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Mészáros S, Piroska M, Leel-Őssy T, Tárnoki ÁD, Tárnoki DL, Jokkel Z, Szabó H, Hosszú É, Csupor E, Kollár R, Kézdi Á, Tabák ÁG, Horváth C. Genetic and environmental determinants of bone quality: a cross-sectional analysis of the Hungarian Twin Registry. GeroScience 2024:10.1007/s11357-024-01265-2. [PMID: 38955996 DOI: 10.1007/s11357-024-01265-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 06/25/2024] [Indexed: 07/04/2024] Open
Abstract
There is abundant evidence that bone mineral content is highly heritable, while the heritability of bone quality (i.e. trabecular bone score [TBS] and quantitative ultrasound index [QUI]) is rarely investigated. We aimed to disentangle the role of genetic, shared and unique environmental factors on TBS and QUI among Hungarian twins. Our study includes 82 twin (48 monozygotic, 33 same-sex dizygotic) pairs from the Hungarian Twin Registry. TBS was determined by DXA, QUI by calcaneal bone ultrasound. To estimate the genetic and environmental effects, we utilized ACE-variance decomposition. For the unadjusted model of TBS, an AE model provided the best fit with > 80% additive genetic heritability. Adjustment for age, sex, BMI and smoking status improved model fit with 48.0% of total variance explained by independent variables. Furthermore, there was a strong dominant genetic effect (73.7%). In contrast, unadjusted and adjusted models for QUI showed an AE structure. Adjustments improved model fit and 25.7% of the total variance was explained by independent variables. Altogether 70-90% of the variance in QUI was related to additive genetic influences. We found a strong genetic heritability of bone quality in unadjusted models. Half of the variance of TBS was explained by age, sex and BMI. Furthermore, the adjusted model suggested that the genetic component of TBS could be dominant or an epistasis could be present. In contrast, independent variables explained only a quarter of the variance of QUI and the additive heritability explained more than half of all the variance.
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Affiliation(s)
- Szilvia Mészáros
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary.
| | - Márton Piroska
- Medical Imaging Centre, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Tamás Leel-Őssy
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Ádám Domonkos Tárnoki
- Medical Imaging Centre, Faculty of Medicine, Semmelweis University, Budapest, Hungary
- Hungarian Twin Registry, Budapest, Hungary
| | - Dávid László Tárnoki
- Medical Imaging Centre, Faculty of Medicine, Semmelweis University, Budapest, Hungary
- Hungarian Twin Registry, Budapest, Hungary
| | - Zsófia Jokkel
- Medical Imaging Centre, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Helga Szabó
- Medical Imaging Centre, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Éva Hosszú
- 2nd Department of Pediatrics, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Emőke Csupor
- Health Service, Buda Castle Local Authorities, Budapest, Hungary
| | - Réka Kollár
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | - Árpád Kézdi
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
- Károly Rácz Conservative Medicine Division, Doctoral College, Semmelweis University, Budapest, Hungary
| | - Ádám G Tabák
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
- Department of Public Health, Faculty of Medicine, Semmelweis University, Budapest, Hungary
- UCL Brain Sciences, University College London, London, UK
| | - Csaba Horváth
- Department of Internal Medicine and Oncology, Faculty of Medicine, Semmelweis University, Budapest, Hungary
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Azimi Manavi B, Mohebbi M, Stuart AL, Pasco JA, Hodge JM, Weerasinghe DK, Samarasinghe RM, Williams LJ. Antipsychotic medication use in association with quantitative heel ultrasound (QUS). Bone Rep 2023; 18:101694. [PMID: 37333887 PMCID: PMC10276211 DOI: 10.1016/j.bonr.2023.101694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 06/02/2023] [Accepted: 06/06/2023] [Indexed: 06/20/2023] Open
Abstract
Purpose Antipsychotic medication use has been associated with decreased bone mineral density; however, less is known whether antipsychotics affect other parameters of bone health. Therefore, the aim of this study was to investigate the association between antipsychotic medication use and quantitative heel ultrasound (QUS) in a population based sample of men and women. Methods Thirty-one antipsychotic users and 155 non-users matched for age and sex were drawn from the Geelong Osteoporosis Study. QUS was undertaken and included the parameters: Broadband ultrasound attenuation (BUA), speed of sound (SOS) and stiffness index (SI). Current medication use, lifestyle factors, anthropometry and socio-economic status were collected. Generalized Estimation Equation models were conducted to determine associations between antipsychotic medication use and each of the QUS parameters, adjusting for covariates. Results Antipsychotic users were less active, consumed less alcohol, were more likely to smoke and take antidepressants; otherwise, the groups were similar. After adjusting for age, sex and weight, antipsychotic users had a 7.7 % lower mean BUA [108.70 (95 % CI 104.26-113.14) vs. 116.42 (95 % CI 115.48-117.37) dB/MHz, p = 0.005] and 7.4 % lower mean SI [89.92 (95 % CI 86.89-92.95) vs. 97.30 (95 % CI 96.48-98.12) %, p < 0.001] compared to non-users. Differences in mean SOS between antipsychotic users and non-users failed to reach statistical significance (p = 0.07). Conclusion Antipsychotic use was associated with lower QUS parameters. The risk of bone deterioration should be considered when antipsychotics are prescribed.
