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1.
Osteoporosis is a progressive systemic skeletal disease characterized by low bone density and microarchitectural deterioration of the bone. A minimum 3-cm difference between arm span and height makes up one of the criteria for suspecting osteoporosis. Therefore, it is easy to determine osteoporotic women by measuring the proportion of height to the arm span. The purposes of this study are to assess the relationship between arm span and height and to compare them in postmenopausal and young healthy women. This was a randomized-controlled, prospective study. There were two groups in this study. Group I included 70 postmenopausal osteoporotic women and group II had 70 healthy young women. Height, weight and arm span of the individuals were measured in all subjects. Bone mineral density and radiological examination of spine were also evaluated. Mean age of postmenopausal women was 64.4 ± 8.6 years and it was 27.3 ± 3.5 years in young healthy women. Mean height was 152 ± 5.1 and 161.5 ± 5.9 cm in group I and II, respectively. Mean arm span length was 159.6 ± 6.3 cm in postmenopausal women and 163.5 ± 6 cm in young healthy women. Mean arm span-height difference was significantly higher in postmenopausal women when compared to healthy young women (7.7 ± 3.6 and 2 ± 2.9 cm, respectively, P < 0.001). We suggest that arm span measurements can be used in the estimation of youth height and age-related loss in stature in postmenopausal women.  相似文献   

2.
CONTEXT: Quantitative ultrasound (QUS) may be more helpful than dual-energy X-ray absorptiometry (DXA) in detecting bone deficits in patients with type 2 diabetes mellitus (T2DM). OBJECTIVE: The objective of the study was to compare differences in bone mass measurement by DXA and QUS in T2DM and nondiabetic postmenopausal women. DESIGN, SETTING, AND PARTICIPANTS: This clinical investigation was a cross-sectional study in 76 patients with T2DM and 86 nondiabetic postmenopausal women. MAIN OUTCOME MEASURES: The primary outcomes were speed of sound (SOS) at the radius, phalanx, and tibia measured by QUS and bone mineral density (BMD) at the lumbar spine (LS), femoral neck (FN), and total hip (TH) measured by DXA. RESULTS: BMDs in T2DM patients were higher (LS, 1.06 +/- 0.12 vs. 0.90 +/- 0.23 g/cm(2); FN, 0.80 +/- 0.13 vs. 0.74 +/- 0.12 g/cm(2); TH, 0.87 +/- 0.14 vs. 0.80 +/- 0.13 g/cm(2), respectively, P < 0.001), whereas SOSs were lower than those in nondiabetics (radius, 4044 +/- 178 vs. 4129 +/- 182 m/sec; phalanx, 3902 +/- 207 vs. 3999 +/- 214 m/sec, respectively, P < 0.001). The positive relationships between SOS and BMD (r = 0.26-0.75, P < 0.05) in nondiabetics were not observed in women with T2DM. T2DM impacted negatively on SOSs (radius, beta= -0.223, P <0.01; phalanx, beta= -0.219, P <0.01) but positively on BMDs (LS, beta = 0.314, P < 0.001; FN, beta = 0.173, P < 0.05; TH, beta = 0.203, P <0.01). CONCLUSIONS: Differences in bone mass as measured by DXA and QUS in postmenopausal T2DM and nondiabetic women do not change in parallel. QUS can provide useful information in the skeletal assessment of patients with T2DM.  相似文献   

