High frequency of vertebral fracture and low bone quality in patients with rheumatoid arthritis—Results from TOMORROW study

Objectives: Osteoporosis is one of the complications in patients with rheumatoid arthritis (RA). In this study, we researched the morbidity of existing vertebral fractures and the risk factors for vertebral fractures in patients with RA.

Methods: This study included 413 participants, 208 patients with RA, and 205 age- and sex-matched controls without RA. Clinical data, radiographic assessment of vertebral fracture from T4 to L4 in thoracic and lumber spine, bone mineral density (BMD), and bone metabolic markers (BMM) were analyzed.

Results: Vertebral fractures were observed more frequently, severe and multiple in patients with RA. In the logistic regression analysis, age (adjusted odds ratios (OR): 1.07, 95% confidence interval (CI): 1.04–1.09) and RA (adjusted OR: 1.72, 95% CI: 1.04–2.83) were risk factors for existing vertebral fracture. Moreover, two bone matrix-related markers, undercarboxylated osteocalcin (ucOC) (adjusted OR: 1.68, 95% CI: 1.02–2.78), and urinary pentocidine (adjusted OR: 2.51, 95% CI: 1.48–4.24) were associated with existing vertebral fracture.

Conclusions: High frequent, multiple, and severe vertebral fractures were found in patients with RA compared to the controls. Low bone quality might be the cause of the frequent prevalence of vertebral fracture in patients with RA.     

Breast arterial calcification and hypertension associated with vertebral fracture

Aim: Arterial calcification and osteoporosis commonly accompany one another in postmenopausal women. Hypertension is a known contributing factor to arterial calcification. Thus, we aimed to investigate any associations between hypertension, arterial calcification and vertebral fractures in a cross‐sectional study in Japanese postmenopausal women. Methods: The medical histories of 421 postmenopausal Japanese women diagnosed with hypertension, diabetes mellitus or hyperlipidemia were investigated. Bodyweight, body height and ultradistal bone mineral density (BMD) were measured. The prevalent vertebral fractures were diagnosed by a semiquantitative method, and the number of breast arterial calcifications (BAC) was investigated by mammography screening. Results: Patients with vertebral fractures were of a significantly higher age, lower height, lower ultradistal BMD and had a higher number of BAC compared with those without vertebral fractures. Furthermore, a significantly higher prevalence of hypertension was observed in the patients with vertebral fractures as compared with those without. A multivariate stepwise regression analysis using these variables for vertebral fractures showed that the significant odds ratios (OR) of age (OR 1.76, 95% CI 1.11–2.77, P = 0.016), the prevalence of BAC (OR 2.52, 95% CI 1.62–3.93, P < 0.001) and the presence of hypertension (OR 1.76, 95% CI 1.11–2.80, P = 0.017) were found as significant independent risk factors for vertebral fractures. Conclusion: This is the first report of the relevance of BAC or hypertension to vertebral fractures in Japanese women. The results suggest that hypertension, BAC and osteoporotic fractures share a common metabolic pathway in their pathogenesis. Geriatr Gerontol Int 2012; 12: 330–335.     

Self-reported fractures and associated factors in women with systemic lupus erythematosus

OBJECTIVE: To determine the frequency of fractures and associated factors in women with systemic lupus erythematosus (SLE). METHODS: Women with SLE (n = 304) completed this cross-sectional study conducted from 1996 to 2002. Self-reported fractures occurring after the diagnosis of SLE were evaluated. Hip and/or lumbar spine bone mineral density (BMD) was measured using dual-energy x-ray absorptiometry, and the results were expressed as BMD Z-scores. Multiple logistic regression analyses were performed to identify factors associated with fractures. RESULTS: Of the 304 women with SLE, 12.5% experienced fractures. Those with fractures had significantly lower BMD Z-scores at the hip (Fracture group -0.55 vs No Fracture group -0.14, group difference 0.41; 95% CI 0.04 to 0.78), but not at the lumbar spine (Fracture group -0.25 vs No Fracture group -0.18, group difference 0.07; 95% CI -0.43 to 0.57). Among women with fractures, 60.5% and 63.2% had normal BMD Z-scores (BMD Z-score > -1.0) at the hip and lumbar spine, respectively, and 50.0% had normal BMD Z-scores at both anatomical sites. In multiple logistic regression analysis, each year of disease duration (adjusted OR 1.11; 95% CI 1.05 to 1.17) and use of osteoporosis medications (adjusted OR 4.75; 95% CI 1.62 to 13.94) were significantly associated with fractures. CONCLUSION:. Longer duration of SLE and use of osteoporosis medications were significantly associated with fractures. Although women with fractures had significantly lower BMD Z-scores at the hip, an unexpectedly high proportion of women with SLE having normal BMD Z-score experienced fractures following SLE diagnosis.     

