International variation in the incidence of hip fractures: cross-national project on osteoporosis for the World Health Organization Program for Research on Aging

Vitamin D Binding Protein and Postsurgical Outcomes and Tissue Injury Markers After Hip Fracture: A Prospective Study

CONTEXT

Hip fracture is a serious injury that can lead to increased morbidity and mortality. Vitamin D binding protein (DBP) is a potential prognostic indicator of outcomes since it is important for actin scavenging and inflammation after tissue injury.

OBJECTIVE

To determine whether circulating DBP is associated with mobility or mortality after hip fracture and its association with acute tissue injury markers.

METHODS

Post hoc analysis of a multisite North American prospective study of 260 patients with hip fracture; mobility assessed at 30 and 60 days and mortality at 60 days after repair surgery. Biochemical markers were measured before, and 2 to 4 days after surgery. Tissue injury markers were measured in 100 randomly selected patients and controls. The primary outcome was mobility and mortality by DBP tertiles. Secondary outcomes were assessment of pre- and postoperative biomarkers.

RESULTS

Among all patients (81 ± 9 years, BMI 25 ± 4 kg/m2; 72% female), the highest DBP tertile had greater mobility at 30 (OR: 2.66; 95% CI: 1.43, 4.92; P = .002) and 60 days (OR: 2.31; 95% CI: 1.17, 4.54; P = .014) and reduced mortality (OR: 0.18; 95% CI: 0.04, 0.86; P = .032) compared with the lowest DBP tertile (<28.0 mg/dL). Total 25-hydroxyvitamin-D did not differ between tertiles (22.0 ± 9.5 ng/mL). Circulating DBP and gelsolin were lower and interleukin-6, C-reactive protein, and F-actin were higher (P < .01) in patients vs controls, and worsened (P < .01) after surgery.

CONCLUSION

High circulating DBP concentrations are associated with better mobility and reduced mortality after hip fracture surgery. The role of DBP as an acute phase reactant to tissue injury and clinical outcomes should be addressed in future study.

A new FRAX model for Brazil

Fracture probabilities derived from the original FRAX model for Brazil were compared to those from an updated model based on more recent regional estimates of the incidence of hip fracture. Fracture probabilities were consistently lower in the updated FRAX model. Despite large differences between models, differences in the rank order of fracture probabilities were minimal.

OBJECTIVE

Recent epidemiological data indicate that the risk of hip fracture in Brazil is lower than that used to create the original FRAX model. This paper describes the epidemiology of hip fracture in Brazil and the synthesis of an updated FRAX model with the aim of comparing this new model with the original model.

METHODS

Hip fracture rates from three cities in three regions were combined, weighted by the population of each region. For other major fractures, incidence rates for Brazil were estimated using Swedish ratios for hip to other major osteoporotic fracture (humerus, forearm or clinical vertebral fractures). Mortality estimates were taken from the UN.

RESULTS

Compared to the original FRAX model, the updated model gave lower 10-year fracture probabilities in men and women at all ages. Notwithstanding, there was a very close correlation in fracture probabilities between the original and updated models (r > 0.99) so that the revisions had little impact on the rank order of risk.

CONCLUSION

The disparities between the original and updated FRAX models indicate the importance of updating country-specific FRAX models with the advent of significant changes in fracture epidemiology.

Epidemiology of Hip Fractures Due to Falls

Background and Objectives: The epidemiological pattern of the hip fracture burden attributable to falls in Central European countries is still insufficiently known. The aim of this study was to assess the regional and national trends of hip fractures due to falls in Central Europe from 1990 to 2019. Materials and Methods: Using the Global Burden of Disease (GBD) 2019 study, this descriptive epidemiological study presents trends in incidence of and Years Lived with Disability (YLDs) from hip fractures due to falls in the region of Central Europe. All estimates (age- and sex-specific rates, and age-standardized rates) were expressed per 100,000. A joinpoint regression analysis was used to assess trends: the average annual percent change (AAPC) with a corresponding 95% confidence interval (95% CI) was calculated. Results: Among all new cases of hip fracture in the population as a whole in Central Europe in 2019, 3.9% in males and 7.0% in females were attributable to falls, while the share of hip fractures due to falls in the population aged 70 and over was 16.9% in males and 20.0% in females. About 400,000 new cases of hip fracture due to falls occurred in the Central European region in 2019 (220,000 among males and 160,000 among females), resulting in 55,000 YLDs (32,000 in females and 22,000 in males). About one-third of all new cases (59,326 in males and 72,790 in females) and YLDs (8585 in males, and 10,622 in females) of hip fractures due to falls were recorded in Poland. From 1990 to 2019, the age-standardized incidence rates of hip fracture due to falls showed a decreasing tendency in females (AAPC = -1.1%), and an increasing tendency in males (AAPC = 0.1%). Both in males and females, YLDs rates of hip fracture due to falls in the Central European region decreased (AAPC = -1.6% and AAPC = -2.4%, respectively). Conclusions: Hip fracture due to falls represents an important health issue in the Central European region, although incidences and YLDs declined in the most recent decades. However, further efforts to reduce the burden of hip fractures attributed to falls are needed.

Resting heart rate, self-reported physical activity in middle age, and long-term risk of hip fracture. A NOREPOS cohort study of 367,386 men and women

Enhanced knowledge regarding modifiable risk factors for hip fractures are warranted. We aimed to study the associations between two indicators of physical fitness (resting heart rate and level of physical activity) in middle-aged individuals, and the risk of hip fractures during the subsequent three decades. Data on objectively measured resting heart rate and self-reported leisure time physical activity from a national health survey (1985-1999) was linked to a database including all hip fractures treated in Norwegian hospitals from 1994 through 2018. We calculated hazard ratios (HR) with 95 % confidence intervals (95 % CI) for hip fractures according to categories of resting heart rate (mean of two repeated measures), and leisure time physical activity level in adjusted Cox proportional hazard models. In total, 367,386 persons (52 % women) aged 40 to 45 years were included, of whom 5482 persons sustained a hip fracture during a mean follow-up of 24.8 years. Higher resting heart rate was associated with higher hip fracture risk. Men with a resting heart rate above 80 bpm, who also reported low levels of physical activity, had a HR of 1.82 (95 % CI 1.49-2.22) for hip fracture compared to men with a resting heart rate below 70 bpm who reported high levels of physical activity. The same measure of association for women was 1.62 (95 % CI 1.28-2.06). Physical fitness measured by low resting heart rate in middle age, and a high physical activity level were associated with a lower long-term risk of hip fractures in both men and women.

Surgical Aspects of Primary Hyperparathyroidism

Parathyroidectomy (PTX) is the treatment of choice for symptomatic primary hyperparathyroidism (PHPT). It is also the treatment of choice in asymptomatic PHPT with evidence for target organ involvement. This review updates surgical aspects of PHPT and proposes the following definitions based on international expert consensus: selective PTX (and reasons for conversion to an extended procedure), bilateral neck exploration for non-localized or multigland disease, subtotal PTX, total PTX with immediate or delayed autotransplantation, and transcervical thymectomy and extended en bloc PTX for parathyroid carcinoma. The systematic literature reviews discussed covered (i) the use of intraoperative PTH (ioPTH) for localized single-gland disease and (ii) the management of low BMD after PTX. Updates based on prospective observational studies are presented concerning PTX for multigland disease and hereditary PHPT syndromes, histopathology, intraoperative adjuncts, localization techniques, perioperative management, "reoperative" surgery and volume/outcome data. Postoperative complications are few and uncommon (<3%) in centers performing over 40 PTXs per year. This review is the first global consensus about surgery in PHPT and reflects the current practice in leading endocrine surgery units worldwide. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

The Role of Soy Isoflavones in the Prevention of Bone Loss in Postmenopausal Women: A Systematic Review with Meta-Analysis of Randomized Controlled Trials

The aim of the report was to determine the effects of soy isoflavones on lumbar spine, femoral neck, and total hip bone mineral density (BMD) in menopausal women. MEDLINE (PubMed), EMBASE, and Cochrane Library databases were searched for articles published in English during 1995–2019. Studies were identified and reviewed for inclusion and exclusion eligibility. Weighted mean differences (WMD) were calculated for each study and were pooled by using the random effects model. Eighteen randomized controlled trials were selected for meta-analysis. Different types of soy phytoestrogens, i.e., genistein extracts, soy isoflavones extracts, soy protein isolate, and foods containing diverse amounts of isoflavones were used in the studies. The analysis showed that daily intake of 106 (range, 40–300) mg of isoflavones for 6–24 months moderately but statistically significantly positively affects BMD, compared with controls: lumbar spine WMD = 1.63 (95% CI: 0.51 to 2.75)%, p = 0004; femoral neck WMD = 1.87 (95% CI: 0.14 to 3.60)%, p = 0.034; and total hip WMD = 0.39 (95% CI: 0.08 to 0.69)%, p = 0.013. Subgroups analyses indicated that the varying effects of isoflavones on BMD across the trials might be associated with intervention duration, racial diversity (Caucasian, Asian), time after menopause, form of supplements (especially genistein), and dose of isoflavones. Our review and meta-analysis suggest that soy isoflavones are effective in slowing down bone loss after menopause.