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Affiliation(s)
- Behnaz Azimi Manavi
- Deakin University, IMPACT – the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Geelong 3220, Australia
| | - Mohammadreza Mohebbi
- Deakin University, IMPACT – the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Geelong 3220, Australia
| | - Amanda L. Stuart
- Deakin University, IMPACT – the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Geelong 3220, Australia
| | - Julie A. Pasco
- Deakin University, IMPACT – the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Geelong 3220, Australia
- Barwon Health, Geelong 3220, Australia
- Department of Medicine-Western Health, The University of Melbourne, St Albans 3021, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne 3004, Australia
| | - Jason M. Hodge
- Deakin University, IMPACT – the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Geelong 3220, Australia
- Barwon Health, Geelong 3220, Australia
| | - D. Kavindi Weerasinghe
- Deakin University, IMPACT – the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Geelong 3220, Australia
| | - Rasika M. Samarasinghe
- Deakin University, IMPACT – the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Geelong 3220, Australia
| | - Lana J. Williams
- Deakin University, IMPACT – the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Geelong 3220, Australia
- Barwon Health, Geelong 3220, Australia
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Pre-fracture Mobility Using Standardized Scale as an Early Indicator of High Health Risk in Patients with a Hip Fracture. AGEING INTERNATIONAL 2021. [DOI: 10.1007/s12126-021-09468-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AbstractHip fracture in older adults is associated with poor prognosis. We tested the hypothesis that a single standardized measure, pre-fracture mobility, can be used as an early indicator of patients at high health risk after a hip fracture. Analysis of prospectively collected data of older adults admitted with a hip fracture between April-2009 and June-2019 in a single NHS hospital, UK. Pre-fracture mobility status (freely mobile, mobilising outdoors with one aid or with two aids, and limited to indoors), was used to predict length of stay (LOS) and mortality in hospital, and discharge destination. Among 3073 (2231 women, 842 men) admitted from their own home (mean ± SD age = 82.7 ± 9.3 yr), 159 died and 2914 survived to discharge: 1834 back to their home, 772 to rehabilitation, 66 to residential care, 141 to nursing care and 101 to unknown destinations. Compared with LOS of 15.9 ± 15.6 days in patients who mobilised freely before fracture (reference), those who were able to mobilise outdoors with one aid stayed 3.5 days, and those with two aids or confined to indoor mobility stayed one week longer in hospital. In-patient mortality was increased among patients who mobilised outdoors with two aids: OR = 2.1 (95%CI = 1.3–3.3), and those limited to indoors: OR = 2.1 (1.3–1.5). Finally, a change in residence on discharge was more likely in those who mobilised outdoors with two aids (OR = 1.8, 95%CI = 1.2–2.6), and those limited to indoors (OR = 1.9, 95%CI = 1.2–2.9). In conclusion, pre-fracture mobility may be a useful early indicator for identifying patients at increased risk of adverse outcomes after an acute hip fracture.
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A Cross-Sectional Study of the Association between Autoantibodies and Qualitative Ultrasound Index of Bone in an Elderly Sample without Clinical Autoimmune Disease. J Immunol Res 2018; 2018:9407971. [PMID: 29854851 PMCID: PMC5952466 DOI: 10.1155/2018/9407971] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 03/05/2018] [Accepted: 03/17/2018] [Indexed: 12/15/2022] Open
Abstract
Bone loss is characteristic of the ageing process and a common complication of many autoimmune diseases. Research has highlighted a potential role of autoantibodies in pathologic bone loss. The confounding effects of immunomodulatory drugs make it difficult to establish the contribution of autoantibodies amongst autoimmune disease sufferers. We attempted to examine the relationship between autoantibodies and bone mass in a population of 2812 elderly participants without clinical autoimmune disease. Serum samples were assayed for a panel of autoantibodies (anti-nuclear, extractable nuclear antigen, anti-neutrophil cytoplasmic, thyroid peroxidase, tissue transglutaminase, anti-cardiolipin, rheumatoid factor, and cyclic citrullinated peptide). Bone mass was measured using quantitative ultrasound (QUS) of the calcaneus. The relationship between each autoantibody and bone mass was determined using linear regression models. Anti-nuclear autoantibodies were the most prevalent, positive in approximately 11%, and borderline in roughly 23% of our sample. They were also the only autoantibody observed to be significantly associated with QUS index in the univariate analysis (n = 1628; r = -0.20; 95% CI: -0.40-0.00; p = 0.046). However, statistical significance was lost after adjustment for various other potential confounders. None of the other autoantibodies was associated with QUS index in either univariate or multivariate analysis. We are limited by the cross-sectional nature of the study and the low prevalence of autoantibodies in our nonclinical sample.
