A 12-year ecological study of hip fracture rates among older Taiwanese adults

Spine, hip, and femoral neck bone mineral density in relation to vegetarian type and status among Taiwanese adults

We determined the association of vegetarian type and status with bone mineral density (BMD) Z-scores at the spine, hip, and femoral neck. Compared to non-vegetarians, current vegetarians, especially vegans, lacto-vegetarians, and lacto-ovo-vegetarians had lower Z-scores at multiple sites. Sole reliance on a vegetarian diet might be detrimental to the bone.

PURPOSE

The impact of vegetarian diets on BMD is contentious. We determined the association of vegetarian type and status with the spine, hip, and femoral neck BMD Z-scores.

METHODS

We analyzed data from 20,110 Taiwan Biobank volunteers. BMD was measured using dual-energy X-ray absorptiometry (DXA). The vegetarian status (non-, former, and current vegetarians) and type (non-vegetarians, ovo-vegetarians, lacto-vegetarians, lacto-ovo-vegetarians, and vegans) were determined using questionnaires.

RESULTS

The participants consisted of 12,910 women and 7200 men, with a mean age of 55.5 years. Based on vegetarian status (reference: non-vegetarians), current vegetarians had significantly lower BMD Z-scores at the spine (unstandardized regression coefficient, B =  - 0.195, p = 0.006), left hip (B =  - 0.125, p = 0.008), and right hip (B =  - 0.100, p = 0.027), respectively. Based on vegetarian status and type (reference: non-vegetarians), current vegans and non-vegans had notably lower BMD Z-scores at specific skeletal sites. For non-vegans, the BMD Z-scores were significant at the spine (B = -0.184, p = 0.010), left hip (B =  - 0.124, p = 0.010), and left femoral neck (B =  - 0.125, p = 0.012). For current vegans, however, the BMD Z-scores were significant only at the right hip (B =  - 0.232; p = 0.028). Nonetheless, after stratifying vegetarian diet into more subgroups, current vegans exhibited a significant reduction in BMD Z-scores at the spine and right hip, with B-coefficients of - 0.326 and - 0.238, respectively. Current lacto-vegetarians also had significantly lower Z-scores (p < 0.05) at the spine (B =  - 0.459), left hip (B =  - 0.313), and right hip (B =  - 0.214). Moreover, current lacto-ovo-vegetarians had significantly lower Z-scores at the spine (B =  - 0.175) and left hip (B =  - 0.115).

CONCLUSION

Current vegetarians, particularly vegans, lacto-vegetarians, and lacto-ovo-vegetarians, demonstrated significantly lower BMD Z-scores at various skeletal sites compared to non-vegetarians. Sole reliance on a vegetarian diet might be detrimental to the bone.

Prevalence of osteoporosis and incidence of related fractures in developed economies in the Asia Pacific region: a systematic review

Robust data on osteoporosis in the Asia Pacific region could improve healthcare decision-making. Osteoporosis affects 10-30% of women aged 40 + , and up to 10% of men in 7 developed economies in Asia Pacific. Fractures affect 500-1000 adults aged 50 + per 100,000 person-years. Policymakers and clinicians must address this problem.

PURPOSE

Osteoporosis and associated fractures result in considerable morbidity, loss of productivity, early mortality, and increased healthcare expenses. Many countries in the Asia Pacific (AP) region, especially middle- and higher-income economies, are faced with aging and increasingly sedentary populations. It is critical to consolidate and analyze the available information on the prevalence and incidence of the disease in these countries.

METHODS

We systematically reviewed articles and gray literature for Australia, China, Hong Kong, Japan, Singapore, South Korea, and Taiwan. We searched PubMed, ScienceDirect, JSTOR, Cochrane, Google Scholar, and other databases for data published 2009-2018. We included articles with prevalence or incidence estimates for adults with osteoporosis or related fractures.

RESULTS

All locations had data available, but of widely varying quantity and quality. Most estimates for osteoporosis prevalence ranged from 10 to 30% for women ages 40 and older, and up to 10% for men. Osteoporotic fracture incidence typically ranged between 500 and 1000 per 100,000 person-years among adults aged 50 and older. Both outcomes typically increased with age and were more common among women.

CONCLUSION

Osteoporosis and associated fractures affect significant portions of the adult population in developed economies in the AP region. Governments and healthcare systems must consider how best to prevent and diagnose osteoporosis, and manage affected individuals, to reduce healthcare costs and mortality associated with fractures.