An updated hip fracture incidence rate for Brazil: the Brazilian Validation Osteoporosis Study (BRAVOS)

Hip fracture incidence rates in three representative geographic areas in Brazil over a period of 2 years (2010-2012) were assessed for the first time. Estimated incidence rates varied regionally, and markedly differed from those previously reported. Thus, national guidelines as well as FRAX Brazil should be revised in light of this new data.

PURPOSE

To determine the annual incidence of hip fractures in individuals aged 50 years and over, living in 3 cities located in different regions of the country. To investigate the age, gender, and regional differences in fracture rates. Based on the obtained data, to estimate the national incidence of hip fractures resulting from osteoporosis, in order to improve prevention strategies.

METHODS

Retrospective, observational study including all patients aged ≥ 50 years admitted in hospitals because of a hip fracture in three cities (Belem, Joinville, and Vitoria) from representative geographic areas in Brazil from 2010 to 2012. Data were obtained from medical records in those cities. We analyzed incidence rates (crude and age- and gender-standardized rates) for hip fractures.

RESULTS

There were 1025 (310 in men and 715 in women) hip fractures in the over 50-year-old merged population from the three cities. The crude incidence rate for hip fracture was 103.3/100,000 (95% confidence interval [CI = 97.0; 109.7), in men 77.4/100,000 (95% CI = 68.8; 86.0), and in women 125.2/100,000 (95% CI = 116.0; 134.4). Incidence standardized for age and gender was 105.9 cases per 100,000 persons per year (95% CI = 99.4; 112.4); 78.5 cases per 100,000 (95% CI = 69.8; 87.3) in men and 130.6 cases 100,000 in women (95% CI = 121.0, 140.2) per year. Belem, located in the equatorial region (latitude 1° 27' S), had significantly lower crude and age-adjusted incidence than Joinville (latitude 26° 18' S) and Vitoria (latitude 20° 19' S), which were no different from each other. The incidence of fractures increased exponentially with age, and women had about twice the risk of fractures than men.

CONCLUSIONS

Hip fracture mainly affects elderly women and presents great variability in incidence between the different regions in Brazil. The incidence of hip fractures in Brazil differed markedly from that reported previously, so that national guidelines and the FRAX model for Brazil should be revised.

Secular trends in hip fractures in adults over 50 years old: a retrospective analysis of hospital admissions to the Brazilian Public Health System from 2004 to 2013

This was a retrospective observational study to determine the secular trends in osteoporosis hip fractures in Brazil from 2004 to 2013. The fracture rates were stable for both sexes, and there was not a secular trend. Fractures were predominant in the South and Southeast Regions. The hip fracture rate was lower in this study than in other studies. These regional differences may be considered in the FRAX Brazil calibration.

PURPOSE

Hip fractures are well-known osteoporotic fractures with high mortality and morbidity. Epidemiological studies in Brazil on hip fractures are scarce, and the great majority have been performed in small populations from a few cities. None of these studies has analyzed the long-term hip fracture secular trends, which are important data for the promotion of public health actions.

METHODS

This was a retrospective observational study with a secular trend analysis in patients over 50 years old who were admitted to the Brazilian Public Health System from 2004 to 2013. We collected hospitalization data according to the ICD-10 for low-trauma hip fractures. The fracture rate was calculated when the patients were stratified by sex, age, and geographic region, and linear regression analysis was performed to evaluate the secular trends.

RESULTS

The hip fracture rate per 100,000 inhabitants was 59.69; the rate was 74.72 in females and 42.95 in males. The fracture rates were higher in the South and Southeast Regions and steadily increased with age, and the average ratio of women-to-men was 1.74. No secular trend was detected in the overall population. Surprisingly, the secular trend only increased in the South region from 2004 to 2013, and the secular trends were stable in the other regions.

CONCLUSION

Although the secular trend was similar to some worldwide studies, the hip fracture rate was lower than that previously observed in regional studies in Brazil. These regional differences may be considered in the FRAX Brazil calibration.

Morphometric vertebral fracture risk in women with postsurgical hypoparathyroidism

INTRODUCTION

Hypoparathyroidism (HP) is a rare endocrine disease and there are little data available on the risk of fragility fractures in these patients. PTH deficiency results in a positive bone balance with higher bone mass in all skeletal sites. However, whether these structural and dynamic skeletal changes have a negative impact on the fracture risk, it is not known.

METHODS

Aiming to investigate the risk of insufficiency vertebral fractures in HP, defined using morphometric criteria, a consecutive sampling of 44 women with chronic postsurgical HP was compared to a control group of 44 adult healthy women, matched by age with patients. Vertebral fractures were analyzed by the semiquantitative Genant's method followed by quantitative vertebral morphometry.

RESULTS

Morphometric vertebral fractures were identified in 5/44 (11.4%) patients and in 3/44 (6.8%) controls (p=0.731). Most fractures were classified as Genant II and III grades in HP patients, whereas most were Genant I in controls. A logistic regression multivariate analysis was conducted in which age, BMI and parathyroid status were the independent variables, and morphometric vertebral fracture was the dependent variable, but none of these factors was a significant predictor of fracture in this population (OR 1.01, 95% CI 0.96-1.07, p=0.634 for age; OR 2.24, 95%CI 0.47-10.50, p=0.306 for the presence/absence of HP and OR 0.92, 95% CI 0.76-1.10, p=0.369 for BMI).

CONCLUSION

The results of this study cannot ensure a higher risk of fragility vertebral fractures in postsurgical HP patients. Instead, we only observed higher Genant grade classification of the deformed vertebrae in our sample.

Incidence of fractures in women in the post-menopause: a cohort study in primary care in southern Brazil

The incidences of total fracture, major fracture, and hip fractures in primary care in Southern Brazil were 22.3, 15.0, and 3.3 per 1000 person/year. The FRAX algorithm showed an adequate discriminatory capacity for the identification of these fractures.

OBEJECTIVE

Few studies are evaluating the incidence of fractures in Latin America and Brazil. This study aimed to estimate the incidence of bone fractures in postmenopausal women seen in primary care and evaluate the FRAX algorithm's performance in these women.

METHODS

A cohort study was carried out in the municipality of Santa Maria, Southern Brazil. Postmenopausal women aged 55 years and over who attended primary health care were included. The recruitment period was from March 1 to August 31, 2013, and the participants were followed for 5 years. The fracture risk was calculated using the FRAX algorithm. The reported incident fractures were confirmed by imaging studies or surgical reports.

RESULTS

Of the 1057 women recruited for the study, 854 were followed. They contributed to 2732 person/year. The mean follow-up time was 3.2 years (SD 1.05). The incidences of total fractures, major fractures, and hip fractures were 22.3, 15.0, and 3.3 per 1000 person/year. The most frequent fracture sites were the wrist, shoulder, and ribs. The fracture predictors were rheumatoid arthritis, previous fracture, and the use of glucocorticoids. The discriminatory capacity of incident fractures calculated by FRAX without the inclusion of BMD was AUC 0.730 (95% CI 0.570, 0.890) for hip fracture and AUC 0.691 (95% CI 0.598, 0.784) for major fractures.

CONCLUSION

The FRAX algorithm showed an adequate discriminatory capacity to identify incident fractures in primary care in our study. The incidence of fractures found in our study appears to be lower than that reported in North America and Europe.

A comparison between Asians and Caucasians in the dimensions of the femoral isthmus based on a 3D-CT analysis of 1189 adult femurs

INTRODUCTION

For successful intramedullary implant placement at the femur, such as nailing in unstable proximal femur fractures, the use of an implant that at least reaches or exceeds the femoral isthmus and yields sufficient thickness is recommended. A number of complications after intramedullary femoral nailing have been reported, particularly in Asians. To understand the anatomical features of the proximal femur and their ethnic differences, we aimed to accurately calculate the femoral isthmus dimensions and proximal distance of Asians and Caucasians.