Clinical utility of calcaneal quantitative ultrasonometry and thoracic kyphosis assessments in identifying vertebral fractures in community settings

OBJECTIVE: Individuals with existing vertebral fractures may not be aware that they are at high risk of subsequent fractures. We investigated if calcaneal quantitative ultrasonometry (QUS) and assessment of thoracic kyphosis could discriminate a group of older women with prevalent vertebral fracture from those without. METHODS: One hundred four women (mean age 71.3 +/- 5.8 yrs) underwent dual-energy x-ray absorptiometry (DEXA) bone mineral density (BMD; lumbar spine and hip), calcaneal QUS, and video rasterstereographic thoracic kyphosis measurements. They were dichotomized into a group with prevalent vertebral fracture (VF, n = 24) or without vertebral fracture (NVF, n = 80). RESULTS: Univariate variables associated with the VF group included broadband ultrasound attenuation (BUA; age-adjusted OR 1.96, 95% CI 1.12-3.42, p = 0.018); speed of sound (SOS; age-adjusted OR 2.01, 95% CI 1.09-3.70, p = 0.026); and thoracic kyphosis (age-adjusted OR 1.72, 95% CI 1.01-2.92, p = 0.049). A composite model (BUA and thoracic kyphosis) had higher area under the receiver-operating characteristic curve (AUC = 0.75) compared to lumbar spine DEXA BMD (AUC = 0.50, p = 0.0004) and total hip DEXA BMD (AUC = 0.60, p = 0.057). CONCLUSION: Reduced calcaneal QUS values and greater thoracic kyphosis were found to be significantly associated with the group of women with prevalent vertebral fractures. A composite risk score (BUA and thoracic kyphosis) had better discriminatory power than the individual risk factor of (low) DEXA BMD.     

A multicenter cross sectional study on bone mineral density in rheumatoid arthritis. Italian Study Group on Bone Mass in Rheumatoid Arthritis

OBJECTIVE: To determine the frequency of osteoporosis in a large cohort of women with rheumatoid arthritis (RA) and to investigate the main determinants of bone mineral density (BMD) and risk factors for vertebral fractures in this population. METHODS: We recruited 925 consecutive female patients with RA at 21 Rheumatology Centers in Italy. For each patient pre-registered demographic, disease, and treatment-related variables were collected. BMD was measured at lumbar spine and proximal femur by dual x-ray absorptiometry technique. Collected variables underwent a univariate and multivariate statistical procedure. Osteoporosis was defined as BMD > -2.5 T score. RESULTS: The frequency of osteoporosis in the whole sample was 28.8% at lumbar spine and 36.2% at femoral neck and increased linearly from Steinbrocker's functional stage I to IV (p = 0.0001). Patients with spinal or femoral osteoporosis were significantly older (p = 0.0001), had a lower body mass index (BMI) (p < 0.02), a significantly longer disease duration (p < 0.02) and a significantly higher Health Assessment Questionnaire (HAQ) score (p = 0.0001). These differences were significant, even after adjusting for age. Steroid use was associated with significantly lower lumbar and femoral BMD (p = 0.0001) even after adjusting for the main confounding covariates. Analysis of lateral spine radiographs revealed 74 women with at least one vertebral fracture. These women had a significantly lower lumbar and femoral BMD (p = 0.0001). The generalized linear model showed that steroid use, menopause, BMI, age, and HAQ were all significant independent predictors of lumbar and femoral BMD. The logistic procedure showed that age (OR 1.05, 95% CI 1.03-1.07), HAQ (OR 1.3, 95% CI 1.07-1.7), menopause (OR 1.9, 95% CI 1.1-3.2), use of steroids (OR 1.5, 95% CI 1.07-2.1), and BMI (OR 0.8, 95% CI 0.8-0.9) were significantly associated with the risk for osteoporosis. The only variables associated with an increased risk for vertebral fracture were age (OR 1.04, 95% CI 1.01-1.08), HAQ (OR 1.7, 95% CI 1.08-2.09), and cumulative steroid intake (OR for 1 g of prednisone 1.03, 95% CI 1.006-1.07). CONCLUSION: To prevent osteoporosis and its dramatic complications in RA the therapeutic challenge is to preserve functional capacity using the lowest possible dosage of corticosteroids.     

