 0.50 and 1.00 μg/g creatinine were at 43% greater risk for hip-BMD–defined osteoporosis, relative to those with levels ≤ 0.50 μg/g (odds ratio = 1.43; 95% confidence interval, 1.02–2.00; p = 0.04). We observed similar effect estimates using self-report of physician-diagnosed osteoporosis. Smokers did not show a statistically increased risk.

Conclusions

Results suggest that U.S. women are at risk for osteoporosis at U-Cd levels below the U.S. Occupational Safety and Health Administration’s 3-μg/g safety standard. Given null findings among smokers, dietary Cd, rather than tobacco, is the likely source of Cd-related osteoporosis risk for the U.S. female population ≥ 50 years of age.     

Osteoporosis for the home care physician. Part 1: etiology and current diagnostic strategies

Osteoporosis affects over 20 million individuals in North America and is responsible for over 1.5 million fractures in the US. Although most cases of osteoporosis are primary, in 20% of older women and 40% of older men presenting with vertebral fractures, a secondary cause can be identified. The WHO based the diagnosis of postmenopausal osteoporosis on the presence of BMD T-score that is 2.5 standard deviations or greater below the mean for young women. The International Society of Clinical Densitometry defined male osteoporosis as BMD T-score of 2.5 or greater below the mean for young men. BMD assessment at the hip and spine by DXA is the standard procedure to assess bone density. Laboratory testing in patients with low BMD is performed to exclude other conditions that could cause low BMD such as multiple myeloma, endocrinopathies and osteomalacia. Bone turnover marker levels currently do not predict bone mass or fracture risk and are only weakly associated with changes in bone mass. Subsequently, they are of limited use in the clinical evaluation of bone density changes.     

A Case�CControl Study on the Origin of Atypical Scrapie in Sheep, France

A matched case–control study (95 cases and 220 controls) was designed to study risk factors for atypical scrapie in sheep in France. We analyzed contacts with animals from other flocks, lambing and feeding practices, and exposure to toxic substances. Data on the prnp genotype were collected for some case and control animals and included in a complementary analysis. Sheep dairy farms had a higher risk for scrapie (odds ratio [OR] 15.1, 95% confidence interval [CI] 3.3–69.7). Lower risk was associated with organic farms (OR 0.15, 95% CI 0.02–1.26), feeding corn silage (OR 0.16, 95% CI 0.05–0.53), and feeding vitamin and mineral supplements (OR 0.6, 95% CI 0.32–1.14). Genetic effects were quantitatively important but only marginally changed estimates of other variables. We did not find any risk factor associated with an infectious origin of scrapie. Atypical scrapie could be a spontaneous disease influenced by genetic and metabolic factors.     

Ex-smokers and risk of hip fracture.

OBJECTIVES: The purpose of this study was to examine the reversibility of the effect of smoking on hip fracture incidence rates. METHODS: A 3-year follow-up cohort study was conducted involving 35,767 adults 50 years of age or older. Of these individuals, 421 suffered a hip fracture. RESULTS: Among participants less than 75 years of age, the relative risk (RR) of hip fracture was elevated for ex-smokers, even for those who had quit smoking more than 5 years previously (men: RR = 4.4, 95% confidence interval [CI] = 1.2, 15.3; women: RR = 1.3, 95% CI = 0.6, 3.0), but was not as high as that for current smokers (men: RR = 5.0, 95% CI = 1.5, 16.9; women: RR = 1.9, 95% CI = 1.2, 3.1). CONCLUSIONS: The effect of smoking on risk of hip fracture was not reversed completely 5 years after smoking cessation.     