3.
The aim of this study was:to assess the long-term efficacy and safety of percutaneous vertebroplasty (PVP) for treating painful vertebral osteoporotic fractures, and to estimate the risk of vertebral fracture in the vicinity of a cemented vertebra. A prospective open study was conducted. PVP were carried out between July 1995 and September 2000 for 16 patients with symptomatic osteoporotic vertebral fracture that had not responded to extensive conservative medical therapy. All the patients were followed-up for more than 1 year. The efficacy of the PVP was assessed by the changes over time in pain on Huskissons visual analog scale (VAS) and on the McGill-Melzack scoring system (MGM). The efficacy of the procedure was also assessed by measuring the changes over time in quality of life assessed by the Nottingham Health Profile (NHP instrument): twenty-one vertebrae treated by PVP in 16 patients were evaluated. The mean duration of follow-up was 35 months. Pain assessed by the VAS significantly decreased from a mean of 71.4 mm±13 before PVP to 36 mm±30 after 6 months, and to 39 mm±33 at the time of maximal follow-up (p<0.05 for both comparisons). The results were also significant for the MGM: 3.00±0.57 before PVP to 1.6±1.4 at the long-term follow-up (p<0.05). The solely statistically significant decrease for quality of life was noted for pain. A slight but not significant improvement was noted for 3/6 dimensions of the NHP scores. A slight but significant increase in social isolation was also found. No severe complication occurred immediately after PVP. At the long term follow-up (35 months) there was a slight but not significantly increased risk of vertebral fracture in the vicinity of a cemented vertebra: odds ratio 3.18 (95% confidence interval (CI) 0.51–19.64). The odds ratio of a vertebral fracture in the vicinity of an uncemented fractured vertebra was 2.14 (95% CI: 0.17–26.31). In conclusion, PVP appears to be safe and effective for treating persistent painful osteoporotic fractures. Controlled studies with long-term follow-up are needed to evaluate the risk of vertebral fractures in the vicinity of a cemented vertebra. Abbreviations MGM McGill-Melzack scoring system - PVP Percutaneous vertebroplasty - VAS Visual analog scale  相似文献   

4.
BACKGROUND: Quantitative ultrasound (QUS) has been claimed as an alternative technique for risk assessment of hip fractures associated with osteoporosis. However, reports concerning modest correlations between QUS parameters and dual energy X-ray absorptiometry (DXA) in women raise questions about the reliability of QUS technology to predict bone mineral density (BMD). Partially, the lack of stronger correlations may be due to heterogeneity in bone architecture deterioration which may be more pronounced in older than in younger women. Therefore, it was thought important to study QUS/DXA interrelationships in subgroups of pre- and postmenopausal women. METHODS: We studied 217 pre- and postmenopausal women between the ages of 25 and 75 years, who were referred for a BMD measurement because of osteoporosis in at least one family member either in the first or in the second degree. All women had a calcaneal QUS and a DXA measurement at the lumbar spine, total hip and femoral neck. RESULTS: The linear regression coefficients between the QUS parameters broadband ultrasound attenuation (BUA) and speed of sound (SOS) and DXA at the various sites in the group as a whole were 0.53 to 0.54 (P<0.0001). Significantly lower regression coefficients between BUA and DXA at the total hip and the femoral neck were found in premenopausal women (r=0.31 and 0.38, P<0.0001) compared to postmenopausal women (r=0.56 and 0.53, P<0.0001). For SOS there was no significant difference between the regression coefficients in the pre- and postmenopausal group. The overall prevalence of osteoporosis as assessed by DXA in the total group was 25% (6% in the pre- and 36% in the postmenopausal group). BUA failed to detect osteoporosis in all five premenopausal women but also in 20 out of 50 postmenopausal women with osteoporosis according to DXA measurements. SOS measurements were even worse in this respect. CONCLUSIONS: Linear regression coefficients between calcaneal QUS parameters and DXA are only modest considering a group of 25--75-year-old Dutch women. In the subgroup of premenopausal women correlations between BUA and BMD at the hip and femoral neck are worse compared to those in postmenopausal women. The predictive value of QUS parameters for BMD is limited, therefore it is not appropriate to use QUS as a surrogate for DXA.  相似文献   

5.
Summary Dual-energy X-ray absorptiometry (DXA) is actually considered as one of the most appropriate techniques for measuring bone mineral content (BMC) and bone mineral density (BMD). An anthropomorphic phantom and a 25-yearold girl were repeatedly measured, 160 times and 50 times respectively, over an 18-month period to investigate performance in vitro and in vivo of a commercial DXA equipment (HOLOGIC QDR 1000). DXA is a highly accurate technique, the BMC and BMD determinations only overestimated the exact value of the phantom by 0.20% and 0.51% respectively. In vivo long-term (18 months) reproducibility of BMD of the spine is characterized by an interassay coefficient of variation (CVt) of 0.8% while, for the different regions of interest of the hip, BMD CVt varies from 1.1% (total zone) to 5.3% (Ward's triangle). In the subject tested, BMD sensitivity for changes of 2.2% at the lumbar spine and 3% at the hip were recorded.  相似文献   