Psychological stress in a Japanese population with systemic lupus erythematosus: Finding from KYSS study

Abstract

Objectives. Daily psychological stress has been proposed as a risk factor for systemic lupus erythematosus (SLE) in Western countries. However, there is little information about the relationship between daily psychological stress and the risk of SLE in a Japanese population. We examined the association between SLE and daily psychological stress.

Methods. A case–control study was conducted to examine the relationship between daily psychological stress and SLE in Japanese females. The participants were 160 female SLE patients and 660 female volunteers. Unconditional logistic regression was used to compute OR and 95% confidence interval (CI), with adjustment for several covariates.

Results. Smoking (OR = 2.59; 95% CI, 1.74–3.86), walking (OR = 1.75; 95% CI, 1.81–2.56) and daily psychological stress (OR = 1.88; 95% CI, 1.14–3.10) were increased in patients with SLE after adjusting for age, region and all factors. Smokers with daily psychological stress (OR = 4.70; 95% CI = 2.53–8.77) were more prevalent than nonsmokers without daily psychological stress in SLE. The multiplicative interaction measures between smoking status and daily psychological stress did not reach statistical significance.

Conclusions. The present study suggests the possibility that daily psychological stress as well as smoking might be associated with an increased risk of SLE.     

Prevalence of and risk factors for low bone mineral density in Japanese female patients with systemic lupus erythematosus

To examine the prevalence of and risk factors for low bone mineral density (BMD) (osteoporosis or osteopenia) in Japanese female patients with systemic lupus erythematosus (SLE). We performed BMD measurements by dual X-ray absorptiometry at the lumbar spine and the hip and collected basic and lifestyle-related, clinical and treatment characteristics among 58 SLE patients. Odds ratios (ORs) and their 95% confidence intervals (CIs) were assessed for associations between low BMD and selected factors among SLE patients. The mean BMD?±?SD was 0.90?±?0.17?g/cm² at the lumbar spine and 0.76?±?0.17?g/cm² at the hip. The prevalence of osteopenia (2.5 SD?<?T score?<?1 SD) was 50.0% and that of osteoporosis (T score?<?2.5 SD) was 13.8% in our SLE patients. After adjustment for age and disease duration, we found the number of deliveries (OR?=?5.58, 95% CI?=?1.31?C26.06; P?=?0.02) to be a risk factor for overall low BMD (T score?<?1 SD) and a maximal dosage of >50?mg/day of oral corticosteroids (OR?=?0.25, 95% CI?=?0.07?C0.91; P?=?0.035) as a preventive factor for low BMD at the lumbar spine. Reduced BMD, especially in spinal trabecular bone, was pronounced in Japanese female patients with SLE, particular in those with a history of delivery. A history of high-dose oral corticosteroids was associated with the preservation of BMD at the lumbar spine, however, further study is needed considering the limited sample size.     

Depression, falls, and risk of fracture in older women. Study of Osteoporotic Fractures Research Group