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Rochira V, Antonio L, Vanderschueren D. EAA clinical guideline on management of bone health in the andrological outpatient clinic. Andrology 2018; 6:272-285. [DOI: 10.1111/andr.12470] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 01/11/2018] [Indexed: 01/16/2023]
Affiliation(s)
- V. Rochira
- Unit of Endocrinology; Department of Biomedical, Metabolic and Neural Sciences; University of Modena and Reggio Emilia; Modena Italy
- Azienda Ospedaliero-Universitaria di Modena; Ospedale Civile di Baggiovara; Modena Italy
| | - L. Antonio
- Department of Endocrinology; University Hospitals Leuven; Leuven Belgium
| | - D. Vanderschueren
- Department of Endocrinology; University Hospitals Leuven; Leuven Belgium
- Department of Clinical and Experimental Medicine; Laboratory of Clinical and Experimental Endocrinology; KU Leuven; Leuven Belgium
- Department of Laboratory Medicine; University Hospitals Leuven; Leuven Belgium
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Rizvi B, Da Silva E, Slatkovska L, Cheung AM, Tavakkoli J, Pejović-Milić A. Technical Note: Bone mineral density measurements of strontium-rich trabecular bone-mimicking phantoms using quantitative ultrasound. Med Phys 2016; 43:5817. [DOI: 10.1118/1.4963805] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
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Hernández JL, Nan D, Martínez J, Pariente E, Sierra I, González-Macías J, Olmos JM. Serum uric acid is associated with quantitative ultrasound parameters in men: data from the Camargo cohort. Osteoporos Int 2015; 26:1989-95. [PMID: 25731808 DOI: 10.1007/s00198-015-3083-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 02/18/2015] [Indexed: 12/13/2022]
Abstract
UNLABELLED This study analyzes the association between serum uric acid levels and heel quantitative ultrasound (QUS) parameters in men aged 50 or more from the Camargo cohort. We found that higher serum uric acid levels are positively associated with all QUS measurements, suggesting a better bone quality in men with elevated serum uric acid values. INTRODUCTION Higher serum uric acid concentrations have been associated with higher bone mineral density and lower prevalence of fractures. However, there are no studies that have assessed the bone quality properties in Caucasians. Therefore, we have analyzed the association between quantitative ultrasound (QUS) and serum uric acid levels in adult men from a population-based cohort. METHODS A total of 868 men older than 50 were recruited from a larger cohort (Camargo Cohort) after excluding those with any known condition or drug treatment with a possible influence on bone metabolism, or those with a previous diagnosis of gout or taking hipouricemic agents. Bone turnover markers (PINP and CTX), 25OH-vitamin D and PTH levels were measured by electrochemiluminiscence. BMD was determined by DXA, and heel QUS with a gel-coupled device. RESULTS Lumbar, femoral neck and total hip BMD was significantly higher in men with higher serum uric acid levels. QUS parameters were also significantly higher in men with high uric acid levels than those with lower values, and increased continuously across quartiles after adjustment for confounding variables. In multiple regression analysis, serum uric acid was significantly associated with all QUS parameters. Finally, men with serum acid levels above median showed higher values in all the QUS parameters than men with lower values. CONCLUSIONS Higher serum uric acid levels in men older than 50 years are positively associated with QUS parameters. These data might suggest a better bone quality in men with elevated serum uric acid values.
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Affiliation(s)
- J L Hernández
- Bone Metabolic Unit, Department of Internal Medicine, Hospital Universitario Marqués de Valdecilla. IDIVAL, Red Temática de Investigación Cooperativa en Envejecimiento y Fragilidad (RETICEF), University of Cantabria, Santander, Spain,
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Rauma PH, Pasco JA, Berk M, Stuart AL, Koivumaa-Honkanen H, Honkanen RJ, Hodge JM, Williams LJ. The association between use of antidepressants and bone quality using quantitative heel ultrasound. Aust N Z J Psychiatry 2015; 49:437-43. [PMID: 25586753 DOI: 10.1177/0004867414565475] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Osteoporosis and depression are major public health problems worldwide. Studies have reported an association between antidepressant use, mainly selective serotonin reuptake inhibitors (SSRIs), and bone mineral density (BMD), but the issue remains unclear. METHODS This study examined data collected from 849 Australian men (aged 24-98 years) participating in the Geelong Osteoporosis Study (GOS). Bone quality was determined using quantitative ultrasound (QUS) and included the following parameters: Broadband Ultrasound Attenuation (BUA), Speed of Sound (SOS) and Stiffness Index (SI). Anthropometry, socio-economic status (SES), medication use and lifestyle factors were determined. The cross-sectional associations between bone quality and use of antidepressants were studied using multivariate linear regression adjusted for potential confounders. RESULTS At the time of assessment, 61 (7.2%) men were using antidepressants, of which 44 (72.1%) used SSRIs. Antidepressant use was associated with lower SI (p = .002), SOS (p = .010) and BUA (p = .053). However, body weight was identified as an effect modifier; QUS values were lower for antidepressant users with lower weight (< 90 kg) only. CONCLUSIONS Use of antidepressants was associated with lower QUS values for men with low body weights. Thus, the risk of osteoporosis should be taken into account when prescribing antidepressants, in particular among men who are in this weight category.