Secular trends in the incidence of fracture hospitalization between 2000 and 2015 among the middle-aged and elderly persons in Taiwan: A nationwide register-based cohort study

OBJECTIVE

Fractures are a common reason for hospital admissions. However, regional and short-term studies show a varying incidence rate (IR) of fractures, and most of the surveys were conducted from only a few medical centers. Therefore, this study aims to investigate the epidemiological data of fracture hospitalizations of middle-aged and elderly persons in Taiwan between 2000 and 2015.

MATERIALS AND METHODS

Data from fractures occurring between 2000 and 2015 were obtained from the National Health Insurance Research Database in Taiwan for this study. The IR of fracture admission in patients, aged 40 years or older at the time of admission and first-time diagnosed with a fracture following admission, was calculated.

RESULTS

We found that the IR of the fracture hospitalizations declined considerably from 95.70 per 10,000 person-years in 2000, to 68.48 per 10,000 person-years in 2015. The three most common fracture hospitalizations accounting for more than 50% of all fractures were fractures of the femur/hip, radius or ulna, and vertebral column. The IR of fracture hospitalization increased with age and was found to be higher in women than in men. The most common cause of fracture hospitalization for men and patients under 65 years of age was traffic accidents. In contrast, falls were the most frequent causes of fracture hospitalization for women and patients over 65 years of age.

CONCLUSION

The present study furnishes an updated picture of the incidence of fracture hospitalization over a 16-year period among middle-aged and elderly persons in Taiwan.

The molecular pathway triggered by zirconia in endothelial cells involves epigenetic control

The requirement to achieve natural looking restorations is one of the most challenging aspects in dentistry. Although zirconia has provided new opportunities for achieving superior aesthetics and physicochemical outcomes, very little has been achieved for its cellular and molecular performance, especially considering angiogenesis and osteogenesis. As angiogenesis is a secondary event and concomitant to osteogenesis, an indirect effect of dental implant on endothelial cells could be the release of active molecules such as those already reported affecting osteoblasts. To better address this issue, we challenged human endothelial cells (HUVECs) with zirconia-conditioned medium up to 72 h to allow analysis specific gene expression and protein pattern of mediators of epigenetic machinery in full. Our data shows involvement of zirconia in triggering intracellular signaling through MAPK-ERK activation, leading the signal to activate histone deacetylase HDAC6 likely with concomitant well-modulated DNA methylation profile by DNMTs and TETs. These signaling pathways seem to culminate in cytoskeleton rearrangement of endothelial cells, an important prerequisite to cell migration expected in angiogenesis. Collectively, this study demonstrates for the first time epigenetic-related molecular mechanism involved in endothelial cells responding to zirconia, revealing a repertoire of signaling molecules capable of executing the reprogramming process of gene expression, which are necessary to drive cell proliferation, migration, and consequently angiogenesis. This set of data can further studies using gene editing approaches to better elucidate functional roles.

Secular trends of patients hospitalized for major osteoporotic fractures based on a national claims database

There was a reduction in the hospitalization rate for major osteoporotic fractures. As per our analysis, hospitalization for site-specific fractures showed a declining trend for hip and vertebral fractures for both the sexes. However, an increasing trend was noted in women regarding hospitalization for forearm fracture.

PURPOSE

Major osteoporotic fractures (MOFs) constitute a large proportion of the total expenditures for public healthcare. Knowing the secular trends of MOF will allow for more efficient use of healthcare resources, but such data are insufficient for the current population of Taiwan. Therefore, we investigated the epidemiological data of MOF hospitalization from adults 50 years of age or older in Taiwan during the period 2000-2015.

METHODS

The data analyzed were acquired from the Taiwan National Health Insurance Research Database (NHIRD) entries between 2000 and 2015. All study subjects were 50 years of age or older at the time of admission and diagnosed as having MOF.

RESULTS

A general decline was observed in the incidence rate (IR) of MOF hospitalization for the whole population, from 74.52 per 10,000 person-years (PYs) in 2000 to 55.19 in 2015. Females aged ≥65 years had the highest rates of hospitalization for MOF among the subgroups analyzed. Apart from the wrist fracture hospitalization rates in both sexes, which remained steady, all other site-specific fracture hospitalization rates exponentially increased with age. Among men, the IRs of all MOF hospitalization were steady, except for a slight decrease in hip and vertebral fracture hospitalizations. In women, hip and vertebral fracture hospitalization rates gradually decreased, humerus and wrist fracture hospitalization remained steady, and forearm fracture hospitalization increased.