BACKGROUND: Previous studies have suggested that depression is associated with falls and with low bone density, but it is not known whether depression leads to an increased risk of fracture. SUBJECTS AND METHODS: We conducted a prospective cohort study in elderly white women who were recruited from population-based listings in the United States. At a second visit (1988-1990), 7414 participants completed the 15-item Geriatric Depression Scale and were considered depressed if they reported 6 or more symptoms of depression. We measured bone mineral density (BMD) in the spine and hip using dual energy x-ray absorptiometry at the second visit, and asked participants about incident falls (yes/no) at 4 follow-up visits. Nonvertebral fractures were ascertained for an average of 6 years following the depression measure, and verified radiologically. We determined incident vertebral fractures by comparing lateral spine films obtained at the first visit (1986-1988) with repeat films obtained an average of 3.7 years later (1991-1992). RESULTS: The prevalence of depression (Geriatric Depression Scale score > or = 6) was 6.3% (467/7414). We found no difference in mean BMD of the hip and lumbar spine in women with depression compared with those without depression. Women with depression were more likely to experience subsequent falls than women without depression (70% vs 59%; age-adjusted odds ratio [OR], 1.6; 95% confidence interval [CI], 1.3-1.9; P<.001), an association that persisted after adjusting for potential confounding variables (OR, 1.4; 95% CI, 1.1-1.8; P=.004). Women with depression had a 40% (age-adjusted hazard ratio [HR], 1.4; 95% CI, 1.2-1.7; P<.001) increased rate of nonvertebral fracture (124 fractures in 3805 woman-years of follow-up) compared with women without depression (1367 fractures in 59 503 woman-years of follow-up). This association remained strong after adjusting for potential confounding variables, including medication use and neuromuscular function (HR, 1.3; 95% CI, 1.1-1.6; P=.008). Further adjustment for subsequent falls appeared to explain part of this association (HR, 1.2; 95% CI, 1.0-1.5; P = .06). Women with depression were also more likely to suffer vertebral fractures than women without depression, adjusting for history of vertebral fracture, history of falling, arthritis, diabetes, steroid use, estrogen use, supplemental calcium use, cognitive function, and hip BMD (OR, 2.1; 95% CI, 1.4-3.2; P<.001). CONCLUSIONS: Depression is a significant risk factor for fracture in older women. The greater frequency of falls among individuals with depression partially explains this finding. Other mechanisms responsible for the association between depression and fracture remain to be determined.     

The prevalence of vertebral fractures in mild ankylosing spondylitis and their relationship to bone mineral density

OBJECTIVE: To determine bone mineral density (BMD) in patients with mild ankylosing spondylitis (AS), to establish the prevalence of vertebral fractures and fracture risk in these patients, and to determine the relationship between BMD and vertebral fractures. METHODS: Sixty-six men with mild AS were studied. BMD of the lumbar spine and femoral neck was measured by dual X-ray absorptiometry (DXA) and radiographs of the thoracic and lumbar spine were obtained in all subjects. From the radiographs, vertebral fractures were characterized by a morphometric technique using established criteria. Thirty-nine healthy male subjects aged 50-60 yr, recruited from primary care registers, had spinal radiographs performed and served as controls for vertebral fractures. RESULTS: In patients with AS, BMD was reduced in both the lumbar spine 0.97 (0.1) g/cm(2) [T score -1.10 (1.3), 95% confidence interval (CI) -0.50, +0.14] and femoral neck 0.82 (0.1) g/cm(2) [T score -1.40 (1.2), 95% CI -0.51, +0.09]. There was no correlation between BMD of either the lumbar spine or femoral neck and duration of disease in patients with AS. Eleven of 66 (16.7%) patients with AS had a vertebral fracture, compared with one of 39 (2.6%) controls; odds ratio 5.92 (95% CI 1.4, 23.8). AS patients with fractures were not significantly older (mean age 41.4 vs 37.8 yr, P=0.17), but had significantly longer disease duration (12.4 vs 9.3 yr, P<0.05) than patients without fractures. No significant difference was found in the visual analogue scores for pain in AS patients with fractures compared with those without. No significant correlation was observed between BMD of the lumbar spine or femoral neck and vertebral fractures in patients with AS. In addition, there was no significant difference in the lumbar spine or femoral neck BMD in AS patients with fractures compared with those without. CONCLUSIONS: Spinal and hip osteopenia and vertebral fractures are a feature of mild AS. However, there was no correlation between BMD and vertebral fractures in these patients. AS patients with mild disease had a higher risk of fractures compared with the normal population and this increased with the duration of disease.     

Reduced carotid intima–media thickness in systemic lupus erythematosus patients treated with cyclosporine A

Abstract

Background Patients with systemic lupus erythematosus (SLE) are at risk of atherosclerosis. An increased carotid intima–media thickness (IMT) is considered to be a marker of early atherosclerosis.

Objective To determine influential factors for increased carotid IMT in SLE patients.

Methods We evaluated the impact of conventional risk factors for atherosclerosis on carotid IMT in 427 healthy controls and of clinical factors on carotid IMT in 94 SLE patients. Carotid IMT was measured by using a newly developed computer-automated system. Unconditional logistic regression was used to assess the adjusted odds ratios (ORs) and 95 % confidence intervals (95 % CI).