METHODS

In total, 1189 Asian and Caucasian segmented 3D CT data sets of femurs were analyzed. The individual femoral isthmus diameter was precisely computed to investigate whether gender, femur length, age, ethnicity or body mass index have an influence on isthmus diameters.

RESULTS

The mean isthmus diameter of all femurs was 10.71 ± 2.2 mm. A significantly larger diameter was found in Asians when compared to Caucasians (p < 0.001). Age was a strong predictor of the isthmus diameter variability in females (p < 0.001, adjusted r² = 0.299). With every year of life, the isthmus showed a widening of 0.08 mm in women. A Matched Pair Analysis of 150 female femurs showed a significant difference between isthmus diameter in Asian and Caucasian femurs (p = 0.05). In 50% of the cases the isthmus was found in a range of 2.4 cm between 16.9 and 19.3 cm distal to the tip of the greater trochanter. The female Asian femur differs from Caucasians as it is wider at the isthmus.

CONCLUSIONS

In absolute values, the proximal isthmus distance did not show much variation but is more proximal in Asians. The detailed data presented may be helpful in the development of future implant designs. The length and thickness of future standard implants may be considered based on the findings.

Incidence and risk factors for osteoporotic non-vertebral fracture in low-income community-dwelling elderly: a population-based prospective cohort study in Brazil. The São Paulo Ageing and Health (SPAH) study

We ascertained the incidence of non-vertebral fracture in a low-income Brazilian elderly cohort. To the best of our knowledge, this is the first population-based study to demonstrate the frequency of non-vertebral fracture in elderly Latin Americans. Age, prior fracture, and bone mineral density (BMD) at hip were predictors of fracture.

INTRODUCTION

No data on incidence of osteoporotic non-vertebral fracture have been reported in low-income countries where the population's aging has been faster. Even in developed countries, currently available prospective data on major fracture rates beyond hip are scarce. The aim of this study is to describe the incidence and risk factors for non-vertebral fracture in a longitudinal prospective Brazilian population-based elderly cohort.

METHODS

Seven hundred seven older adults (449 women, 258 men) were evaluated at baseline and after a mean follow-up of 4.3 ± 0.8 years. Clinical questionnaire, bone mineral density (BMD), and laboratory tests were performed at baseline. New non-vertebral fracture (hip, proximal humerus, rib, forearm) was determined during the follow-up. Multivariate Poisson regression models were used to identify independent predictors of fracture.

RESULTS

The age-standardized incidence of non-vertebral fracture was 1562.3/100,000 (1085.7-2248.1/100,000) person-years (pyr) in women and 632.8/100,000 (301.7-1327.3/100,000) in men. Concerning to hip fractures, the incidence was 421.2/100,000 (210.7-842.3/100,000) pyr in women and 89.9/100,000 (12.7-638.5/100,000) in men. In a multivariate analysis, age (RR 2.07, 95% CI 1.13-3.82, p = 0.019, each 10-year increase), prior non-vertebral fracture (RR 3.08, 95% CI 1.36-6.95, p = 0.007), and total hip BMD (RR 1.68, 95% CI 1.11-2.56, p = 0.015, each 1 SD decrease) were predictors of new non-vertebral fracture. In men, fitting a model of risk factors for fracture was prevented by the limited number of events in male sample.

CONCLUSION

This is the first population-based study to ascertain the incidence of major non-vertebral fractures in elderly Latin Americans, confirming the high frequency of the disorder. Age, prior fracture, and hip BMD were predictors of the short-term incidence of fracture.

Delayed Presentation of Patients with Hip Fractures during the COVID-19 "Stay-at-Home" Order in the Southmost Region of the United States

To evaluate the effects of COVID-19 and stay-at-home orders in traumatic hip fractures presentation, we conducted a retrospective chart review cohort study from March 13 to June 13 in 2020 compared to 2019 from a single-hospital Trauma Level 2 Center. Males and females, 18 years of age and older presenting with a diagnosis of displaced or nondisplaced, intracapsular, or extracapsular hip fracture, underwent standard of care—comparative analysis of the patient's characteristics and clinical outcomes. The primary study outcomes included age, sex, ethnicity, and body mass index, the onset of injury, date of arrival, payer, the primary type of injury and comorbidities, mechanism of injury, treatment received, postoperative complications, days in an intensive care unit (ICU), discharge disposition, pre- and postinjury functional status, and COVID-19 test. Age, sex, ethnicity, and body mass index were similar in the patients in 2019 compared to 2020. The patients' average age was 76 years old, 80% reported Hispanic ethnicity, and 63% of the patients were females. Most injuries (90%) occurred due to falls. On average, patients in 2020 presented 4.8 days after the injury onset as compared to 0.7 days in 2019 (p < 0.05). There was an increase in displaced fractures in 2019 compared to 2020 and an increase in patients' disposition into rehabilitation facilities compared to skilled nursing facilities. Despite the delay in presentation, length of stay, days in the ICU, or functional outcomes of the patients were not affected. Although the patients showed a delayed presentation after hip fracture, this does not appear to significantly interfere with the short-term or the 6-month mortality outcomes of the patients, suggesting the possibility of guided delayed care during times of national emergency and increased strain in hospital resources.

Burden of fractures in France: incidence and severity by age, gender, and site in 2016

PURPOSE

Fractures are common events, but the exact incidence and severity of fractures have not been clearly determined for most anatomical sites. We estimated the incidence and severity of fractures in France regardless of the anatomical site.

METHODS

Observational cross-sectional study in France in 2016 based on the national health data system. All incident fractures in patients 20 years and older were included. We determined the anatomical fracture site (12 sites) and the severity using a 4-point scale (outpatient care, hospitalization, surgery, and in-hospital death).

RESULTS

We identified 562,094 incident fractures, predominantly occurring in women (319,858: 56.9%); with a mean age of 63.6 years, and an exponential increase after the age of 70 years. Distal upper limb (172,591: 30.7%), distal lower limb (84,602: 15.1%), and femoral neck (78,766: 14.0%) accounted for more than one-half of all fractures. Sex and age of onset distributions varied widely according to fracture sites, with earlier onset for distal lower limb fractures (mean age: 54.2 years) and distal upper limb fractures (mean age: 55.2 years) with a men predominance for skull fractures. Only 105,165 (18.7%) fractures were treated on an outpatient basis; 11,913 (2.1%) in-hospital deaths occurred in patients with a mean age of 79.5 years. High mortality was observed for skull (12.9%), rib (4.9%), and femoral fractures (femoral neck 4.3% and proximal lower limb 4.2%).

CONCLUSION

We estimated the incidence of fractures in France by sex and anatomical site. We also showed that fractures remain common and serious life events, especially in older people.

A scorecard for osteoporosis in four Latin American countries: Brazil, Mexico, Colombia, and Argentina

The state of osteoporosis care in Latin America is not well known. The results of our scorecard indicate an urgent need to improve policy frameworks, service provision, and service uptake for osteoporosis in Brazil, Mexico, Colombia, and Argentina. The scorecard serves as an important marker to measure future progress.

PURPOSE

We developed a scorecard to summarize key indicators of the burden of osteoporosis and its management in Brazil, Mexico, Colombia, and Argentina. The goal of the scorecard is to reduce the risk of osteoporotic fractures by promoting healthcare policies that will improve patient access to timely diagnosis and treatment.

METHODS

We conducted a systematic review of osteoporosis. We also interviewed several key opinion leaders to gather information on government policy, access to fracture risk assessments, and access to medications. We then leveraged a peer-reviewed template, initially applied to 27 European countries, to synthesize the information into a scorecard for Latin America. We presented information according to four main categories: burden of disease, policy framework, service provision, and service uptake and used a traffic light color coding system to indicate high, intermediate, and low risk.

RESULTS

The systematic review included 108 references, of which 49 were specific to Brazil. The number of osteoporotic fractures in Brazil, Mexico, Colombia, and Argentina was forecasted to increase substantially (34% to 76% in each country) from 2015 to 2030. In general, policy frameworks, service provision, and service uptake were not structured to support current patients with osteoporosis and did not account for the future increases in fracture burden. Across all four countries, there was inadequate access to programs for secondary fracture prevention and only a small minority of patients received treatment for osteoporosis.

CONCLUSIONS

Osteoporosis management, including the rate of post-fracture care, is very poor in Brazil, Mexico, Colombia, and Argentina and needs to be strengthened. Improvements in the rates of care are necessary to curb the debilitating impact of osteoporotic fractures on patients and health systems.