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Affiliation(s)
- Päivi H Rauma
- Social Pharmacy, School of Pharmacy, University of Eastern Finland (UEF), Kuopio, Finland Bone and Cartilage Research Unit, Institute of Clinical Medicine, UEF, Kuopio, Finland
| | - Julie A Pasco
- School of Medicine, Deakin University, Geelong, Australia North West Academic Centre, Department of Medicine, The University of Melbourne, St Albans, Australia
| | - Michael Berk
- School of Medicine, Deakin University, Geelong, Australia The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, Australia
| | | | - Heli Koivumaa-Honkanen
- Institute of Clinical Medicine, Psychiatry, UEF, Kuopio, Finland Departments of Psychiatry, Kuopio University Hospital, South-Savonia Hospital District, Mikkeli; North Karelia Central Hospital, Joensuu; SOSTERI, Savonlinna; SOTE, Iisalmi; Lapland Hospital District, Rovaniemi, Finland
| | - Risto J Honkanen
- Bone and Cartilage Research Unit, Institute of Clinical Medicine, UEF, Kuopio, Finland
| | - Jason M Hodge
- School of Medicine, Deakin University, Geelong, Australia Barwon Biomedical Research, The Geelong Hospital, Geelong, Australia
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Sritara C, Thakkinstian A, Ongphiphadhanakul B, Pornsuriyasak P, Warodomwichit D, Akrawichien T, Vathesatogkit P, Sritara P. Work- and travel-related physical activity and alcohol consumption: relationship with bone mineral density and calcaneal quantitative ultrasonometry. J Clin Densitom 2015; 18:37-43. [PMID: 24878331 DOI: 10.1016/j.jocd.2014.04.117] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 04/10/2014] [Indexed: 11/17/2022]
Abstract
A number of healthy workers rarely exercise because of a lack of time or resources. Physical activity related to work and everyday travel may be more feasible, but evidence of its beneficial effect on bone health is scarce. We assessed if this form of physical activity was associated with higher bone mineral density (BMD) and stiffness index (SI) when adjusted for recreational physical activity, age, body mass index, smoking, alcohol consumption, education, and serum level of 25-hydroxyvitamin D. Healthy workers, aged 25-54 yr, of the Electricity Generating Authority of Thailand were surveyed. The outcomes were BMD (lumbar spine, femoral neck, and total hip) and calcaneal SI. Physical activity was estimated using the global physical activity questionnaire and considered active when >600 metabolic equivalent tasks (min). Of 2268 subjects, 74% were men. Active male subjects had significantly higher BMD at the femoral neck and total hip (p<0.005). However, the association was not significant with male lumbar spine BMD, male SI, or any bone parameters in women (p>0.05). In men, work and travel physical activity seems beneficial to male bone health; hence, it should be encouraged. Furthermore, smoking appeared harmful while moderate alcohol consumption was beneficial.
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Affiliation(s)
- Chanika Sritara
- Department of Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
| | - Ammarin Thakkinstian
- Section for Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Boonsong Ongphiphadhanakul
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Prapaporn Pornsuriyasak
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Daruneewan Warodomwichit
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Tawatchai Akrawichien
- Medical and Health Office, Electricity Generating Authority of Thailand, Nonthaburi, Thailand
| | - Prin Vathesatogkit
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Piyamitr Sritara
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Lavado-Garcia JM, Moran JM, Roncero-Martin R, Calderon-Garcia JF, Pedrera-Canal M, Rodriguez-Dominguez T, Fernandez-Fernandez P, Pedrera-Zamorano JD. Quantitative ultrasound measurements of the calcaneus and hand phalanges in elderly Spanish men: relationship with peripheral bone mineral density of the hand phalanges. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2014; 33:1279-1285. [PMID: 24958415 DOI: 10.7863/ultra.33.7.1279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVES The aims of this pilot study were to describe quantitative ultrasound (US) measurements and peripheral bone mineral density (BMD) of the hand phalanges on dual-energy x-ray absorptiometry and to examine the correlations between them in elderly Spanish men. METHODS We studied 199 healthy men (mean age ± SD, 73.31 ± 5.10 years). The participants were not taking any medications, and they reported no diseases, including diseases that are associated with abnormalities in mineral metabolism. Phalangeal and calcaneal quantitative US measurements and phalangeal BMD measurements were performed in all participants. RESULTS A bivariate correlation analysis showed no association between quantitative US assessments at the phalanges or the calcaneus (P = .409). After adjustment for potential confounders, the correlation between phalangeal BMD and phalangeal quantitative US measurements was r = 0.417 (P < .0001), and the correlation for calcaneal quantitative US was r = 0.26 (P = .001). Further adjustment by percentage of body fat increased quantitative US correlations with phalangeal BMD: r = 0.450 (P < .0001) at the phalanges; r = 0.291 (P = .001) at the calcaneus. CONCLUSIONS There is a small correlation between quantitative US measurements at the calcaneus and phalangeal BMD that increases to a moderate level with quantitative US measurements at the phalanges in elderly Spanish men.
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Affiliation(s)
| | - Jose M Moran
- Metabolic Bone Diseases Research Group, University of Extremadura, Cáceres, Spain
| | - Raul Roncero-Martin
- Metabolic Bone Diseases Research Group, University of Extremadura, Cáceres, Spain
| | | | - Maria Pedrera-Canal
- Metabolic Bone Diseases Research Group, University of Extremadura, Cáceres, Spain
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Abstract
Studies examining fear of falling among older adult men remain limited. The objectives of this study were to compare balance confidence in 2 age cohorts of older clergy and identify predictive determinants of balance confidence in a liturgical research initiative. Participants included 131 community-dwelling Roman Catholic priests age 60–97 yr living in religious communities in 10 mid-Atlantic states. Subjects completed the Activities-specific Balance Confidence Scale (ABC), Berg Balance Scale (BBS), timed up-and-go (TUG) test, and 15-item Geriatric Depression Scale (GDS). Younger priests (60–74 yr) demonstrated a significantly higher ABC score than the older cohort (75 and above yr) of priests (89.1 ± 12.6 vs.78.4 ± 13.9,p= .001). Confidence was significantly correlated with BBS (rho = .69,p< .01), TUG (r= –.58,p< .01), and GDS (r= –.39,p< .01) scores. A stepwise-regression model demonstrated that balance ability, mood, assistive-device use, and physical activity predicted 52% of the variance in balance confidence.