Results Multivariate-adjusted mean carotid IMT (mm) was significantly reduced in SLE patients (0.51, 95 % CI = 0.36–0.66) compared to healthy controls (0.55, 95 % CI = 0.40–0.70) (P = 0.003). The SLE Disease Activity Index (SLEDAI) was associated with carotid IMT in a dose-dependent manner (P_trend = 0.041). The current use of cyclosporine A (adjusted OR = 0.02, 95 % CI = 0.01–0.40, P = 0.011) and a history of steroid pulse therapy (adjusted OR = 0.01, 95 % CI = 0.01–0.25, P = 0.006) were significantly associated with a decreased risk of increased carotid IMT.

Conclusions Our findings suggest that the current use of cyclosporine A can protect against increased carotid IMT, leading to a decreased risk of arteriosclerosis. Future studies with a larger sample size need to confirm that this association holds longitudinally.     

Bone density threshold and other predictors of vertebral fracture in patients receiving oral glucocorticoid therapy

OBJECTIVE: To evaluate predictors of vertebral fractures, including a threshold for bone mineral density (BMD), in patients receiving oral glucocorticoids (GCs). METHODS: Data were obtained from 2 randomized clinical trials (prevention and treatment trials of risedronate) using similar methods, but different inclusion criteria were applied with regard to prior exposure to GCs. Predictors of vertebral fracture in the placebo group were identified using Cox regression with forward selection. The BMD threshold analysis involved a comparison of the 1-year fracture risk in postmenopausal women receiving placebo in the GC trials with that in postmenopausal women not taking GCs in 3 other trials. RESULTS: The study population comprised 306 patients with baseline and 1-year followup data on vertebral fractures (111 receiving placebo and 195 receiving risedronate). In the placebo group, the statistically significant predictors of incident fracture were the baseline lumbar spine BMD (for each 1-point decrease in T score, relative risk [RR] 1.85, 95% confidence interval [95% CI] 1.06-3.21) and the daily GC dose (for each 10-mg dose increase, RR 1.62, 95% CI 1.11-2.36). In the BMD threshold analysis, compared with nonusers of GCs, patients receiving GCs were younger, had a higher BMD at baseline, and had fewer prevalent fractures; nevertheless, the risk of fracture was higher in the GC users compared with nonusers (adjusted RR 5.67, 95% CI 2.57-12.54). The increased risk of fracture was observed in GC users regardless of whether osteoporosis was present. CONCLUSION: The daily, but not cumulative, GC dose was found to be a strong predictor of vertebral fracture in patients receiving GCs. At similar levels of BMD, postmenopausal women taking GCs, as compared with nonusers of GCs, had considerably higher risks of fracture.     

Radiographic measure of aorta calcification is a site-specific predictor of bone loss and fracture risk at the hip

OBJECTIVE: To investigate whether aorta calcification (AC) - a surrogate marker of atherosclerosis - is an independent indicator of low bone mass density (BMD), accelerated bone loss, and risk of future fractures in postmenopausal women. DESIGN: A prospective epidemiological study. Follow-up period was 7.5 years. SETTING: Community-based sample followed by a research institute. SUBJECTS: A total of 2662 generally healthy postmenopausal women with a mean age of 65.0 +/- 7.1 years at baseline. MAIN OUTCOME MEASURES: Annual rate of changes in BMD (DEXA) and AC (X-rays), vertebral fractures (X-rays), hip fractures (questionnaire). RESULTS: Advanced AC at baseline was significantly associated with lower BMD and accelerated bone loss from the proximal femur. In a multivariate logistic regression model, age (OR 1.1, 95% CI 1.0-1.2, P = 0.02), body mass index (BMI; OR 0.9, 95% CI 0.8-1.0, P = 0.03) and the severity of AC (OR 2.3, 95% CI 1.1-4.8, P = 0.03) were independent predictors of hip fractures. Adjusted OR for vertebral fracture was 1.2 (95% CI 1.0-1.5, P = 0.12). CONCLUSIONS: Aorta calcification seems to independently contribute to the development of osteoporosis in the proximal femur. Further studies are needed to clarify whether effective atherosclerosis prevention lowers hip fracture risk.     