6.
目的 系统评价阿仑膦酸钠对绝经后妇女骨质疏松性骨折的一级预防和二级预防的作用. 方法 按照Cochrane系统评价的方法,计算机检索美国国立生物医学信息中心Pubmed医学数据库、荷兰医学文摘Embase数据库、Cochrane图书馆临床对照试验数据库(2011年第2期)、中国生物医学文献数据库(CBM)、中文科技期刊全文数据库(CNKI)、万方及维普数据库,并检索所纳入文献的参考文献.收集所有相关随机对照试验,采用Cochrane协作网提供的软件RevMan 5.0进行Meta分析. 结果 共纳入11项随机对照试验进行评价.Meta分析结果显示,就二级预防而言,每天服用10 mg阿仑膦酸钠对减少脊椎、髋、腕部骨折发生率有统计学意义(RR=0.57,95%CI:0.49~0.67);但就一级预防而言,除减少椎体骨折的发生有统计学意义外(RR=0.55,95%CI:0.38~0.80),未发现减少其他骨折有统计学意义.与阿仑膦酸钠相关的不良反应无增加,敏感性分析结果无改变(RR=0.95,95%CI:0.83~1.09). 结论 阿仑膦酸钠的二级预防能减少绝经后妇女骨质疏松性骨折的发生,仍需对一级预防的疗效进行大样本研究.  相似文献   

7.
The aim of this study was to determine whether the probability of osteoporosis and osteopenia was affected by the risk factors, physical examination findings, or radiological investigations such as spinal X-rays in postmenopausal women. We assessed risk factors such as use of hormone replacement therapy, physical activity level, calcium intake, smoking, caffeine consumption, long-term immobilization, previous history of fracture, family history of fracture, presence of certain systemic diseases (hyperthyroidism or hyperparathyroidism), or use of medications (corticosteroids or others), physical examinations, and presence of vertebral fractures on spinal X-rays. Patients bone mineral density (BMD) was evaluated using dual energy X-ray absorptiometry (DXA) in the lumbar spine, and we compared the risk factors between osteopenic and osteoporotic women according to DXA. We evaluated 235 postmenopausal women who attended our osteoporosis outpatient clinic. Those patients were divided into two groups as either osteopenic (n=67, mean age: 63.1 years) or osteoporotic (n=168, mean age: 66.2 years) according to WHO criteria. The lumbar spinal (L1–L2) T-score values were –1.5±0.6 and –3.1±0.6 in osteopenic and osteoporotic groups, respectively. There were significant differences between the two groups in terms of mean age and lumbar BMD (p=0.009 and p<0.001, respectively). We also observed that vertebral tenderness on palpation, back pain, and existing vertebral fracture (fx) were significantly different between the osteopenic and osteoporotic groups (p<0.05). As a result of the statistical analysis, we found an equation to determine osteopenic and osteoporotic women by using those four factors (age, vertebral tenderness on palpation, back pain, and existing vertebral fx) in multivariate stepwise logistic regression. The equation is as follows: (DXA) = –2.9024 + 0.044 (age in year) + 0.819 (vertebral fx) + 0.877 (pain) + 1.136 (vertebral tenderness). We can estimate whether a postmenopausal woman is osteopenic or osteoporotic based on these risk factors by using the stepwise logistic regression equation.  相似文献   

8.
绝经后妇女脊椎压缩性骨折与骨密度的关系   总被引:2,自引:0,他引:2  
目的探讨绝经后妇女脊椎压缩性骨折与骨密度(BMD)的关系。方法为病例一对照研究,入选250例有脊椎压缩性骨折的绝经后妇女,另有250名无脊椎压缩性骨折的绝经后妇女作为对照组。两组均有胸腰椎正侧位X线摄片,并应用双能X线吸收仪检测腰椎1~4和左股骨近端各部位BMD。结果脊椎压缩性骨折组身高、体重、腰椎2~4和股骨近端各部位BMD值均显著低于对照组(均P〈0.01)。腰椎2~4BMD是发生脊柱骨折的预报因子(r=-0.416,P〈0.01)。身高和全髋部BMD与骨折次数和骨折椎体数目呈负相关(均P〈0.01)。按股骨颈和全髋部BMD值,骨折组骨质疏松检出率各为50.8%和50.4%;另外剔除在腰椎2~4发生椎体骨折53例,按腰椎2~4BMD检出骨质疏松占64.5%。同时,腰椎2~4、股骨颈或全髋部BMD值低于-2.5s者发生脊柱压缩性骨折的风险分别是BMD正常者的4.76、2.36和3.52倍。结论腰椎呈低骨量是发生脊椎压缩性骨折的重要危险因素。身高的下降和全髋部低BMD值是骨折发生次数和受累椎体数目的危险因子;对绝经后妇女在重视BMD测量的同时,应重视脊柱X线正侧位检查。  相似文献   