CONCLUSIONS

Hospitalization rates of MOF decreased. The trend of site-specific fracture hospitalization analysis showed that hip and vertebral fractures decreased for both sexes. However, an increasing trend in forearm fracture hospitalization was noticed among females.

Prevalence and risk factors associated with osteoporosis among residents aged above 20 years old in Chongqing, China

Standardized prevalence of osteoporosis was 19.90% in the whole subjects aged between 50 and 87, 5.87% in men and 30.23% in women respectively. Risk factors associated with osteoporosis were analyzed. It is the first time to estimate the prevalence and characterize the epidemiology of osteoporosis in Chongqing, China.

PURPOSE

To investigate bone mineral density (BMD) profiles, osteoporosis prevalence, and its risk factors among residents aged above 20 years old in Chongqing Municipality, China.

METHODS

The study population consisted of 770 men and 1085 women aged 20 years and older with BMD measurements using central dual-energy X-ray absorptiometry (DXA). Information on sociodemographic characteristics and the potential risk factors associated with osteoporosis were collected by a standardized interviewer-administered questionnaire.

RESULTS

Crude prevalence of osteoporosis was 12.99% in the whole subjects, 4.42% for men, and 19.08% for women by WHO criteria at various skeletal regions (among lumbar spine, femoral neck, and total hip). Standardized prevalence of osteoporosis was 19.90% in the whole subjects aged between 50 and 87, 5.87% in men and 30.23% in women respectively. Prevalence of osteoporosis increased with age, and the prevalence of osteoporosis in women was 6.10 times higher than it in men. The prevalence of osteoporosis was significantly associated with the past medical history of fracture (OR = 1.794, P = 0.007); overweight and obesity were considered to be protective factors for osteoporosis with OR of 0.514 and 0.300, respectively; high school graduate (OR = 0.399, P = 0.000 ) and milk intake (OR = 0.648, P = 0.008) were also protective factors for osteoporosis in men and women considered together; menopause was an independent risk factor of osteoporosis in females (OR = 1.782, P = 0.029); current smoking was an independent risk factor of osteoporosis in males (OR = 2.437, P = 0.046).

CONCLUSION

The prevalence of osteoporosis and osteopenia was high among residents in Chongqing, China. Health education and behavior intervention should be focused on the elderly or female residents to promote the formulation of healthy lifestyle. Necessary steps are needed for more public education and a wider dissemination of information about osteoporosis and its prevention.

Comparison of Bone Mineral Densitometry at 2 Sites Versus 3 Sites in Patients Suspicious for Osteoporosis

Objectives:

In this study, we aim to evaluate the bone mineral density (BMD) results of 2 standard sites with 3 sites including wrist in diagnosing osteoporosis.

Methods:

We evaluated the BMD results of 1272 individuals referred for suspected osteoporosis between 2012 and 2015. Those individuals were included with BMD at lumbar spine, femur neck, and wrist. Bone mineral density was measured using a dual-energy X-ray absorptiometry (DXA) device. Bone mineral density and T score were measured for all 3 sites.

Results:

There was significant correlation between wrist T score with hip T score (r = 0.606, P < .001) and lumbar T score (r = 0.527, P < .001). With BMD of 2 sites, patients had osteopenia in 46.3% and osteoporosis in 23.7%, while by adding wrist T-BMD, subjects had osteopenia in 46.6% and osteoporosis in 33%. Between BMD at 2 sites and 3 sites, there was concordance in 81.9%, minor discordance in 17.6%, and major discordance in 0.5%.

Conclusions:

We observed discordance between BMD measurements of 2 sites and 3 sites, with latter detecting more cases with osteoporosis. In fact, measurement of T scores of wrist along with lumbar and femur neck improves the diagnosis.

Does coffee drinking have beneficial effects on bone health of Taiwanese adults? A longitudinal study

Background

Results from studies investigating the association between coffee consumption and osteoporosis or bone mineral density (BMD) have been inconsistent. This longitudinal study was performed to assess the effect of coffee drinking on bone health of Taiwanese adults.