Relative fracture risk in patients with diabetes mellitus, and the impact of insulin and oral antidiabetic medication on relative fracture risk

Aims/hypothesis We studied the association between fractures and type 1 and type 2 diabetes mellitus.Methods In this case-control study, all subjects diagnosed with a fracture (n=124,655) in Denmark served as cases, and for each case three control subjects (n=373,962) matched for sex and age were retrieved from the general population.Results Type 1 and type 2 diabetes were associated with an increased risk (1) of any fracture (odds ratio [OR]=1.3, 95% CI: 1.2–1.5 for type 1 diabetes and 1.2, 95% CI: 1.1–1.3 for type 2 diabetes after adjustment for confounders) and (2) of hip fractures (OR=1.7, 95% CI: 1.3–2.2 for type 1 diabetes, and 1.4, 95% CI: 1.2–1.6 for type 2 diabetes). Furthermore, type 2 diabetes was associated with a significant increase in forearm fractures (OR=1.2, 95% CI: 1.0–1.5), and type 1 diabetes was associated with an increased risk of spine fractures (OR=2.5, 95% CI: 1.3–4.6), whereas type 2 diabetes was not. Use of metformin and sulphonylureas was associated with a significantly decreased risk of any fracture, whereas a non-significant trend towards decreased risk of any fracture was associated with the use of insulin. Except for a decrease in hip fractures with use of sulphonylureas, no change in fracture risk in the hip, spine or forearm was associated with the use of insulin or oral antidiabetic drugs.Conclusions/interpretation Type 1 and type 2 diabetes are associated with an increased risk of any fracture and hip fractures. The use of drugs to control diabetes may reduce the association between diabetes and fractures.     

Prevalence of and risk factors for low bone mineral density and vertebral fractures in patients with systemic lupus erythematosus

OBJECTIVE: To examine the prevalence of and risk factors for low bone mineral density (BMD) and vertebral fractures in patients with systemic lupus erythematosus (SLE). METHODS: We studied 107 SLE patients. Demographic and clinical data were collected, and radiographs of the thoracic and lumbar spine and BMD measurements by dual x-ray absorptiometry were performed. Vertebral deformities were scored according to the method of Genant et al: fractures were defined as a reduction of > or = 20% of the vertebral body height. Osteoporosis was defined as a T score less than -2.5 SD and osteopenia as a T score less than -1.0 SD in at least 1 region of measurement. RESULTS: Osteopenia was present in 39% of the patients and osteoporosis in 4% (93% female; mean age 41.1 years). In multiple regression analysis, low BMD in the spine was associated with a low body mass index (BMI), postmenopausal status, and 25-hydroxyvitamin D deficiency. Low BMD in the hip was associated with low BMI and postmenopausal status. At least 1 vertebral fracture was detected in 20% of the patients. Vertebral fractures were associated with ever use of intravenous methylprednisolone and male sex. CONCLUSION: Risk factors for low BMD in SLE patients are low BMI, postmenopausal status, and vitamin D deficiency. While osteoporosis defined as a low T score was found in only 4% of the patients, osteoporotic vertebral fractures were detected in 20%. The high prevalence of low BMD and vertebral fractures implies that more attention must be paid to the prevention and treatment of osteoporosis and fractures in SLE.     

Prevalence of vertebral deformities and symptomatic vertebral fractures in corticosteroid treated patients with rheumatoid arthritis.

OBJECTIVE: This study was designed to determine whether the prevalence of vertebral deformities in patients with rheumatoid arthritis (RA) treated with corticosteroids (Cs) is higher than in RA patients not receiving Cs therapy. PATIENTS AND METHODS: This multicentre cross-sectional study included 205 patients with RA who were receiving Cs orally on a daily basis and 205 patients with RA who did not receive Cs, matched for sex and age. Vertebral deformities were scored according to the Kleerekoper method. RESULTS: Vertebral deformities were found in 52 (25%) patients on Cs and in 26 (13%) patients not on Cs. Sixteen (8%) patients in the group on Cs had experienced clinical manifestations of an acute vertebral fracture in the past vs only three patients (1.5%) among those not on Cs. The use of Cs tended to increase the risk of developing a vertebral deformity [adjusted odds ratio (OR) 1.56, 95% confidence interval (CI) 0.81-2.99] and symptomatic vertebral fracture (adjusted OR 1.42, 95% CI 0.24-8.32). Each 1-mg increase in the current daily Cs dose increased the risk of a vertebral deformity (adjusted OR 1.05, 95% CI 0.98-1.13) and of a symptomatic vertebral fracture (adjusted OR 1.05, 95% CI 0.89-1.24). CONCLUSION: There is a higher prevalence of vertebral deformities and clinical manifestations of vertebral fractures in patients on Cs than in those not on Cs. Our data indicate that the use of Cs and each 1-mg increase in the current daily Cs dose may increase the risk of development of a vertebral deformity and symptomatic vertebral fracture in patients with RA.     