9.
【摘要】 目的  评估经皮椎体后凸成形术对骨质疏松椎体压缩骨折的临床疗效。 方法  将50例骨质疏松椎体压缩骨折患者随机分为试验组与对照组,试验组患者采取经皮椎体后凸成形术治疗,对照组患者采取常规经皮椎体成形术治疗,比较两组患者视觉模拟评分(VAS)、Oswestry评分以及4项影像学指标(后凸角以及伤椎前缘、中线、后缘高度)变化。 结果  两组患者术后VAS评分均显著下降(P<0.05),但试验组下降幅度更大(P<0.05);两组患者术后Oswestry评分均显著下降(P<0.05),但试验组下降幅度较对照组更大(P<0.05);试验组患者后凸角以及伤椎前缘、中线、后缘高度术后均显著改善(P<0.05),而对照组手术前后差异无统计学意义(P>0.05)。 结论  采用经皮椎体后凸成形术治疗骨质疏松椎体压缩骨折疗效优于经皮椎体成形术,但经皮椎体后凸成形术治疗成本高于经皮椎体成形术。今后应根据患者实际情况选择术式。  相似文献   

10.
The aim of this study was to establish whether quantitative ultrasound (QUS) parameters could identify patients classified as osteoporotic and osteopenic on the basis of dual energy X-ray absorptiometry (DEXA). One hundred and twenty-three patients (39 male, 84 female) with osteoporosis and suspected of having osteoporosis were included in this study. Broadband ultrasound attenuation (BUA) and speed of sound (SOS) were measured and bone mineral densities (BMD) of the lumbar spine and left hip was measured by DEXA. Subjects were classified into three groups (normal, osteopenic and osteoporotic) on the basis of BMD T-scores measured by DEXA. QUS parameters of the osteoporotic group were significantly lower than those of osteopenic and normal groups; there was no difference in QUS parameters between the normal and osteopenic groups. Correlations of both right and left SOS and BUA with the spine and femoral neck BMD were moderate (r = 0.343-0.539, P < 0.001). There was also reasonable correlation between DEXA and QUS T-scores (r = 0.364-0.510, P < 0.001). QUS had a sensitivity of 21% and a specificity of 95% for diagnosing osteoporosis. We concluded that, although DEXA and QUS parameters were significantly correlated, QUS parameters can not predict osteopenia as defined by DEXA, and sensitivities and specificities of QUS parameters were not sufficiently high for QUS to be used as an alternative to DEXA.  相似文献   

11.
Aim: The aim of this study is to compare total weight, % body fat (% BF), fat mass (FM) and fat‐free mass (FFM) measured by bioelectrical impedance analysis (BIA) and dual‐energy X–ray absorptiometry (DXA). Methods: This cross‐sectional study included 159 women (mean age: 49.1 ± 10.0 years) and 124 men (mean age: 51.4 ± 8.0 years) subdivided according to sex and body mass index (BMI): BMI < 30 kg/m2 (66 women and 50 men); BMI 30–35 kg/m2 (53 women and 44 men) and BMI ≥ 35 kg/m2 (40 women and 30 men). Bioelectrical impedance was performed in the fasting state on a Tanita TBF‐215 leg‐to‐leg analyser (Tanita, Tokyo, Japan). Whole‐body DXA scans were performed on a Hologic QDR 4500 A bone densitometer (Hologic, Bedford, MA, USA). Total weight, % BF, FM and FFM were tested for intermethod differences. Linear regression and correlation analysis was performed. Limits of agreement and Bland–Altman plots were built. Results: DXA‐derived body composition parameters were not significantly different from BIA estimates and were highly correlated (e.g. for FFM, r = 0.82–0.95). In lean individuals, BIA tended to produce lower values for FM and % BF and higher ones for FFM in comparison with DXA. This trend was reversed at BMI > 35 kg/m2. The correlations decreased with increasing BMI. The limits of agreement were much better in men than in women and increased with increasing BMI in both sexes. Conclusions: Compared with DXA, the leg‐to‐leg Tanita TBF‐215 analyser accurately assessed body composition in a heterogeneous group of both sexes. In the very obese women (BMI > 35 kg/m2), BIA measurements should be viewed with caution.  相似文献   