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Laurent M, Gielen E, Claessens F, Boonen S, Vanderschueren D. Osteoporosis in older men: recent advances in pathophysiology and treatment. Best Pract Res Clin Endocrinol Metab 2013; 27:527-39. [PMID: 24054929 DOI: 10.1016/j.beem.2013.04.010] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Osteoporosis remains underrecognized and undertreated but more so in men, adding considerably to fracture burden and costs. Fracture-related morbidity and mortality is higher in men, partly due to greater frailty. Improved peak bone mass, geometry and turn-over contribute to lower fracture incidence in men. Bioavailable androgens and oestrogens regulate these aspects of musculoskeletal sexual dimorphism, yet the direct cellular and molecular targets of sex steroids in bone remain incompletely understood. Screening with clinical risk factors and dual energy X-ray absorptiometry are advised in men from age 70 (or 50 with additional risk factors). We now have compelling evidence that osteoporosis drugs are equally effective in men and women, not only to increase bone density but also to prevent osteoporotic fractures. The use of testosterone or selective androgen receptor modulators for osteoporosis, sarcopenia, frailty and falls in men with late-onset hypogonadism requires further investigation.
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Affiliation(s)
- Michaël Laurent
- Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium; Gerontology and Geriatrics, Department of Clinical and Experimental Medicine, KU Leuven, Herestraat 49, 3000 Leuven, Belgium; Laboratory of Molecular Endocrinology, Department of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
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Gould H, Brennan SL, Nicholson GC, Kotowicz MA, Henry MJ, Pasco JA. Calcaneal ultrasound reference ranges for Australian men and women: the Geelong Osteoporosis Study. Osteoporos Int 2013; 24:1369-77. [PMID: 22814945 DOI: 10.1007/s00198-012-2082-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Accepted: 07/04/2012] [Indexed: 11/27/2022]
Abstract
UNLABELLED Heel ultrasound is a more portable modality for assessing fracture risk than dual-energy X-ray absorptiometry and does not use ionising radiation. Fracture risk assessment requires appropriate reference data to enable comparisons. This study reports the first heel ultrasound reference ranges for the Australian population. INTRODUCTION This study aimed to develop calcaneal (heel) ultrasound reference ranges for the Australian adult population using a population-based random sample. METHODS Men and women aged≥20 years were randomly selected from the Barwon Statistical Division in 2001-2006 and 1993-1997, respectively, using the electoral roll. Broadband ultrasound attenuation (BUA), speed of sound (SOS) and stiffness index (SI) were measured at the heel using a Lunar Achilles Ultrasonometer. Gender-specific means and standard deviations for BUA, SOS and SI were calculated for the entire sample (men 20-93 years, n=1,104; women 20-92 years, n=914) and for participants aged 20-29 years (men, n=157; women, n=151). Associations between ultrasound measures and age were examined using linear regression. RESULTS For men, mean±standard deviation BUA, SOS and SI were 118.7±15.8 dB/MHz, 1,577.0±43.7 m/s and 100.5±20.7, respectively; values for women were consistently lower (111.0±16.4 dB/MHz, P<0.001; 1,571.0±39.0 m/s, P=0.001; and 93.7±20.3, P<0.001, respectively). BUA was higher in young men compared with young women (124.5±14.4 vs 121.0±15.1 dB/MHz), but SOS (1,590.1±43.1 vs 1,592.5±35.0 m/s) and SI (108.0±19.9 vs 106.3±17.7) were not. The relationships between age and each ultrasound measure were linear and negative across the age range in men; associations were also negative in women but non-linear. CONCLUSION These data provide reference standards to facilitate the assessment of fracture risk in an Australian population using heel ultrasound.
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Affiliation(s)
- H Gould
- NorthWest Academic Centre, Department of Medicine, The University of Melbourne, St Albans, Victoria, Australia.
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Bhattoa HP, Nagy E, More C, Kappelmayer J, Balogh A, Kalina E, Antal-Szalmas P. Prevalence and seasonal variation of hypovitaminosis D and its relationship to bone metabolism in healthy Hungarian men over 50 years of age: the HunMen Study. Osteoporos Int 2013; 24:179-86. [PMID: 22422303 DOI: 10.1007/s00198-012-1920-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Accepted: 01/25/2012] [Indexed: 10/28/2022]
Abstract
UNLABELLED This study reports a high prevalence of hypovitaminosis D and low bone mineral density (BMD) in a healthy Hungarian male cohort over 50 years of age. Men with 25-hydroxyvitamin D levels of <75 nmol/L had a significantly higher 10-year hip and major osteoporotic fracture probability using the country-specific fracture risk assessment (FRAX) algorithm. INTRODUCTION The aim of this study is to characterize the prevalence and seasonal variation of hypovitaminosis D and its relationship to bone metabolism in healthy Hungarian men over 50 years of age. METHODS We determined levels of 25-hydroxyvitamin D (25-OH-D), PTH, osteocalcin (OC), C-terminal telopeptides of type-I collagen (CTX-I), procollagen type 1 amino-terminal propeptide (PINP), BMD at L1-L4 (LS) and femur neck (FN), daily dietary calcium intake, and the 10-year probability of hip fracture and a major osteoporotic fracture using the country-specific FRAX algorithm in 206 randomly selected ambulatory men. RESULTS The mean (range) age of the volunteers was 60 (51-81) years. The prevalence of hypovitaminosis D (25-OH-D, <75 nmol/L) was 52.9%. The prevalence of low (T-score < -1.0) BMD at the FN and LS was 45% and 35.4%, respectively. The mean (range) FRAX hip fracture and FRAX major osteoporotic fracture was 0.8% (0-9.4%) and 3.8% (1.7-16%), respectively. On comparing the vitamin D sufficient to the insufficient group, there was a statistically significant difference between the FRAX hip fracture and FRAX major osteoporotic fracture indexes. There was significant seasonal variation in the vitamin D levels; the lowest levels were measured in winter and the highest in summer. CONCLUSIONS A high prevalence of hypovitaminosis D and low BMD were observed in the studied Hungarian male population. This is the first study reporting higher 10-year hip and major osteoporotic fracture probability using the country-specific FRAX algorithm in individuals with hypovitaminosis D.