2型糖尿病患者血戊糖素水平与椎体骨折的研究

目的 探讨2型糖尿病患者骨密度的变化,研究血戊糖素与2型糖尿病患者椎体骨折的相关性.方法 选取100例2型糖尿病患者作为糖尿病组,另选取70名非糖尿病者作为对照组,受试者年龄均大于60岁.所有受试者均行胸腰椎X线检查以确定椎体骨折,同时检测受试者的腰椎骨密度,抽取空腹静脉血查戊糖素及骨代谢指标.判断两组腰椎骨密度、椎体骨折发生率的差异,同时分析血戊糖素水平与椎体骨折的相关性.结果 两组的年龄、体重指数、骨代谢指标、骨密度水平差异均无统计学意义(P均＞0.05).糖尿病组戊糖素水平及椎体骨折的发生率均较对照组明显升高(t =5.764,x2=6.286,P均＜0.05).相关性分析提示,椎体骨折与戊糖素水平呈正相关(r=0.236,P=0.018).回归分析显示,椎体骨折与戊糖素水平独立相关(OR=1.008,95％ CI:1.001～ 1.015,P=0.032).结论 血戊糖素可能作为老年2型糖尿病患者椎体骨折风险评估的指标.     

Prevalent vertebral fractures among children initiating glucocorticoid therapy for the treatment of rheumatic disorders

Objective

Vertebral fractures are an under‐recognized problem in children with inflammatory disorders. We studied spine health among 134 children (87 girls) with rheumatic conditions (median age 10 years) within 30 days of initiating glucocorticoid therapy.

Methods

Children were categorized as follows: juvenile dermatomyositis (n = 30), juvenile idiopathic arthritis (n = 28), systemic lupus erythematosus and related conditions (n = 26), systemic arthritis (n = 22), systemic vasculitis (n = 16), and other conditions (n = 12). Thoracolumbar spine radiograph and dual x‐ray absorptiometry for lumbar spine (L‐spine) areal bone mineral density (BMD) were performed within 30 days of glucocorticoid initiation. Genant semiquantitative grading was used for vertebral morphometry. Second metacarpal morphometry was carried out on a hand radiograph. Clinical factors including disease and physical activity, calcium and vitamin D intake, cumulative glucocorticoid dose, underlying diagnosis, L‐spine BMD Z score, and back pain were analyzed for association with vertebral fracture.

Results

Thirteen vertebral fractures were noted in 9 children (7%). Of these, 6 patients had a single vertebral fracture and 3 had 2–3 fractures. Fractures were clustered in the mid‐thoracic region (69%). Three vertebral fractures (23%) were moderate (grade 2); the others were mild (grade 1). For the entire cohort, mean ± SD L‐spine BMD Z score was significantly different from zero (?0.55 ± 1.2, P < 0.001) despite a mean height Z score that was similar to the healthy average (0.02 ± 1.0, P = 0.825). Back pain was highly associated with increased odds for fracture (odds ratio 10.6 [95% confidence interval 2.1–53.8], P = 0.004).

Conclusion

In pediatric rheumatic conditions, vertebral fractures can be present prior to prolonged glucocorticoid exposure.

     

Risk of fracture in women with type 2 diabetes: the Women's Health Initiative Observational Study