12.
老年骨质疏松性椎体压缩性骨折是老年骨质疏松症患者的一种常见骨折,常导致脊柱后凸,引起疼痛和功能障碍。该文对老年骨质疏松性椎体压缩性骨折的治疗进展作一综述。  相似文献   

13.
14.
BACKGROUND: It is a matter of controversy whether or not Colles' fracture is an osteoporotic fracture. Indeed, the usefulness of quantitative ultrasound in distinguishing Colles' fracture from normal fractures is also unclear. METHODS: A cross-sectional case-control study was done on 469 postmenopausal Spanish women, 121 with Colles' fracture and 348 controls. Assessment of risk factors for osteoporosis and measurement of calcaneus quantitative ultrasound were carried out using a Sahara, Hologic device. RESULTS: Patients with Colles' fracture had BUA, SOS, and QUI values that were similar to those of controls, and no statistically significant differences were found. We estimated ROC curves for SOS and a score based on a linear combination of height and SOS (SH-Score). The areas under both curves were 0.56 and 0.61, respectively, which was statistically significant. To obtain 5% false-negative and 10% false-positive figures, the T-score cut-off for SOS was -2.45 and -0.045, respectively. Of these, only 9.2% were classified as high risk and 11% as low risk with 79.8% undetermined. CONCLUSIONS: Patients with Colles' fracture had BUA, SOS, and QUI values that were similar to those of controls. Nevertheless, ROC curves calculated by a combination of height and SOS showed that quantitative calcaneus ultrasound may be a useful tool for identifying postmenopausal women with Colles' fracture. These results indicate that measuring bone mineral density with ultrasound only captures limited aspects of the pathophysiology of Colles' fractures.  相似文献   

15.
Summary Bone mineral content (BMC) and bone mineral density (BMD) of lumbar spine have been measured in 695 healthy postmenopausal and 64 type I osteoporotic Belgian, Caucasian females. Bone loss is strongly correlated to time elapse from menopause (Tm) with a maximum rate of bone loss during the first five years of menopause. BMC (gHA)=41.6+0.662 ln Tm –0.481 (ln Tm)2 and BMD (gHA/cm2)=0.91+0.00711 in Tm –0.00846 (ln Tm)2 (in both cases p<0.001 and Tm expressed in months of menopause). After 20 years of menopause, 50 to 60% of normal women have vertebral BMC and BMD values below the 90th percentile of women with vertebral fractures and, thus, might be considered to have asymptomatic osteoporosis. We conclude that prevention of postmenopausal osteoporosis should be initiated as soon as possible after the onset of menopause and that bone density screening should be extended in elderly in order to detect and allow treatment of asymptomatic densitometric osteoporosis.  相似文献   

16.
目的:观察老年骨质疏松椎体骨折(OVF)患者行椎体成形术(VP)围手术期服用阿司匹林的安全性及对手术疗效影响。方法:回顾性队列研究,分析2016年1月到2020年12月北京医院骨科136例行VP治疗OVF患者的临床资料,比较服用阿司匹林组(接受PVP术前服用阿司匹林,100 mg/d,并排除服用其他抗凝药物的患者)71...  相似文献   