Tobacco smoking and risk of hip fracture in men and women

BACKGROUND: Previous findings suggest that tobacco smoking increases the risk of hip fracture in women. A similar adverse effect of smoking is suspected to be present in men, but bone mineral density studies have raised the concern that men may be more sensitive to the deleterious effect of smoking on bone than women. In this study we prospectively determined the influence of current, previous, and cumulative smoking history on risk of hip fracture in men and women and addressed the issue of possible gender difference in the susceptibility to tobacco smoking. METHODS: Pooled data from three population studies conducted in Copenhagen with detailed information on smoking habit. A total of 13,393 women and 17,379 men, initially examined between 1964 and 1992, were followed until 1997 for first admission due to hip fracture. The relative risks (RR) of hip fracture associated with smoking were estimated by means of multiplicative Poisson regression models. RESULTS: During follow-up, 722 hip fractures were identified in women, and 447 in men. After adjustment for potential confounders, including body mass index, female current smokers had an RR of hip fracture of 1.36 (95% CI: 1.12-1.65) and male smokers 1.59 (95% CI: 1.04-2.43) relative to never smokers. In both sexes, the RR of hip fracture gradually increased by current and accumulated tobacco consumption. The RR were consistently higher in men than in women, but the test for interaction between sex and tobacco smoking was insignificant. After 5 years, male ex-smokers had an adjusted RR of 0.73 (95% CI: 0.55-0.98) relative to current smokers, while no significant decrease in risk was observed in female ex-smokers (RR = 0.91; 95% CI: 0.72-1.17)). Approximately 19% of all hip fractures in the present study population were attributable to tobacco smoking. CONCLUSION: Tobacco smoking is an independent risk factor for hip fracture in men and women, and there appears to be no gender differences in smoking related risk. Smoking cessation reduces the risk of hip fracture in men after 5 years, while the deleterious effect of smoking seems to be more long-lasting in female ex-smokers.     

Calcium intake and hip fracture risk in men and women: a meta-analysis of prospective cohort studies and randomized controlled trials

BACKGROUND: The role of total calcium intake in the prevention of hip fracture risk has not been well established. OBJECTIVE: The objective of the study was to assess the relation of calcium intake to the risk of hip fracture on the basis of meta-analyses of cohort studies and clinical trials. RESULTS: In women (7 prospective cohort studies, 170,991 women, 2,954 hip fractures), there was no association between total calcium intake and hip fracture risk [pooled risk ratio (RR) per 300 mg total Ca/d = 1.01; 95% CI: 0.97, 1.05]. In men (5 prospective cohort studies, 68,606 men, 214 hip fractures), the pooled RR per 300 mg total Ca/d was 0.92 (95% CI: 0.82, 1.03). On the basis of 5 clinical trials (n = 5666 women, primarily postmenopausal, plus 1074 men) with 814 nonvertebral fractures, the pooled RR for nonvertebral fractures between calcium supplementation (800-1600 mg/d) and placebo was 0.92 (95% CI: 0.81, 1.05). On the basis of 4 clinical trials with separate results for hip fracture (6,504 subjects with 139 hip fractures), the pooled RR between calcium and placebo was 1.64 (95% CI:1.02, 2.64). Sensitivity analyses including 2 additional small trials with <100 participants or per-protocol results did not substantially alter results. CONCLUSIONS: Pooled results from prospective cohort studies suggest that calcium intake is not significantly associated with hip fracture risk in women or men. Pooled results from randomized controlled trials show no reduction in hip fracture risk with calcium supplementation, and an increased risk is possible. For any nonvertebral fractures, there was a neutral effect in the randomized trials.     