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Affiliation(s)
- H P Bhattoa
- Department of Laboratory Medicine, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary.
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Paggiosi MA, Barkmann R, Glüer CC, Roux C, Reid DM, Felsenberg D, Bradburn M, Eastell R. A European multicenter comparison of quantitative ultrasound measurement variables: the OPUS study. Osteoporos Int 2012; 23:2815-28. [PMID: 22349910 DOI: 10.1007/s00198-012-1912-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Accepted: 01/13/2012] [Indexed: 10/28/2022]
Abstract
UNLABELLED Quantitative ultrasound (QUS) measurement variables vary between European countries in a different way to hip bone mineral density. Standardization of data can be achieved through statistical approaches to reduce any between-center differences in QUS measurement variables. However, further validation of this method is required before it can be widely applied. INTRODUCTION European between-center differences in hip bone mineral density (BMD) have been shown to exist; however, little is known about the geographical heterogeneity of QUS measurement variables. We aimed to examine the differences in QUS variables between three different European countries. METHODS Five calcaneal and phalangeal QUS devices in Sheffield, Aberdeen (UK), Kiel and Berlin (Germany), and three devices in Paris (France) were used to measure QUS variables in younger (n = 463, 20-39 years old) and older (n = 2,399, 55-79 years old) women participating in the European multicenter Osteoporosis and Ultrasound (OPUS) study. Broadband ultrasound attenuation, speed of sound, stiffness index, amplitude-dependent speed of sound, bone transmission time, and ultrasonic bone profiler index data were collected. Between-center differences were examined using ANOVA followed by post hoc Fisher's least significant difference tests, and ANCOVA with linear contrasts. p < 0.05 indicated statistical significance. RESULTS Between-center differences in nonstandardized QUS measurement variables existed for younger (p = 0.0023 to p < 0.0001) and older women (p < 0.001). Anthropometric characteristics exerted a significant influence on nonstandardized data (p = 0.045 to p < 0.001). However, following statistical standardization, based on height and weight or based on measurements made in young people, geographical heterogeneity in QUS measurement variables was no longer apparent. CONCLUSIONS QUS measurement variables vary between European countries in a different way to those for hip BMD. Standardization of data can be achieved through statistical approaches to reduce any between-center differences in QUS measurement variables. However, further validation of this method is required before it can be widely applied.
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Affiliation(s)
- M A Paggiosi
- Sheffield NIHR Biomedical Research Unit for Musculoskeletal Disease, University of Sheffield and Sheffield Teaching Hospitals NHS Foundation Trust, Centre for Biomedical Research, Northern General Hospital, Herries Road, Sheffield, S5 7AU, UK.
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Chin KY, Soelaiman IN, Mohamed IN, Ibrahim S, Wan Ngah WZ. The effects of age, physical activity level, and body anthropometry on calcaneal speed of sound value in men. Arch Osteoporos 2012; 7:135-45. [PMID: 23225291 DOI: 10.1007/s11657-012-0091-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Accepted: 06/21/2012] [Indexed: 02/03/2023]
Abstract
UNLABELLED The influences of age, physical activity, and body anthropometry on calcaneal speed of sound are different among young adults, middle-aged, and elderly men. INTRODUCTION Quantitative ultrasound assessment of bone health status is much needed for developing countries in the screening of osteoporosis, but further studies on the factors that influence the quantitative ultrasound indices are required. OBJECTIVES The present study examined the influence of age, lifestyle factors, and body anthropometry on calcaneal speed of sound (SOS) in a group of Malaysian men of diverse age range. SUBJECTS AND METHODS A cross-sectional study was conducted, and data from 687 eligible males were used for analysis. They answered a detailed questionnaire on their physical activity status, and their anthropometric measurements were taken. Their calcaneal SOS values were evaluated using the CM-200 sonometer (Furuno, Nishinomiya City, Japan). RESULTS Subjects with higher body mass index (BMI) had higher calcaneal SOS values albeit significant difference was only found in the elderly subjects (p < 0.05). Sedentary subjects had lower calcaneal SOS values than physically active subjects, but significant difference was only found in the middle-aged subjects (p < 0.05). Calcaneal SOS was significantly (p < 0.05) correlated with age in young men; height, BMI, and physical activity score in middle-aged men; height and physical activity score in elderly men; and age and physical activity score for overall subjects. In a multivariate regression model, significant (p < 0.05) predictors for calcaneal SOS included age for young men; physical activity, BMI, body fat percentage, and height for middle-aged men; height for elderly men; and age, height, physical activity, weight, and body fat percentage for overall subjects. CONCLUSION Age, body anthropometry, and physical activity level have significant effects on the calcaneal SOS value in men.