The Epidemiology of Fracture in Patients with Acute Ischemic Stroke in Korea

BACKGROUND

Patients who survive an acute phase of stroke are at risk of falls and fractures afterwards. However, it is largely unknown how frequent fractures occur in the Asian stroke population.

METHODS

Patients with acute (< 7 days) ischemic stroke who were hospitalized between January 2011 and November 2013 were identified from a prospective multicenter stroke registry in Korea, and were linked to the National Health Insurance Service claim database. The incidences of fractures were investigated during the first 4 years after index stroke. The cumulative incidence functions (CIFs) were estimated by the Gray's test for competing risk data. Fine and Gray model for competing risk data was applied for exploring risk factors of post-stroke fractures.

RESULTS

Among a total of 11,522 patients, 1,616 fracture events were identified: 712 spine fractures, 397 hip fractures and 714 other fractures. The CIFs of any fractures were 2.63% at 6 months, 4.43% at 1 year, 8.09% at 2 years and 13.00% at 4 years. Those of spine/hip fractures were 1.11%/0.61%, 1.88%/1.03%, 3.28%/1.86% and 5.79%/3.15%, respectively. Age by a 10-year increment (hazard ratio [HR], 1.23; 95% confidence interval [CI], 1.17-1.30), women (HR, 1.74; 95% CI, 1.54-1.97), previous fracture (HR, 1.72; 95% CI, 1.54-1.92) and osteoporosis (HR, 1.44; 95% CI, 1.27-1.63) were independent risk factors of post-stroke fracture.

CONCLUSION

The CIFs of fractures are about 8% at 2 years and 13% at 4 years after acute ischemic stroke in Korea. Older age, women, pre-stroke fracture and osteoporosis raised the risk of post-stroke fractures.

Incidence and excess mortality of hip fractures in a predominantly Caucasian population in the South of Brazil

INTRODUCTION

Osteoporosis is a very common disease, and data on its epidemiology is important for health care strategy implementation. Brazil is a developing country; its population is aging, leading to an expected increase in hip fractures and their undesirable consequences.

OBJECTIVE

Assess the incidence of osteoporotic hip fractures and subsequent mortality in Southern Brazil as part of a large epidemiological study aiming to reinforce the data for FRAX Brazil.

STUDY DESIGN

This study evaluated all admissions for fragility hip fractures between April 1, 2010, and March 31, 2012, in the city of Joinville, including both genders of patients 50 years old or older, which corresponded to 19.2% of the local population. Joinville was chosen because it is the third largest city in the south of Brazil, with a representative population predominantly composed of descendants of European immigrants.

RESULTS

There were 213 cases of hip fractures, predominantly in Caucasians (n = 204, 96.7%) whose mean age was 77.7, ± 10.5, of which 143 (67.1%) were women (79.5 ± 9.6 years) and 70 (32.9%) were men (74 ± 11.3 years). The annual incidence of hip fractures was 268.8 for women and 153.0 for men/100,000 inhabitants. In the 60 to 64-year group, the overall incidence was 92.1/100,000, with an age-related increase of 1410.1/100,000 in the 80 to 84-year group. The mortality rate during hospitalization was 7.5%, and 25% died during the 12 months following their fractures.

CONCLUSION

The incidence of hip fractures among the oldest in this predominantly Caucasian population living in Southern Brazil was similar to that of European populations from the northern hemisphere. The annual incidence of fragility hip fractures among people in their 80s was 59 times higher than that among people in their 50s. The mortality rate was 4.3 times higher in the first year after hip fracture than in the age-related local population.

Evaluation of clinical risk factors for osteoporosis and applicability of the FRAX tool in Joinville City, Southern Brazil

Clinical risk factors for fracture in Southern Brazil are similar to those used in Fracture Risk Assessment Tool (FRAX®). Age-dependent intervention thresholds had higher accuracy than a fixed cut-off point.

INTRODUCTION

Access to bone mineral density testing is wanted for a large part of the Brazilian population. The FRAX® has an option to calculate the risk of fracture without this costly evaluation but relies on the clinical risk factors (CRFs) identified in the source cohorts used to generate FRAX.

OBJECTIVE

The aims of this study were to determine whether the CRFs used in FRAX are also risk indicators for individuals in Southern Brazil and to evaluate possible intervention thresholds for treatment in Brazil.

METHODS

We determined the CRFs for hip fractures in women and men aged 50 years and more with a hip fracture and controls in Joinville, Southern Brazil (April 1, 2010, and March 31, 2012). For intervention thresholds, we determined the accuracy of using the fixed thresholds of National Osteoporosis Foundation (NOF), USA, compared with the age-dependent thresholds of the National Osteoporosis Guideline Group (NOGG), UK.

RESULTS

CRFs that were significant for hip fracture were very similar to FRAX, apart from chronic obstructive pulmonary disease and malabsorptive intestinal disease. FRAX based on the NOGG and NOF models had an accuracy of 64.2 and 58.7%, respectively.

CONCLUSION

CRFs used in FRAX® were similar to those in the Southern Brazil. The NOGG model seems to be more accurate to discriminate patients with increased fracture risk in this population compared to the NOF model, but not significantly.

Brazilian guidelines for the diagnosis and treatment of postmenopausal osteoporosis

Osteoporosis is the leading cause of fractures in the population older than 50 years. This silent disease affects primarily postmenopausal women and the elderly, and the morbidity and mortality rates are high. The main goal of treating osteoporosis is the prevention of fractures. The identification of populations at risk through early diagnosis and treatment is essential. The last Brazilian guideline for the treatment of postmenopausal osteoporosis was elaborated in 2002. Since then, new strategies for diagnosis and risk stratification have been developed, and drugs with novel action mechanisms have been added to the therapeutic arsenal. The Osteoporosis and Osteometabolic Diseases Committee of the Brazilian Society of Rheumatology, in conjunction with the Brazilian Medical Association and other Societies, has developed this update of the guidelines for the treatment of postmenopausal osteoporosis according to the best scientific evidence available. This update is intended for professionals in many medical and health specialties involved in the treatment of osteoporosis, for physicians in general and for health-related organizations.

Fat, Sugar, and Bone Health: A Complex Relationship

With people aging, osteoporosis is expected to increase notably. Nutritional status is a relatively easily-modified risk factor, associated with many chronic diseases, and is involved in obesity, diabetes, and coronary heart disease (CHD), along with osteoporosis. Nutrients, such as fats, sugars, and proteins, play a primary function in bone metabolism and maintaining bone health. In Western nations, diets are generally high in saturated fats, however, currently, the nutritional patterns dominating in China continue to be high in carbohydrates from starch, cereals, and sugars. Moreover, high fat or high sugar (fructose, glucose, or sucrose) impart a significant impact on bone structural integrity. Due to diet being modifiable, demonstrating the effects of nutrition on bone health can provide an approach for osteoporosis prevention. Most researchers have reported that a high-fat diet consumption is associated with bone mineral density (BMD) and, as bone strength diminishes, adverse microstructure changes occur in the cancellous bone compartment, which is involved with lipid metabolism modulation disorder and the alteration of the bone marrow environment, along with an increased inflammatory environment. Some studies, however, demonstrated that a high-fat diet contributes to achieving peak bone mass, along with microstructure, at a younger age. Contrary to these results, others have shown that a high-fructose diet consumption leads to stronger bones with a superior microarchitecture than those with the intake of a high-glucose diet and, at the same time, research indicated that a high-fat diet usually deteriorates cancellous bone parameters, and that the incorporation of fructose into a high-fat diet did not aggravate bone mass loss. High-fat/high-sucrose diets have shown both beneficial and detrimental influences on bone metabolism. Combined, these studies showed that nutrition exerts different effects on bone health. Thus, a better understanding of the regulation between dietary nutrition and bone health might provide a basis for the development of strategies to improve bone health by modifying nutritional components.

Bone mechanical properties and changes with osteoporosis

This review will define the role of collagen and within-bone heterogeneity and elaborate the importance of trabecular and cortical architecture with regard to their effect on the mechanical strength of bone. For each of these factors, the changes seen with osteoporosis and ageing will be described and how they can compromise strength and eventually lead to bone fragility.

Is the Swedish FRAX model appropriate for Swedish immigrants?

The incidence of hip fracture in Sweden is substantially lower in immigrants than in the population born in Sweden. Thus, the use of a FRAX® model in immigrants overestimates the risk of fracture, and the use of country of origin-specific models may be more appropriate.