Arsenic Exposure from Drinking Water and QT-Interval Prolongation: Results from the Health Effects of Arsenic Longitudinal Study

Background: Arsenic exposure from drinking water has been associated with heart disease; however, underlying mechanisms are uncertain.Objective: We evaluated the association between a history of arsenic exposure from drinking water and the prolongation of heart rate–corrected QT (QTc), PR, and QRS intervals.Method: We conducted a study of 1,715 participants enrolled at baseline from the Health Effects of Arsenic Longitudinal Study. We assessed the relationship of arsenic exposure in well water and urine samples at baseline with parameters of electrocardiogram (ECG) performed during 2005–2010, 5.9 years on average since baseline.Results: The adjusted odds ratio (OR) for QTc prolongation, defined as a QTc ≥ 450 msec in men and ≥ 460 msec in women, was 1.17 (95% CI: 1.01, 1.35) for a 1-SD increase in well-water arsenic (108.7 µg/L). The positive association appeared to be limited to women, with adjusted ORs of 1.24 (95% CI: 1.05, 1.47) and 1.24 (95% CI: 1.01, 1.53) for a 1-SD increase in baseline well-water and urinary arsenic, respectively, compared with 0.99 (95% CI: 0.73, 1.33) and 0.86 (95% CI: 0.49, 1.51) in men. There were no apparent associations of baseline well-water arsenic or urinary arsenic with PR or QRS prolongation in women or men.Conclusions: Long-term arsenic exposure from drinking water (average 95 µg/L; range, 0.1–790 µg/L) was associated with subsequent QT-interval prolongation in women. Future longitudinal studies with repeated ECG measurements would be valuable in assessing the influence of changes in exposure.     

Prospective cohort study of lead exposure and electrocardiographic conduction disturbances in the Department of Veterans Affairs Normative Aging Study

Background: No studies have examined the association between cumulative low-level lead exposure and the prospective development of electrocardiographic conduction abnormalities, which may mediate the association between lead and several cardiovascular end points.Objective: We prospectively examined the association between lead exposure and the development of electrocardiographic conduction abnormalities.Methods: We assessed blood lead, bone lead—a biomarker of cumulative lead exposure—measured with K-shell X-ray fluorescence, and electrocardiographic end points among 600 men in the Normative Aging Study who were free of electrocardiographic abnormalities at the time of the baseline ECG. Of these men, we had follow-up data from a second electrocardiogram for 496 men 8.1 (SD = 3.1) years later, on average. We used repeated measures linear regression to analyze change in electrocardiographic conduction timing and logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for developing specific conduction disturbances and adjusted for potential confounders.Results: Mean (± SD) blood (5.8 ± 3.6), patella bone (30.3 ± 17.7), and tibia bone (21.6 ± 12.0) lead concentrations were similar to those found in samples from the general U.S. population and much lower than those reported in occupationally exposed groups. Compared with those in the lowest tertile of tibia lead, those in the highest had a 7.94-ms (95% CI, 1.42–14.45) increase in heart rate–corrected QT (QTc) interval and a 5.94-ms increase in heart rate–corrected QRS (95% CI, 1.66–10.22) duration > 8 years. Those in the highest tertile of tibia lead also had increased odds of QT prolongation (QTc ≥ 440 msec; OR = 2.53; 95% CI, 1.22–5.25) and JT prolongation (heart rate–corrected JT > 360 msec; OR = 2.53; 95% CI, 0.93–6.91). Results were weaker for patella lead. No associations were identified with blood lead.Conclusions: This study suggests that low-level cumulative exposure to lead is associated with worse future cardiac conductivity in the ventricular myocardium, as reflected in QT interval characteristics.     

Who is at risk of osteoporosis?

This contribution assesses who is at risk of osteoporosis, by delineating the key risk factors involved in the condition. Osteoporosis represents a major public health problem through its association with fragility fractures, primarily of the hip, spine and distal forearm. Some risk factors for fragility fracture act through bone mineral density (BMD), for example female gender, asian or Caucasian race, premature menopause, primary or secondary amenorrhoea, primary and secondary hypogonadism in men, prolongued immobilisation, low dietary calcium intake, vitamin D deficiency. However, a number of others contribute significantly to fracture risk over and above their association with BMD (age, high bone turnover, poor visual acuity, neuromuscular disorders, previous fragility fracture, glucocorticoid therapy, family history of hip fracture, low body weight, cigarette smoking, excess alcohol consumption).     