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Affiliation(s)
- Kok-Yong Chin
- Pharmacology Department, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300, Kuala Lumpur, Malaysia
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17
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Kwok T, Khoo CC, Leung J, Kwok A, Qin L, Woo J, Leung PC. Predictive values of calcaneal quantitative ultrasound and dual energy X ray absorptiometry for non-vertebral fracture in older men: results from the MrOS study (Hong Kong). Osteoporos Int 2012; 23:1001-6. [PMID: 21528361 DOI: 10.1007/s00198-011-1634-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Accepted: 03/02/2011] [Indexed: 10/18/2022]
Abstract
UNLABELLED Calcaneal QUS is comparable to DXA in predicting non-vertebral fractures in older Chinese men. INTRODUCTION The predictive values of calcaneal quantitative ultrasound (QUS) and dual-energy X-ray absorptiometry (DXA) for non-vertebral fractures in older Chinese men were examined. METHODS One thousand nine hundred twenty-one Chinese men aged 65-92 years had calcaneal QUS and axial DXA bone mineral density (BMD) measurements. The incidence of non-vertebral fractures was documented. Cox regression and receiver operating curve (ROC) analysis were used to examine the associations of QUS parameters and BMD with the incidence of non-vertebral fractures. RESULTS The duration of follow-up was (mean ± SD) 6.5 ± 1.7 years. One hundred thirty-one non-vertebral fractures were recorded, 71 of which were major fragility fractures. Broadband ultrasound attenuation (BUA) and quantitative ultrasound index (QUI) were significantly associated with non-vertebral fractures and major fragility fractures, with age and fracture history-adjusted hazard ratio (95% CI) of 1.23 (1.03, 1.47) and 1.32 (1.10, 1.59) per standard deviation reduction, respectively, for non-vertebral fractures; 1.32 (1.04, 1.68) and 1.43 (1.11, 1.84), respectively, for major fragility fractures. Age and fracture history-adjusted areas under ROC curves of hip or spine BMDs were significantly greater than that of BUA or QUI in predicting major fragility fractures, but not in predicting all non-vertebral fractures. The addition of BUA or QUI had no effect on AUCs of total hip BMD alone. CONCLUSIONS The ability of calcaneal QUS to predict non-vertebral fractures was comparable to that of axial BMD by DXA, but was inferior to BMD in predicting major fragility fractures in older Chinese men.
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Affiliation(s)
- T Kwok
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong, China.
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Lee DM, Pye SR, Tajar A, O'Neill TW, Finn JD, Boonen S, Bartfai G, Casanueva FF, Forti G, Giwercman A, Han TS, Huhtaniemi IT, Kula K, Lean MEJ, Pendleton N, Punab M, Silman AJ, Vanderschueren D, Wu FCW. Cohort Profile: The European Male Ageing Study. Int J Epidemiol 2012; 42:391-401. [DOI: 10.1093/ije/dyr234] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Chin KY, Ima-Nirwana S, Isa Naina M, Norazlina M, Ahmad Nazrun S, Norliza M, Faizah O, Farihah HS, Elvy Suhana MR, Wan Zurinah WN. Calcaneal quantitative ultrasound value for middle-aged and elderly Malaysian Chinese men and its association with age and body anthropometry. J Clin Densitom 2012; 15:86-91. [PMID: 22169197 DOI: 10.1016/j.jocd.2011.09.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Revised: 08/13/2011] [Accepted: 09/22/2011] [Indexed: 11/15/2022]
Abstract
Quantitative ultrasound (QUS) is a relatively easy, reliable, and safe method for bone status assessment, but reference data for Asian males remain scarce. Our study aimed to determine the values for one QUS parameter, the speed of sound (SOS) at the calcaneus, in Malaysian Chinese men and to determine the association between the SOS and several demographic characteristics, such as age, weight, height, and body mass index. Three hundred forty-eight Malaysian Chinese men aged 40 yr and older were recruited, and their calcaneal QUS value was determined using the CM-200 densitometer (Furuno Electric, Nishinomiya City, Japan). The results indicated a significant correlation between SOS and age, and multiple stepwise regression analysis indicated that age and height were important predictors of SOS. A significant reduction in SOS value was observed when men 60 yr and older were compared with men aged 40-49 yr. Compared with the reference data for Japanese males, Chinese men in Malaysia showed higher SOS values across all the age groups studied. In conclusion, there is an age-related decrease in SOS values in Malaysian Chinese men, and the SOS values established in this study can be used as a reference for future studies.