INTRODUCTION

Age-specific fracture and mortality rates vary between countries so that FRAX tools are country-specific. In the case of immigrants, it is not known whether the model for the original or the new country is most appropriate. The aim of this study was to compare the incidence of hip fractures in foreign-born and Swedish-born individuals residing in Sweden.

METHODS

We studied the incidence of hip fracture in all men and women aged 50 years or more in Sweden between 1987 and 2002. The population comprised 2.8 million Swedish-born and 270,000 foreign-born individuals.

RESULTS

Incident hip fractures occurred in 239,842 Swedish-born and 12,563 foreign-born individuals. The hip fracture incidence rose with age for both groups and was higher for women than men amongst both Swedish-born and foreign-born individuals. The hip fracture incidence for the Swedish-born cohort was approximately twice that of immigrants. For example, at the age of 70 years, the annual hip fracture incidence (per 100,000) was 450 (95 % CI 446-454) for a Swedish-born woman and 239 (95 % CI 223-257) for a foreign-born woman at the time of immigration. The hip fracture incidence rose slowly with time from immigration (0.6 % per annum, 95 % CI 0.5-0.8 %) but remained significantly lower than for Swedish-born individuals even after 40 years of residence.

CONCLUSIONS

The incidence of hip fracture in Sweden is substantially lower in immigrants than in the population native to Sweden. Although there was a small rise in age- and sex-specific incidence after immigration, the incidence remained markedly lower than that observed in Swedish-born individuals. Thus, the use of a FRAX model for Sweden will overestimate the risk of fracture for foreign-born individuals living in Sweden.

Incidence of hip fracture in Brazil and the development of a FRAX model

The Brazilian FRAX model is described and used to determine intervention thresholds for the treatment of osteoporosis.

INTRODUCTION

A FRAX model for Brazil was released May 1, 2013. This paper describes the data used to develop the Brazilian FRAX(®) model, illustrates its features and develops intervention thresholds.

METHODS

Age- and sex-stratified hip fracture incidence rates were extracted from four regional estimates from the age of 40 years. For other major fractures, Brazilian incidence rates were estimated using Swedish ratios for hip to other major osteoporotic fracture (humerus, forearm or clinical vertebral fractures). Assessment and intervention thresholds were determined using the approach recommended by the National Osteoporosis Guideline Group (UK) applied to the Brazilian FRAX model.

RESULTS

Fracture incidence rates increased with increasing age: for hip fracture, incidence rates were higher amongst younger men than women but with a female preponderance from the age of 50 years. Ten-year probability of hip or major fracture was increased in patients with a clinical risk factor, lower BMI, female gender, a higher age and a decreased BMD T-score. Of the clinical risk factors, prior fracture accounted for the greatest increase in 10-year fracture probability at younger ages while a parental hip fracture history was the strongest risk factor at ages 80-90 years. Age-dependent probability-based intervention thresholds were developed equivalent to women with a prior fragility fracture.

CONCLUSIONS

The FRAX tool is the first to provide a country-specific fracture prediction model for Brazil. It is based on the original FRAX methodology, which has been externally validated in several independent cohorts. Despite some limitations, the strengths make the Brazilian FRAX tool a good candidate for implementation into clinical practice.

WOMAC and SF-36: instruments for evaluating the health-related quality of life of elderly people with total hip arthroplasty. A descriptive study

CONTEXT AND OBJECTIVES

Quality-of-life results have increasingly been evaluated among patients undergoing joint replacements. The objective of this study was to compare two assessment instruments for health-related quality of life (one generic and the other specific), among elderly patients undergoing total hip arthroplasty.

DESIGN AND SETTING

Cross-sectional descriptive study in a reference hospital in the region of Campinas.

METHODS

The subjects were 88 elderly outpatients aged 60 years or over who underwent primary total hip arthroplasty. Two instruments for assessing health-related quality of life were applied: the generic Medical Study 36-item Short-Form Health Survey (SF-36) and the specific Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Cronbach's alpha and the ceiling and floor effects of the instruments were evaluated.

RESULTS

The scores from both instruments showed that issues of a physical nature affected these elderly people's quality of life most. The pain and stiffness dimensions of WOMAC showed ceiling effects and only the functional capacity and pain dimensions of the SF-36 did not show the ceiling effect. The SF-36 presented floor effects in the dimensions of physical and emotional aspects. Cronbach's alpha was considered satisfactory in both instruments (α > 0.70).

CONCLUSIONS

The floor and ceiling effects that were observed suggest that these instruments may present some limitations in detecting changes to the majority of the SF-36 dimensions, except for functional capacity and pain, and to the pain and stiffness dimensions of WOMAC, when applied to elderly people with total hip arthroplasty.

The 21st-century landscape of adult fractures: cohort study of a complete adult regional population

Recent reports on adult fracture epidemiology have focused mainly on the hip in the elderly, in whom increasing rates lately have changed to a decline. New reports of the preponderance of nonhip fractures in health expenditure call for a wider scope. We therefore examined current overall and site-specific fracture epidemiology in adults. We ascertained all fractures diagnosed in inpatient and outpatient care in all men and women aged 20 years or older in Skåne County, Sweden, from 1999 to 2010 (10 million person-years). For each fracture type, we estimated age-specific and sex-specific rates and evaluated potential time trends. We found 205,908 fractures yielding an overall fracture rate of 192 per 10,000 person-years. The age-standardized overall fracture rate increased by 1.2 per 10,000 and year (95% confidence interval, 0.8 to 1.5), but time trends were different for different fracture types, age strata, and for men and women. For example, in both women and men aged ≥50 years the rates of proximal humerus fracture increased (0.6 and 0.2 per 10,000 and year, respectively) while hip fracture rates declined (-1.0 and -0.3 per 10,000/year, respectively). Overall age-specific number of fractures increased with age in women but was stable in men. The increasing overall fracture rate is a major concern in the context of a growing and aging population. Effective and affordable preventive strategies and treatments should be an urgent priority to meet the challenges, especially in older women in whom most fractures occur. Comprehensive current detailed data, as provided in this study, may serve as reference for projections and for cost calculations of fracture care in other settings before results of similar examinations are available there.

Incidence and risk factors for osteoporotic vertebral fracture in low-income community-dwelling elderly: a population-based prospective cohort study in Brazil. The São Paulo Ageing & Health (SPAH) Study

We ascertained the incidence and predictors of radiographic vertebral fracture in a Brazilian elderly cohort, since no data in this field have been reported in low-income countries. This is the first population-based study to demonstrate the high frequency of vertebral fracture in elderly Latin Americans. Age, prior fracture, BMD, and bone turnover were predictors of fracture.

INTRODUCTION

Vertebral fractures are associated with increased future fracture risk and mortality. No data on incidence of osteoporotic vertebral fracture have been reported in low-income countries where the population's aging has been faster. Thus, we sought to describe the incidence and risk factors for radiographic vertebral fracture in a longitudinal prospective Brazilian population-based elderly cohort.

METHODS

707 older adults (449 women and 258 men) were evaluated with spinal radiographs obtained at baseline and after a mean follow-up of 4.3 ± 0.8 years. New vertebral fracture was defined as distinct alteration in the morphology of vertebrae resulting in higher grade of deformity on the second radiograph when compared to the baseline radiograph. Clinical questionnaire, bone mineral density (BMD), and laboratory tests were performed at baseline. Multivariate Poisson regression models were used to identify independent predictors of fracture.

RESULTS

The age-standardized incidence of vertebral fracture was 40.3/1,000 person-years in women and 30.6/1,000 in men. In women, three models of risk factors for fracture were fitted: (1) age (relative risks (RR) 2.46, 95 % confidence interval (CI) 1.66-3.65), previous osteoporotic fracture (RR 1.65, 95 % CI 1.00-2.71), and lumbar spine BMD (RR 1.21, 95 % CI 1.03-1.41); (2) age (RR 2.25, 95 % CI 1.52-3.34) and femoral neck BMD (RR 1.42, 95 % CI 1.11-1.81); (3) age (RR 2.11, 95 % CI 1.41-3.15) and total hip BMD (RR 1.56, 95 % CI 1.21-2.0). In men, the highest quartile of cross-linked C-telopeptide (CTx) (RR 1.96, 95 % CI 0.98-3.91) and prior fracture (RR 2.10, 95 % CI 1.00-4.39) were predictors of new vertebral fracture.