Methods

Data were retrieved from the Li-Shin (Landseed) Hospital in Taoyuan City. In 2006, 6152 participants completed a questionnaire on coffee drinking and other lifestyle factors. In 2014, 5077 of them were followed up. Nonetheless, a total of 2395 participants with incomplete data were excluded. The final analyses included 2682 participants comprising 1195 men and 1487 women (706 premenopausal and 781 postmenopausal). T-scores were derived from the osteo-sono assessment index (OSI) which is a surrogate of BMD. Coffee drinking was categorized as “no, medium, and high” based on the number of cups that were consumed per week in both 2006 and 2014.

Results

In general, medium and high coffee drinking were associated with higher T-scores. However, significant results were observed only among high drinkers (β = 0.158; P = 0.0038). Nonetheless, the test for linear trend was significant (P = 0.0046). After stratification by sex, medium and high coffee drinking were associated with higher T-scores. However, significant results were prominent only among high male drinkers (β = 0.237; P = 0.0067) and the test for trend was significant (P = 0.0161). Based on menopausal status, coffee drinking was associated with higher T-scores. Nevertheless, significant results were found only among premenopausal women (β = 0.233; P = 0.0355 and β = 0.234; P = 0.0152 for medium and high coffee drinking, respectively. The test for linear trend was significant (P = 0.0108).

Conclusion

Coffee drinking was significantly associated with higher T-scores hence, a lower risk of osteoporosis in men and premenopausal women.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6168-0) contains supplementary material, which is available to authorized users.

Secular trends in incidence of osteoporosis in Taiwan: A nationwide population-based study

Background

The present study aimed to assess the changes in trend of osteoporosis among the Taiwanese population from 2001 to 2011.

Methods

The National Health Insurance Research Database (NHIRD) of Taiwan, containing records from approximately 23 million insures from 2001 to 2011, was analyzed. Insurees aged≧50 years with osteoporosis were identified either from previously documented osteoporotic diagnosis or osteoporosis-related fractures according to Clinical Modification (ICD-9-CM) diagnostic code.

Results

The prevalence of osteoporosis increased from 17.4% in 2001 to 25.0% in 2011. The prevalence trend increased from 2001 to 2005 and plateaued thereafter. During 2001–2005, the incidence rate of hip fracture held steady from 277 to 281 per 100,000 person-years, and decreased thereafter from 262 to 247 per 100,000 person-years. The overall incidence of osteoporosis declined among patients younger than 84 years from 2001 to 2011, especially after 2005. As compared with 2005 and before, the incidence rate of osteoporosis was significantly decreased since 2006.

Conclusions

The secular changes of osteoporosis in Taiwan are quite similar to the trend in western countries. It reveals how osteoporosis awareness and policy interventions can affect the prevalence trend of osteoporosis.

Fractures and the increased risk of suicide

Aims

A high rate of suicide has been reported in patients who sustain fractures, but the association remains uncertain in the context of other factors. The aim of this study was to examine the association between fractures and the risk of suicide in this contextual setting.

Patients and Methods

We performed a case-control study of patients aged 40 years or older who died by suicide between 2000 and 2011. We included patients’ demographics, physical and mental health problems, and socioeconomic factors. We performed conditional logistic regression to evaluate the associations between fractures and the risk of suicide.

Results

We included a total of 34 794 patients who died by suicide and 139 176 control patients. We found that fractures as a homogenous group (adjusted odds ratios (aOR), 1.48; 95% confidence interval (CI) 1.43 to 1.53), and specifically pelvic (aOR 2.04; 95% CI 1.68 to 2.47) and spinal fractures (aOR 1.53; 95% CI 1.43 to 1.64), were associated with a higher risk of suicide. In addition, we found that patients who had a lower income, had never married, had lower levels of educational attainment, or had coexistent physical and mental conditions such as anxiety, mood disorders, and psychosis-related disorders had a higher risk of suicide.

Conclusion

Fractures, specifically those of the hip and spine, were associated with an increased risk of suicide. The findings suggest that greater clinical attention should be given to this risk in patients with fractures, especially for those with additional risk factors. Cite this article: Bone Joint J 2018;100-B:780–6.