17.
Background: Osteopenia and osteoporosis are frequent complications in Crohn's disease, and these features are associated with an increased risk of vertebral and appendicular fractures. Bone mineral density (BMD) measurements are widely accepted to assess the fracture risk in postmenopausal osteoporosis. In recent years, quantitative ultrasound (QUS) has become attractive for the diagnosis of osteopenia as a nonionizing method. The aim of the present study was to investigate QUS and BMD measurements in osteopenic patients with Crohn's disease. Methods: BMD of the lumbar spine and femoral neck and QUS of proximal phalanges II-V (DBM Sonic 1200; IGEA) were performed prospectively in 171 patients with Crohn's disease. The amplitude-dependent sound-of-speed (AD-SoS) and the ultrasound bone profile score (UBPS) were calculated using the WinSonic PRO 1.1 software program. X-ray examination of the spine was performed in 131 patients. Vertebral deformity was morphometrically defined according to the published methods of McCloskey and Eastell. Results: BMD of the lumbar spine and femoral neck correlated significantly (r = 0.62), but no correlation between BMD and QUS could be demonstrated. Vertebral deformities (VD) were detected in 28/131 (21.4%) patients. Two patients had a history of femoral fracture (FF). Lumbar BMD was lower in patients with either VD or FF than in those patients with no preexisting fractures (T-score: −2.46 vs −2.04; P = 0.0233). QUS parameters correlated negatively to patients' age but could not be used to discriminate between patients with and without VD/FF. Conclusions: Osteoporosis-related fractures are associated with a low lumbar bone density in Crohn's disease patients. QUS of the proximal phalanges cannot detect manifest osteoporosis in Crohn's disease patients and is therefore not valuable as a screening tool for these patients. Received: January 10, 2002 / Accepted: August 30, 2002 Acknowledgments. Morphometry of vertebral radiographs was supported by the Osteoporosis Study Group of the Clinic for Radiology and Nuclear Medicine, Klinikum Benjamin Franklin, Berlin, Germany. Reprint requests to: C. von Tirpitz  相似文献   

18.
The objective of this study was to estimate the unit costs of non-vertebral osteoporotic fractures in five European countries based on the results of the SOTI and TROPOS clinical trials in postmenopausal osteoporotic women. The information recorded in the Case Report Forms was used. The perspective of third party payers was adopted. Hip fracture unit cost was the highest. The ranges of costs among countries was narrow for hip from 8,346€ (Italy) to 9,907€ (France), but wider for other fractures: 890€ (Spain) to 2,022€ (Italy) for wrist, 1,167€ (Spain) to 3,268€ (Italy) for pelvis, 837€ (Spain) to 2,116€ (Italy) for sternum/clavicle, 565€ (Spain) to 908€ (France) for rib, 1,518€ (Spain) to 3,651€ (Belgium) for humerus, 1,805€ (Spain) to 3,521€ (Italy) for leg. The costs of those fractures should be considered when estimating the cost of osteoporosis.Conflict of Interest: Professors Meunier and Reginster have received fees from Servier for their support as consultant for the research conducted by Servier.This is the first published study estimating the cost of osteoporotic fractures other than vertebral, hip and wrist. The estimates are based on data collected in two clinical trials and might concern a selected subgroup of women meeting the inclusion criteria.  相似文献   

19.
Garnero P  Sornay-Rendu E  Delmas PD 《Lancet》2000,355(9207):898-899
The link between serum insulin-like growth factor 1 (IGF-1) and postmenopausal osteoporosis remains controversial. In this study of healthy postmenopausal women, decreased serum concentrations of IGF-1 were strongly associated with an increased risk of osteoporotic fractures independently of bone-mineral density.  相似文献   

20.
We aimed at evaluating the relationship of lean and fat mass to bone mass in osteoporotic postmenopausal women. We invited 65 women who were being treated at the São Paulo Hospital osteoporosis outpatients’ clinic to participate. Body composition and bone mineral density (BMD) measurements were performed using Dual-energy X-ray absorptiometry methodology (DXA). The mean age and weight were 69.7 ± 6.4 years and 56.3 ± 7.6 kg, respectively. Accordingly to the body mass index (BMI), 52.8% were of normal weight and 47.1% of the patients were overweight. Overweight women had significantly higher bone mass. Similarly, skeletal muscle index (SMI) showed a positive effect on BMD measurements and women with sarcopenia had significantly lower BMD measurements in total femur and femoral neck. In multiple regression analysis only lean mass and age, after adjustments to fat mass and BMI, were able to predict total body bone mineral content (BMC) (R2 = 28%). Also lean mass adjusted to age and BMI were able to predict femoral neck BMD (R2 = 14%). On the other hand, none of the components of the body composition (lean mass or fat mass) contributed significantly to explaining total femur BMD and neither body composition measurements were associated with spine BMD. These findings suggest that lean mass has a relevant role in BMC and BMD measurements. In addition, lower BMI and lean mass loss (sarcopenia) is associated to lower BMC and BMD of femoral neck and total femur and possible higher risk of osteoporotic fracture.  相似文献   

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