CONCLUSIONS

This is the first population-based study to ascertain the incidence of vertebral fracture in elderly Latin Americans, confirming the high frequency of the disorder. Age, prior fracture, BMD, and bone turnover were predictors of the short-term incidence of vertebral fracture.

Factors in relation to bone mineral density in Korean middle-aged and older men: 2008-2010 Korea National Health and Nutrition Examination Survey

BACKGROUND/AIMS

Studies on determinants of bone mineral density (BMD) among Asian middle-aged and older men are very limited. The aim of this study was to investigate general determinants and dietary factors influencing BMD in Korean middle-aged and older men.

METHODS

This study was conducted using data from the 2008-2010 Korea National Health and Nutrition Examination Survey. A total of 2,305 male subjects aged 50-79 years were included. Whole-body, total femur, femoral neck, and lumbar spine BMDs were measured by dual-energy X-ray absorptiometry. Dietary intake was estimated by 24-hour dietary recall. A food frequency questionnaire for 63 food items was also administered.

RESULTS

Proportions of osteoporosis at the total femur, femoral neck, and lumbar spine were 0.7, 3.3 and 7.0%, respectively. Age, height, weight, body mass index, fat mass, lean body mass, waist circumference, serum vitamin D, parathyroid hormone, and exercise were related to BMD, but the relationships were site specific. Diet quality and intake of vegetables, fruits, and calcium were associated with BMD.

CONCLUSIONS

These results suggest that a high-quality diet, an adequate intake of fruits, vegetables, and calcium, as well as exercise, high serum vitamin D and weight maintenance might be determinants of BMD among middle-aged and older Asian men.

Epidemiology of fractures in Iceland and secular trends in major osteoporotic fractures 1989-2008

The incidence of the most common fracture types in Iceland is reported based on individual data from the Reykjavik Study 1967-2008. Time trend is reported for the major osteoporotic fractures (MOS) 1989-2008.

INTRODUCTION

This study aims to assess the incidence of all fractures in Iceland, with emphasis on the rate of hip fractures, and compare the incidence with other populations as well as examine the secular changes.

METHODS

Individuals from the prospective population-based cohort Reykjavik Study were examined between 1967 and 2008 (follow-up 26.5 years), which consisted of 9,116 men and 9,756 women born in 1907-1935, with age range 31-81 years. First fracture incidence was estimated using life table methods with age as the timescale.

RESULTS

Fracture rate increased proportionally with age between the sexes for vertebral and proximal humerus but disproportionally for hip and distal forearm fractures. The ratio of first fracture incidence between the sexes varied considerably by site: 2.65 for hip fractures and the highest for distal forearm fractures at 4.83. By the age of 75, 36.7% of women and 21% of men had sustained a fracture, taking into account competing risk of death. The incidence of hip fractures was similar to results previously published from USA, Sweden, Norway, and Scotland. The incidence of MOS fractures in both sexes decreased over the last decade, except hip fractures in men, which remained unchanged, as reflected in the women/men ratio for the hip, which changed from 2.6 to 1.7.

CONCLUSION

This study adds information to scarce knowledge on the relative fracture incidence of different fractures. The incidence of MOS fractures increased in the latter part of the last century in both sexes and declined during the last decade, less dramatically for men. This information is important for planning health resources.

Risk factors for contra-lateral hip fracture in elderly patients with previous hip fracture

INTRODUCTION

Contra-lateral hip fractures in elderly patients with a previous hip fracture increase the incidence of complications and socioeconomic burden. The purpose of this study was to identify the risk factors that contribute to the occurrence of contra-lateral hip fracture in elderly patients.

MATERIALS AND METHODS

Among 1093 patients treated for a hip fracture, 47 patients sustained a contra-lateral hip fracture. These patients were compared with 141 patients with a unilateral hip fracture (controls).

RESULTS

The incidence of contra-lateral hip fracture was 4.3% among the 1093 patients treated for a hip fracture at our institute. A contra-lateral hip fracture occurred within 2 years of initial fracture in 66%, and subsequently, the annual incidence rate decreased. A similar fracture pattern was noted in 70% of patients who sustained an intertrochanteric fracture. In terms of preoperative factors, respiratory disease (OR 2.57, P=0.032) and visual impairment (OR 2.51, P=0.012) were higher in patients with a contra-lateral hip fracture than in controls, and for postoperative factors, the proportions of patients with postoperative delirium (OR 2.91, P=0.022), late onset of rehabilitation (OR 1.05, P=0.023), and poor ambulatory status at 3 months (OR 1.34, P=0.002) were also significantly higher in patients than in controls.

CONCLUSIONS

Postoperative delirium and underlying visual impairment and respiratory disease could be risk factors of contra-lateral fracture in elderly patients. Early and active rehabilitation after surgery is important to prevent the occurrence of contra-lateral hip fracture in the elderly.

Idiopathic osteoporosis in men

Over the last decade, the increasingly significant problem of osteoporosis in men has begun to receive much more attention than in the past. In particular, recent observations from large scale population studies in males led to an advance in the understanding of morphologic basis of growth, maintenance and loss of bone in men, as well as new insights about the pathophysiology and treatment of this disorder. While fracture risk consistently increases after age 65 in men (with up to 50 % of cases due to secondary etiologies), osteoporosis and fractures may also occur in young or middle aged males in the absence of an identifiable etiology. For this category (so called idiopathic osteoporosis), there are still major gaps in knowledge, particularly concerning the etiology and the clinical management. This article provides a summary of recent developments in the acquisition and maintenance of bone strength in men, as well as new insights about the pathogenesis, diagnosis, and treatment of idiopathic osteoporosis.

Risk factors of postoperative urinary retention after hip surgery for femoral neck fracture in elderly women

AIM

The aim of the present study was to evaluate risk factors for postoperative urinary retention (POUR) in female patients with femoral neck fractures.

METHODS

We recruited 72 female patients (age 86.5 ± 6.7 years) from among 90 cases of hip surgery carried out between January and December 2011 at Goto Chuo Hospital. We evaluated the risk factors for POUR, including the administration of anticholinergic drugs, diabetes mellitus, preoperative dementia and/or delirium, neurological disorders, age, hypertension, overactive bladder, and the postoperative duration of the use of an indwelling urethral catheter using a multiple logistic regression analysis.

RESULTS

In the present study, POUR occurred in eight out of 72 cases (11.1%). The multivariate analysis showed that the indwelling period of the urethral catheter (per 1-day increase; P = 0.04, OR 0.33 95% CI 0.11-0.96), and preoperative dementia and/or delirium (P = 0.03, OR10.4, 95%CI 1.21-89.2) correlated with the occurrence of POUR. Diabetes mellitus (P = 0.78), anticholinergic agents (P = 0.23), neurological disorders (P = 0.83), age (P = 0.86), hypertension (P = 0.76) and overactive bladder (P = 0.34) did not significantly correlate with the occurrence of POUR.

CONCLUSIONS

The present study showed that the early removal of the urethral catheter, and preoperative dementia and/or delirium had significant correlations with POUR. The femoral neck fractures and the surgical procedure used for the hip surgery do not induce damage to the bladder and nerve system related to the voiding function, and the voiding function in all of the patients recovered after short-term intermittent catheterization. Physicians should not place permanent indwelling urethral catheters without carrying out urological assessments.

Association between low bone mass and calcium and caffeine intake among perimenopausal women in Southern Brazil: cross-sectional study

CONTEXT AND OBJECTIVE

Osteoporosis is a skeletal abnormality characterized by reduction and alteration of bone microarchitecture that results in increased fragility and greater predisposition to fractures. Age and low bone mass are the main non-modifiable risk factors for osteoporotic fractures. The modifiable factors include sedentary lifestyle, inadequate calcium intake, excessive alcohol and/or caffeine consumption, smoking and low body weight. The aim here was to evaluate the association between low bone mass and calcium and caffeine intake among perimenopausal women in Southern Brazil.

DESIGN AND SETTING

Cross-sectional study conducted in Porto Alegre and Canoas, Rio Grande do Sul, Brazil.

METHODS

Women (n = 155) of mean age 53.6 ± 9.5 years were evaluated through a cross-sectional study in Southern Brazil. Food frequency questionnaires, bone mass evaluation using calcaneal ultrasound and anthropometric assessment were used.

RESULTS

The prevalence of overweight was 67.7%. In the bone mass screening, 30.3% had low bone mass and 4.5% had osteoporosis. The median calcium intake was 574.94 mg/day and the caffeine intake was 108.11 mg/day. No association was found between bone mass and anthropometric parameters, calcium intake or caffeine intake. It was found that 38.4% of the women had low bone mass.