Icariin regulates the osteoblast differentiation and cell proliferation of MC3T3-E1 cells through microRNA-153 by targeting Runt-related transcription factor 2

Osteoporosis has become one of the most serious public health problems. Icariin, miR-153 and Runt-related transcription factor 2 (Runx2) have been demonstrated to regulate cell proliferation and differentiation in multiple cells. The aim of the present experiments was to investigate the potential mechanism underlying osteoblast differentiation and cell proliferation of MC3T3-E1 cells treated with icariin. Cell Counting kit-8, alkaline phosphatase (ALP) activity and alizarin red S assays, as well as reverse transcription-quantitative polymerase chain reaction and western blot analysis, were performed to examine whether icariin promoted osteoblast differentiation and cell proliferation in MC3T3-E1 cells. Subsequently, miR-153 target and pathway prediction, and functional analysis were assessed. The results demonstrated that icariin promoted proliferation, mineral content and ALP activity in MC3T3-E1 cells. In addition, miR-153 and Runx2 expression levels were increased following treatment with icariin. Luciferase assay revealed that miR-153 significantly upregulate the luciferase activity of wild-type (Wt) Runx2 3′-untranslated region. Furthermore, the group treated with a combination of miR-153 mimics and icariin exhibited a significantly higher expression of Runx2 in comparison with the miR-153 mimic-treated alone group. Finally, icariin reversed the potential effect of miR-153 inhibitor in MC3T3-E1 cells. In conclusion, icariin exerted a strong osteoblast differentiation effect in MC3T3-E1 cells through the miR-153/Runx2 pathway. The current study provided evidence suggesting that icariin should be considered as an effective candidate for the management of osteoporosis.

Prevalence of and factors associated with adopting bone health promoting behaviours among people with osteoporosis in Taiwan: a cross-sectional study

OBJECTIVES

To detect osteopenia, osteoporosis, treatments received and bone health promoting behaviours early among postmenopausal women and elderly men, and to explore the associated factors.

DESIGN

A community-based cross-sectional study.

SETTINGS

Two rural townships in Yunlin County, Taiwan.

PARTICIPANTS

A total of 941 adults including 651 postmenopausal women and 290 elderly men aged >65 years.

OUTCOME MEASURES

Bone mineral density was measured using dual-energy X-ray absorptiometry. Adults with a T-score <-1.0 for bone mineral density were classified as having osteopenia, and those with a T-score <-2.5 as having osteoporosis. The main outcome measures were prevalence of osteopenia, osteoporosis, receiving medication and bone health promoting behaviours. A logistic regression model was used to analyse the factors associated with adopting bone health promoting behaviours.

RESULTS

Across both genders, 63.7% of participants were identified as having osteopenia (46.9%) or osteoporosis (16.8%). A high proportion of participants reported never or seldom performing regular exercise, or having sunlight exposure, a diet containing calcium/vitamin D or taking medications/supplements for bone health. Although 34.8% reported taking supplements, 92.4% were inadequate. The logistic regression model indicated that older age (OR 1.03, 95% CI 1.01 to 1.05, p=0.006) and a high education level (OR 1.07, 95% CI 1.03 to 1.11, p<0.001) were significant factors associated with bone health promoting behaviours.

CONCLUSION

The prevalence of osteopenia and osteoporosis among postmenopausal women and elderly men is worryingly high and most of them receive inadequate treatment and perform few bone health promoting behaviours. Interventions are therefore urgently required to address the right methods for delaying osteoporosis among postmenopausal women and elderly men in rural areas.

Use of Oral Corticosteroids and Risk of Hip Fracture in the Elderly in a Case-Control Study

Aim: Little is known regarding the relationship between use of oral corticosteroids and hip fracture in the elderly in Taiwan. The aim of the study was to examine this issue.

Methods: A retrospective population-based case-control study using the database of the Taiwan National Health Insurance Program (2000–2013) was conducted. We identified 4538 individuals aged ≥ 65 years with newly diagnosed hip fracture as the cases. We randomly selected 4538 individuals without hip fracture as the control subjects. The cases and the control subjects were matched with sex, age, comorbidities, and the year of index date. Individuals who never had a prescription for oral corticosteroids were defined as never use. Individuals who ever had at least one prescription for oral corticosteroids were defined as ever use. The odds ratio (OR) and 95% confidence interval (CI) of hip fracture associated with oral corticosteroids use was estimated by a multivariable unconditional logistic regression analysis.