A 12 year prospective study of circulatory disease among Danish shift workers

Background

Previous studies of the risk of heart disease after shift work reached different estimates and review authors disagree about the validity of some of the studies. A cross sectional study showed that shift workers had a higher prevalence of nearly every unfavourable work environment factor investigated. Conflicts at work and low decision latitude were more frequent among shift workers, and all‐day walking or standing work and part‐time jobs were more often found among female shift workers.

Objectives

To estimate the risk of circulatory disease in a prospective follow up of a representative sample of gainfully employed Danes, considering known or suspected confounding factors.

Methods

A cohort of 5517 people who were gainfully employed in 1990 were followed up for all hospital treatments due to circulatory diseases (390–458, ICD‐8; I00–I99, ICD‐10) from 1991 to 2002 inclusive. A log linear Poisson regression model was applied to control confounding factors and calculate the relative risk for 927 men and women working nights, evenings, or other non‐day shifts compared to 4579 day workers.

Results

Non‐day workers compared to day workers had a relative risk (RR) for all circulatory diseases of 1.31 (95% CI 1.06–1.63). Without control for BMI and smoking, the RR estimate was 1.33 (95% CI 1.07–1.65). For a subgroup of workers with at least three years'' seniority, the RR was 1.40 (95% CI 1.09–1.81). The population based aetiological fraction of shift work was estimated to 5%.

Conclusion

This study adds to a growing body of evidence suggesting that shift work carries an excess risk of circulatory diseases.     

Lung Cancer Risk in Men and Compliance with the 2018 WCRF/AICR Cancer Prevention Recommendations

Lung cancer is the most common and deadly form of cancer worldwide, especially in men. The 2018 World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) updated cancer prevention recommendations, and a standard scoring system (2018 WCRF/AICR Score) was published. The purpose of this study was to develop the adapted version of the 2018 WCRF/AICR Score with respect to lung cancer prevention recommendation (Ad-LC WCRF/AICR Score) and to examine the association between lung cancer risk in men and the Ad-LC WCRF/AICR Score as well as its single components. A case–control study was conducted among 439 men aged 45–80 years (187 controls, 252 primary lung cancer cases). Lifestyle and dietary data were collected with a questionnaire including the 62-item food frequency questionnaire (FFQ-6^®). The Ad-LC WCRF/AICR Score was used as a categorized and continuous variable. Odds ratios (ORs) and 95% confidence intervals (95% CIs) for lung cancer risk were calculated with the partly and fully adjusted model. One component of the score was independently associated with a lower risk of lung cancer in men, regardless of the set of confounders used. In the fully adjusted model following the recommendation “Limit smoking” was associated with a lower risk of lung cancer—in the never smokers by 87% (OR: 0.13; 95% CI: 0.04–0.37; p = 0.0002) and in the moderate smokers by 45% (OR: 0.55; 95% CI: 0.33–0.91; p = 0.0189) compared with the heavy smokers as a reference. By adding the single components making up the Ad-LC WCRF/AICR Score, the combination of three components or more, reducing the risk of lung cancer compared to lower compliance as a reference by 45% to 78% and by 39% to 66% for intermediate compliance (except two models out of seven) and higher compliance, respectively. In the fully adjusted model, the risk of lung cancer for the total Ad-LC WCRF/AICR Score was lower by 47% (OR: 0.53; 95% CI: 0.32–0.88; p = 0.0129) in higher compliance with the score compared to those with the lower compliance. Each one-point increase in the Ad-LC WCRF/AICR Score reduced lung cancer risk by 34% (OR: 0.66; 95% CI: 0.45–0.95; p = 0.0267). The results support previous evidence that limiting smoking reduces the risk of lung cancer in men. It also provides an insight into cancer research by showing that following the combined 2018 cancer prevention recommendations related to diet, lifestyle and body fatness was associated with a lower risk of lung cancer in men.