CONCLUSIONS

No association was found between calcium and caffeine intake and bone mass. High prevalence of low bone mass was observed.

FRAX® probabilities and risk of major osteoporotic fracture in France

The incidence of hip fracture, death and the estimated incidence of major osteoporotic fracture in France were used to determine the lifetime and 10-year probability of fracture and incorporated into a probability model (FRAX®) calibrated to the French population.

INTRODUCTION

Fracture probabilities in the French population have not been determined. Our aim was to determine the incidence of hip fracture in France and the estimated 10-year probabilities of hip and major osteoporotic fractures.

METHODS

The study population included adults over 50 years living in France in 2004. Incident hip fracture cases were identified from the French PMSI database. Incidence of the other major osteoporotic fractures was imputed from the relationship between hip fracture incidence and other major fracture in Sweden. These data were used to calculate population-based fracture probabilities according to age and BMD using cutoff values for femoral neck T-scores from the NHANES III data in Caucasian women. The probability model (FRAX®) calibrated to the French population was used to compute individual fracture probabilities according to specific clinical risk factors.

RESULTS

We identified 15,434 men and 51,469 women with an incident hip fracture. The remaining lifetime probability of hip fracture at 50 years was approximately 10 and 30% respectively. With a femoral neck T-score of -2 SD, one in two women and one in five men would sustain a major osteoporotic fracture in their lifetime. The 10-year probability of other major osteoporotic fractures increased with declining T-score and increasing age. Low body mass index and other clinical risk factors had an independent effect on fracture probability whether or not BMD was included in the FRAX® model.

CONCLUSION

This analysis provides detailed estimation on the risk of fracture in the French population and may help to define therapeutic guidelines.

A systematic review of hip fracture incidence and probability of fracture worldwide

The country-specific risk of hip fracture and the 10-year probability of a major osteoporotic fracture were determined on a worldwide basis from a systematic review of literature. There was a greater than 10-fold variation in hip fracture risk and fracture probability between countries.

INTRODUCTION

The present study aimed to update the available information base available on the heterogeneity in the risk of hip fracture on a worldwide basis. An additional aim was to document variations in major fracture probability as determined from the available FRAX models.

METHODS

Studies on hip fracture risk were identified from 1950 to November 2011 by a Medline OVID search. Evaluable studies in each country were reviewed for quality and representativeness and a study (studies) chosen to represent that country. Age-specific incidence rates were age-standardised to the world population in 2010 in men, women and both sexes combined. The 10-year probability of a major osteoporotic fracture for a specific clinical scenario was computed in those countries for which a FRAX model was available.

RESULTS

Following quality evaluation, age-standardised rates of hip fracture were available for 63 countries and 45 FRAX models available in 40 countries to determine fracture probability. There was a greater than 10-fold variation in hip fracture risk and fracture probability between countries.

CONCLUSIONS

Worldwide, there are marked variations in hip fracture rates and in the 10-year probability of major osteoporotic fractures. The variation is sufficiently large that these cannot be explained by the often multiple sources of error in the ascertainment of cases or the catchment population. Understanding the reasons for this heterogeneity may lead to global strategies for the prevention of fractures.

Incidence of hip fracture and prevalence of osteoporosis in Turkey: the FRACTURK study

The incidence of hip fractures in Turkey increased markedly from that reported in 1988/1989 so that FRAX® models for Turkey should be revised.

INTRODUCTION

The MEDOS study in 1988/1989 reported that men and women from Turkey had exceptionally low rates of hip fracture. The aim of the FRACTURK study was to estimate current and future hip fracture risks and the prevalence of osteoporosis in Turkey.

METHODS

Hip fracture cases in 2009 were identified from interviews of a population-based sample of 26,424 residents aged 50 years or more in 12 different regions of Turkey and in two hospital surveys. Bone mineral density was evaluated by DXA in an age-stratified sample of 1,965 men and women.

RESULTS

Hip fracture incidence in the community-based survey was similar to that in the hospital survey. The age-specific incidence in men and women was substantially higher than that reported for 1988/1989. At the age of 50 years, the remaining lifetime probability of a hip fracture was 3.5% in men and 14.6% in women. In 2009, there were approximately 24,000 hip fractures estimated in Turkey, 73% of which were found in women. Assuming no change in the age- and sex-specific incidence, the number of hip fractures was expected to increase to nearly 64,000 in 2035. The prevalence of osteoporosis at the femoral neck was 7.5% and 33.3% in men and women, respectively, aged 50 years or more.

CONCLUSION

Although Turkey is still among the countries with low hip fracture rates in Europe, the incidence has increased markedly in the last 20 years. This finding can be used to recalibrate fracture risk assessment models for Turkey.

Geographic trends in incidence of hip fractures: a comprehensive literature review

A comprehensive review of literature was conducted to investigate variation in hip fracture incident rates around the world. The original crude incidence rates were standardized for age and sex for comparability. After standardization, the highest rates of hip fracture were found in Scandinavia and the lowest rates in Africa.

INTRODUCTION

This study was conducted to investigate the geographic trends of the incidence of osteoporotic hip fractures through a comprehensive review of literature.

METHODS

Studies were identified for inclusion in the review by searching the MEDLINE database via PubMed and applying strict inclusion and exclusion criteria. Age-specific incidence rates were extracted from the articles, and in order to provide a common platform for analysis, we used directly age-standardized and age-sex-standardized rates (using the 2005 United Nations estimates of the world population as standard) to complete the analysis.

RESULTS

Forty-six full text articles spanning 33 countries/regions were included in the review. For ease of comparison, the results were analyzed by geographic regions: North America, Latin America, Scandinavia, Europe (excluding Scandinavia), Africa, Asia, and Australia. The highest hip fracture rates were found in Scandinavia and the lowest in Africa. We found comparable rates from countries in North America, Australia, and Europe outside of Scandinavia. The diverse makeup of the Asian continent also resulted in quite variable hip fracture rates: ranging from relatively high rates in Iran to low rates, comparable to those from Africa, in mainland China.

CONCLUSIONS

Given the aging of populations globally, and in the industrialized countries specifically, hip fractures will become a progressively larger public health burden. The geographic trends observed in hip fracture incidence rates can provide important clues to etiology and prevention.

Incidence and mortality following hip fracture in Korea

The authors evaluated the incidence of hip fracture and subsequent mortality in Korea using nationwide data obtained from the Health Insurance Review and Assessment Service. This study was performed on patient population, aged 50-yr or older who underwent surgical procedures because of hip fracture (ICD10; S720, S721). All patients were followed using patient identification code to identify deaths. Crude hip fracture rates increased from 191.9/100,000 in 2005 to 207.0/100,000 in 2008 in women and from 94.8/100,000 in 2005 to 97.8/100,000 in 2008, in men respectively. Crude mortality within 12 months after hip fracture showed a similar trend (18.8% in 2005 and 17.8% in 2007). The mean of standardized mortality ratio of hip fracture was 6.1 at 3 months, 3.5 at 1 yr, and 2.3 at 2 yr post-fracture. The increasing incidence and the high mortality after hip fracture are likely to become serious public health problems and a public health program should begin to prevent hip fractures in Korea.

Genistein aglycone effect on bone loss is not enhanced by supplemental calcium and vitamin D3: a dose ranging experimental study

Genistein aglycone (GEN) has a favorable effect on bone loss. We investigated the effects of GEN alone or in combination with supplemental calcium and vitamin D(3) in an animal model of bone loss to evaluate if there was additional benefit. Ovariectomized (OVX) and SHAM-OVX rats were used. OVX were divided into 12 groups and randomized to receive: GEN at 27, 54, 200, 500 or 1000 mg (human equivalent dose (HED)/day/ip injection alone or with calcium carbonate (Ca) (360 mg/kg/day/gavages) and vitamin D(3) (D(3)) (50 IU/kg/day/gavages) or Ca/D(3) without GEN or untreated for 6 weeks. SHAM-OVX were randomized into 7 groups and treated with: Ca and D(3) alone or in combination with GEN (same doses as OVX), or left untreated. Bone mineral density (BMD), bone-alkaline phosphatase (b-ALP), collagen C-telopeptides (CTX), osteoprotegerin (OPG) and soluble receptor activator of NFκB ligand (sRANKL) were assessed. Femurs were excised and tested for breaking strength and histology. Uterine weight was analyzed to assess GEN's estrogenic effects on the SHAM-OVX. The most effective dose of GEN, independent of Ca/D(3) supplementation, was 54 mg/day. Higher doses yielded no further improvement in bone biomarkers, histology or strength. Only 1000 mg/day HED of genistein produced statistically significant changes in uterine weight of the SHAM-OVX. This study suggests that 54 mg/day of GEN is the threshold dose for efficacy. In addition, supplemental calcium and vitamin D(3), beyond normal dietary intake do not enhance the effects of genistein on improving measures of bone loss. This observation has implications regarding the use of calcium and vitamin D(3) supplementation.