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Affiliation(s)
- Kok-Yong Chin
- Department of Pharmacology, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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Pye SR, Almusalam B, Boonen S, Vanderschueren D, Borghs H, Gielen E, Adams JE, Ward KA, Bartfai G, Casanueva FF, Finn JD, Forti G, Giwercman A, Han TS, Huhtaniemi IT, Kula K, Labrie F, Lean MEJ, Pendleton N, Punab M, Silman AJ, Wu FCW, O’Neill TW. Influence of insulin-like growth factor binding protein (IGFBP)-1 and IGFBP-3 on bone health: results from the European Male Ageing Study. Calcif Tissue Int 2011; 88:503-10. [PMID: 21503646 PMCID: PMC3920365 DOI: 10.1007/s00223-011-9484-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2010] [Accepted: 01/11/2011] [Indexed: 10/18/2022]
Abstract
The aim of this study was to determine the influence of insulin-like growth factor binding protein (IGFBP)-1, IGFBP-3, and IGF-I on calcaneal ultrasound parameters in middle-aged and elderly European men. Men aged 40-79 years were recruited from population registers for participation in the European Male Ageing Study (EMAS). Subjects were invited by letter to complete a postal questionnaire and to attend for an interviewer-assisted questionnaire, quantitative ultrasound (QUS) of the calcaneus, and a fasting blood sample from which serum levels of IGFBP-1, IGFBP-3, IGF-I, estradiol (E(2)), and SHBG were assayed. The questionnaires included the Physical Activity Scale for the Elderly (PASE) and questions about smoking and alcohol consumption. Estimated bone mineral density (eBMD) was derived as a function of the QUS parameters speed of sound and broadband ultrasound attenuation. Height and weight were measured in all subjects. 3057 men, mean age 59.7 years (standard deviation 11.0) were included in the analysis. After adjusting for age, center, and BMI, higher levels of IGFBP-1 were associated with lower eBMD. Higher levels of both IGFBP-3 and IGF-I were associated with higher eBMD. After further adjustment for PASE score, current smoking, alcohol consumption, free E(2), and SHBG, IGFBP-3 and IGF-I, though not IGFBP-1, remained significantly associated with eBMD. IGFBP-1 was associated with bone health, though the effect could be explained by other factors. IGFBP-3 and IGF-I were independent determinants of bone health in middle-aged and elderly European men.
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Affiliation(s)
- Stephen R Pye
- Arthritis Research UK Epidemiology Unit, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Bader Almusalam
- Arthritis Research UK Epidemiology Unit, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Steven Boonen
- Leuven University Division of Geriatric Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
- Leuven University Center for Metabolic Bone Diseases, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Dirk Vanderschueren
- Leuven University Center for Metabolic Bone Diseases, Katholieke Universiteit Leuven, Leuven, Belgium
- Department of Andrology and Endocrinology, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Herman Borghs
- Leuven University Center for Metabolic Bone Diseases, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Evelien Gielen
- Leuven University Division of Geriatric Medicine, Katholieke Universiteit Leuven, Leuven, Belgium
- Leuven University Center for Metabolic Bone Diseases, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Judith E Adams
- Clinical Radiology, Imaging Science and Biomedical Engineering, The University of Manchester, and the Royal Infirmary, Manchester Academic Health Science Centre, Manchester, UK
| | - Kate A Ward
- Clinical Radiology, Imaging Science and Biomedical Engineering, The University of Manchester, and the Royal Infirmary, Manchester Academic Health Science Centre, Manchester, UK
- MRC Human Nutrition Research, Elsie Widdowson Laboratory, Cambridge, UK
| | - Gyorgy Bartfai
- Department of Obstetrics, Gynaecology and Andrology, Albert Szent-Gyorgy Medical University, Szeged, Hungary
| | - Felipe F Casanueva
- Department of Medicine, Santiago de Compostela University, Complejo Hospitalario Universitario de Santiago (CHUS); CIBER de Fisiopatología Obesidad y Nutricion (CB06/03), Instituto Salud Carlos III; Santiago de Compostela, Spain
| | - Joseph D Finn
- Andrology Research Unit, Developmental & Regenerative Biomedicine Research Group, The University of Manchester, Manchester Academic Health Science Centre, Manchester Royal Infirmary, Manchester, UK
| | - Gianni Forti
- Endocrinology Unit, Department of Clinical Physiopathology, University of Florence, Florence, Italy
| | - Aleksander Giwercman
- Reproductive Medicine Centre, Skåne University Hospital, University of Lund, Malmo, Sweden
| | - Thang S Han
- Department of Endocrinology, University College London, London, UK
| | - Ilpo T Huhtaniemi
- Department of Reproductive Biology, Imperial College London, Hammersmith Campus, London, UK
| | - Krzysztof Kula
- Department of Andrology and Reproductive Endocrinology, Medical University of Lodz, Lodz, Poland
| | - Fernand Labrie
- Laboratory of Molecular Endocrinology and Oncology, Laval University, Quebec City, Quebec, Canada
| | - Michael EJ Lean
- Department of Human Nutrition, University of Glasgow, Glasgow, Scotland
| | - Neil Pendleton
- School of Community Based Medicine, The University of Manchester, Salford Royal NHS Trust, Salford, UK
| | - Margus Punab
- Andrology Unit, United Laboratories of Tartu University Clinics, Tartu, Estonia
| | | | - Frederick CW Wu
- Andrology Research Unit, Developmental & Regenerative Biomedicine Research Group, The University of Manchester, Manchester Academic Health Science Centre, Manchester Royal Infirmary, Manchester, UK
| | - Terence W O’Neill
- Arthritis Research UK Epidemiology Unit, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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