CONTEXT: Some but not all studies have shown higher rates of fracture in individuals with type 2 diabetes. OBJECTIVE: The objective of the study was to determine the risk of fracture in postmenopausal women with type 2 diabetes and determine whether risk varies by fracture site, ethnicity, and baseline bone density. DESIGN, SETTING, AND PARTICIPANTS: Women with clinically diagnosed type 2 diabetes at baseline in the Women's Health Initiative Observational Cohort, a prospective study of postmenopausal women (n = 93,676), were compared with women without diagnosed diabetes and risk of fracture overall and at specific sites determined. MAIN OUTCOME MEASURES: All fractures and specific sites separately (hip/pelvis/upper leg; lower leg/ankle/knee; foot; upper arm/shoulder/elbow; lower arm/wrist/hand; spine/tailbone) were measured. Bone mineral density (BMD) in a subset also was measured. RESULTS: The overall risk of fracture after 7 yr of follow-up was higher in women with diabetes at baseline after controlling for multiple risk factors including frequency of falls [adjusted relative risk (RR) 1.20, 95% confidence interval (CI) 1.11-1.30]. In a subsample of women with baseline BMD scores, women with diabetes had greater hip and spine BMD. The elevated fracture risk was found at multiple sites (hip/pelvis/upper leg; foot; spine/tailbone) among black women (RR 1.33, 95% CI 1.00-1.75) and women with increased baseline bone density (RR 1.26, 95% CI 0.96-1.66). CONCLUSION: Women with type 2 diabetes are at increased risk for fractures. This risk is also seen among black and non-Hispanic white women after adjustment for multiple risk factors including frequent falls and increased BMD (in a subset).     

Relationship between bone mineral density changes and fracture risk reduction in patients treated with strontium ranelate

OBJECTIVE: Our objective was to analyze the relationship between bone mineral density (BMD) changes and fracture incidence during 3-yr treatment with strontium ranelate. PATIENTS: Women from the strontium ranelate arm of the Spinal Osteoporosis Therapeutic Intervention study and the TReatment Of Peripheral OSteoporosis study were evaluated. OUTCOME MEASURES: The outcome measures included BMD at the lumbar spine, femoral neck, and total proximal femur assessed at baseline and after a follow-up of 1 and 3 yr; semiquantitative visual assessment of vertebral fractures; and nonvertebral fractures based on written documentation. RESULTS: After 3 yr of strontium ranelate treatment, each percentage point increase in femoral neck and total proximal femur BMD was associated with a 3% (95% adjusted confidence interval, 1-5%) and 2% (1-4%) reduction in risk of a new vertebral fracture, respectively. The 3-yr changes in femoral neck and total proximal femur BMD explained 76% and 74%, respectively, of the reduction in vertebral fractures observed during the treatment. Three-year changes in spine BMD were not statistically associated with the incidence of new vertebral fracture (P = 0.10). No significant associations were found between 3-yr changes in BMD and incidence of new nonvertebral fractures, but a trend was found for femoral neck BMD (P = 0.09) and for total proximal femur BMD (P = 0.07). An increase in femoral neck BMD after 1 yr was significantly associated with the reduction in incidence of new vertebral fractures observed after 3 yr (P = 0.04). CONCLUSION: During 3-yr strontium ranelate treatment, an increase in femoral neck BMD was associated with a proportional reduction in vertebral fracture incidence.     

Osteoporotic fractures and heart failure in the community

Purpose

Recent findings suggest a role for heart failure in the etiology of osteoporotic fractures, yet the temporal sequence of occurrence of the 2 conditions needs clarification.

Methods

Using the Rochester Epidemiology Project, the authors conducted a 2-phase study: a case-control study compared osteoporotic fracture history among Olmsted County, Minnesota, residents newly diagnosed with heart failure in 1979-2002 with age- and sex-matched community controls without heart failure (961 pairs; mean age 76 years; 54% women). Both groups were then followed to July 2009 to evaluate their subsequent fracture risk in a cohort study.

Results

Prior fractures were more frequent in heart failure cases than controls (23.1% vs. 18.8%, P = .02). The adjusted odds ratio (OR) for heart failure associated with prior fracture was 1.39 (95% confidence interval [CI], 1.07-1.81), mainly driven by hip fractures (OR 1.82; 95% CI, 1.25-2.66) with little or no association with other fractures. Over a mean follow-up of 7.5 years, 444 individuals developed subsequent osteoporotic fractures. The adjusted fracture risk was marginally elevated in heart failure patients compared with controls (hazard ratio [HR] 1.32; 95% CI, 0.98-1.79), again largely attributable to hip fractures (HR 1.58; 95% CI, 1.03-2.41).

Conclusions

In this community, the association with fracture risk was about as strong before as after the diagnosis of heart failure and was nearly entirely attributable to hip fractures. Additional work is needed to identify common underlying mechanisms for heart failure and hip fracture, which may define prevention opportunities.