Official Positions for FRAX® clinical regarding international differences from Joint Official Positions Development Conference of the International Society for Clinical Densitometry and International Osteoporosis Foundation on FRAX®

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

O custo direto da fratura de fêmur por quedas em pessoas idosas: análise no setor privado de saúde na cidade de Brasília, 2009

OBJETIVO: estimar o custo direto dos recursos médico-hospitalares utilizados no tratamento cirúrgico da fratura de fêmur decorrente de quedas durante a hospitalização e pós-operatório até dois meses após a lesão. MÉTODO: estudo transversal, descritivo e retrospectivo em pacientes de ambos os sexos, com 60 anos ou mais de idade, no período de janeiro de 2008 a junho de 2009. Os dados foram extraídos das contas hospitalares de um convênio credenciado à rede hospitalar privada da cidade de Brasília. RESULTADOS: a frequência de fratura por quedas para o sexo feminino foi 76,2% (n=16), e no masculino, 23,8%(n=5), sendo que 66,7% (n=14) das lesões resultaram em fratura de fêmur proximal. A média de permanência hospitalar das cirurgias foi de 7,1 dias e 2,7 dias em UTI. Houve 16 pacientes com fratura de fêmur e a média do tratamento cirúrgico foi R$ 39.160,75, totalizando R$ 626.572,06. O custo direto dos recursos médico-hospitalares durante a internação ficou entre R$ 8.293,55 e R$ 139.837,50; já no pós-operatório, corresponderam a 5,7% do custo total da internação. CONCLUSÃO: o custo cirúrgico da fratura de fêmur é considerável para os convênios do sistema de saúde suplementar e confirmou a vulnerabilidade do sexo feminino para as fraturas de quadril. As maiores despesas foram com a prótese, material e medicamentos, e variaram em função do tipo de cirurgia, período de hospitalização e faixa etária.

Distribution of cortical bone in the femoral neck and hip fracture: a prospective case-control analysis of 143 incident hip fractures; the AGES-REYKJAVIK Study

In this prospective nested case-control study we analyzed the circumferential differences in estimated cortical thickness (Est CTh) of the mid femoral neck as a risk factor for osteoporotic hip fractures in elderly women and men. Segmental QCT analysis of the mid femoral neck was applied to assess cortical thickness in anatomical quadrants. The superior region of the femoral neck was a stronger predictor for hip fracture than the inferior region, particularly in men. There were significant gender differences in Est CTh measurements in the control group but not in the case group. In multivariable analysis for risk of femoral neck (FN) fracture, Est CTh in the supero-anterior (SA) quadrant was significant in both women and men, and remained a significant predictor after adjustment for FN areal BMD (aBMD, dimensions g/cm², DXA-like), (p=0.05 and p<0.0001, respectively). In conclusion, Est CTh in the SA quadrant best discriminated cases (n=143) from controls (n=298), especially in men. Cortical thinning superiorly in the hip might be of importance in determining resistance to fracture.

Periodontal conditions in elderly men with and without osteoporosis or osteopenia

BACKGROUND

The purpose of this case-control study is to investigate the periodontal conditions in elderly men with and without osteoporosis or osteopenia and to determine their possible association with periodontal destruction.

METHODS

A total of 200 community-dwelling Chinese males (age range: 69 to 78 years; mean ± SD age: 71.9 ± 3.3 years) were recruited from the Jockey Club Center for Osteoporosis Care and Control, The Chinese University of Hong Kong, including 67 subjects with osteoporosis, 66 subjects with osteopenia, and 67 age-matched normal control subjects based on bone mineral density at the hip, spine, and whole body measured by dual-energy x-ray densitometry. All subjects were interviewed using questionnaires and received a full-mouth periodontal examination.

RESULTS

Subjects with osteoporosis exhibited a significantly higher percentage of sites with clinical attachment loss (AL) > or= 6 mm compared to subjects with osteopenia (P <0.05); subjects with osteoporosis also showed a greater percentage of sites with interproximal gingival recession (GR) > or = 5 mm than did control subjects (P <0.05) after excluding smokers. Subjects with osteoporosis were more likely (odds ratio = 3.3; P <0.05) to exhibit interproximal GR > or = 5 mm than were control subjects. Osteoporosis remained significantly associated with severe clinical AL and interproximal GR after adjusting for age, supragingival plaque, and number of teeth lost.

CONCLUSION

This study suggests that osteoporosis is associated with severe clinical AL and interproximal GR in elderly Chinese men.

Epidemiology of hip fracture: Worldwide geographic variation

Osteoporosis is a major health problem, especially in elderly populations, and is associated with fragility fractures at the hip, spine, and wrist. Hip fracture contributes to both morbidity and mortality in the elderly. The demographics of world populations are set to change, with more elderly living in developing countries, and it has been estimated that by 2050 half of hip fractures will occur in Asia. This review conducted using the PubMed database describes the incidence of hip fracture in different regions of the world and discusses the possible causes of this wide geographic variation. The analysis of data from different studies show a wide geographic variation across the world, with higher hip fracture incidence reported from industrialized countries as compared to developing countries. The highest hip fracture rates are seen in North Europe and the US and lowest in Latin America and Africa. Asian countries such as Kuwait, Iran, China, and Hong Kong show intermediate hip fracture rates. There is also a north-south gradient seen in European studies, and more fractures are seen in the north of the US than in the south. The factors responsible of this variation are population demographics (with more elderly living in countries with higher incidence rates) and the influence of ethnicity, latitude, and environmental factors. The understanding of this changing geographic variation will help policy makers to develop strategies to reduce the burden of hip fractures in developing countries such as India, which will face the brunt of this problem over the coming decades.

Geographic variation in osteoporotic hip fracture incidence: the growing importance of asian influences in coming decades

Studies over the last few decades have demonstrated geographic variation in the incidence of hip fracture across continents and among different parts of the same region. This paper studies the epidemiology of hip fracture worldwide, with special emphasis on the geographic variation among Asian countries. Using the Pubmed database, keywords that were employed included hip fracture, incidence rate, geographic variation, osteoporosis, and epidemiology. Articles were chosen based on the basis of (1) focus: studies that were said to specifically focus on geographic variation in hip fracture from different continents with a focus on Asia; (2) language: studies that were in English; (3) methods: studies that used statistical tests to examine hip fracture incidence rates. The highest hip fracture rates are seen in Scandinavian countries and the US and the lowest in African countries. Fracture rates are intermediate in Asian populations. Among different ethnic populations, the highest fracture rates are seen in Caucasians and the lowest in blacks. There is also a north-south gradient, particularly in Europe, where more hip fractures occur in North Europe compared to the South.

Correlation of undercarboxylated osteocalcin (ucOC) concentration and bone density with age in healthy Korean women

Uncarboxylated osteocalcin (ucOC) is important in evaluating vitamin K status and it is inversely associated with bone mineral density (BMD). We studied the correlationship between ucOC and BMD in healthy Korean women. This study recruited 337 healthy women between ages 20-70 were recruited. Serum ucOC, calcium, alkaline phosphatase, body mass index (BMI), and BMD were measured and compared. Mean BMI was lowest (20.3+/-1.9 kg/m(2)) in the 20 yr old group and highest (24.8+/-2.6 kg/m(2)) in the 60 yr old group. Women age 20-70 yr old had ucOC inversely related to BMD independent of other factors that may influence BMD. Serum ucOC concentration and BMD of lumbar spine showed a significant inverse relationship. Serum mean alkaline phosphatase was lowest (122+/-30 IU/L) in the age 30 group and highest (190.3+/-55.8 IU/L) in the age 60 group. Serum ucOC was inversely associated with BMI, and positively associated with alkaline phosphatase. Uncarboxylated osteocalcin (ucOC) was inversely associated with spinal BMD in healthy Korean women. Serum mean ucOC was highest in the age 20 group, followed by age 50 group, which may indicate vitamin K insufficiency could be related to high bone turnover in these groups. These results suggest that vitamin K supplement may be considered to help both bone growth and bone loss during these periods.