Results: After adjustments for potential confounding factors, the multivariable logistic regression model showed that the adjusted OR of hip fracture was 1.17 for individuals with ever use of oral corticosteroids (95%CI 1.08, 1.28), compared to those with never use of oral corticosteroids. An sub-analysis showed that for every 1-mg increase in cumulative dose of oral corticosteroids, the adjusted OR of hip fracture was 1.01 (95% CI 1.01, 1.02). The adjusted ORs were 1.31 (95% CI 1.17, 1.47) for cumulative exposure to oral corticosteroids ≥ 3 months and 1.09 (95% CI 0.98, 1.20) for cumulative exposure < 3 months.

Conclusion: We conclude that oral corticosteroids use is associated with a trivial but statistically significant increase in risk of hip fracture in Taiwan. Additionally, the results suggest that there are dose-response and duration-response effects of oral corticosteroids on the risk of hip fracture. The results confirm our understanding of oral corticosteroid-associated hip fracture in the elderly.

Economic burden of osteoporosis-related hip fracture in Asia: a systematic review

This review analyzes the economic costs of HF in Asia. The availability and quality of studies on the burden of osteoporosis in Asia are very scarce. There is a need to encourage more quality cost of osteoporosis studies based on standardized methods to convince healthcare authorities in implementing appropriate strategies.

INTRODUCTION

Osteoporosis fractures, especially hip fractures, impose large economic costs to governments and societies. This review aimed to systematically analyze available evidence on healthcare costs associated with osteoporosis-related hip fractures (HF) in Asia.

METHODS

Articles were systematically sought from databases including PubMed, EMBASE, and EBSCOHost between 2000 and 2015. Total costs associated with HF care, the cost components, and length of stays were retrieved and analyzed. Study designs were also qualitatively analyzed.

RESULTS

The availability of published studies on economic burden of HF in Asia is severely lacking with only 15 articles met the inclusion criteria. Even among the included studies, only two studies reported comprehensive costs evaluating all costs including indirect or intangible costs. Most studies satisfactorily reported criteria for conducting economic evaluation, but large variations existed in the methodological design. Due to study design and other influencing factors, large variation in the cost of HF treatment from US$774 to US$14,198.90 (median S$2943), representing an average of 18.95% (range: 3.58-57.05%) of the countries' 2014 GDP/capita, was observed. This highlighted the heavy burden of managing HF in Asia with about 40% of the included studies reported using more than one third of GDP/capita.

CONCLUSION

There is a paucity of burden of illness studies of osteoporosis in the Asian region. For the few available studies, there was a lack of standardization in methodological approach in evaluating the economic burden of the disease. There is a need to encourage more quality burden of illness studies of osteoporosis to inform policymakers in healthcare planning.

Trends in hip fracture rates in Taiwan: a nationwide study from 1996 to 2010

There was an initial increase and a later decrease in hip fracture rates in Taiwan between 1996 and 2010 (457.9 to 390.0 fractures per 100,000 people per year). Mortality rates decreased but re-emerged later (2.26 to 1.91 deaths per 100 hip fracture admissions). The turning point for change in trends was 2003.

INTRODUCTION

Fractures of the proximal femur remain a major cause of mortality and morbidity. We aimed to examine recent trends in hip fracture rates, in-hospital mortality rates, and length of hospital stay (LOS) due to hip fractures in people aged 55 and over in Taiwan.

METHODS

This is a time-trend study. We used data from the National Health Insurance Research Database between 1996 and 2010 in Taiwan. Insurants aged 55 and over were included. The outcome measures were age-adjusted hip fracture rates, age-adjusted in-hospital mortality rates, and LOS due to hip fractures. We classified hip fractures into femoral neck, trochanteric, and subtrochanteric fractures.

RESULTS

We identified 250,919 hospitalizations for hip fractures. The total number of hip fractures increased steadily from 12,479 to 19,841 cases. There was a trend towards initial increase and then later decrease in hip fracture rates (from 457.9 to 390.0 fractures per 100,000 people per year). LOS decreased by 46.5 % (17.53 to 9.38 days). By contrast, mortality rates for hip fractures decreased initially, but re-emerged later with a total decrement of 15.5 % (2.26 to 1.91 deaths per 100 hip fracture admissions). Women outnumbered men in all types of hip fractures, but men had higher in hospital mortality rates. LOS was similar between genders and among age groups. The turning point for change in trends was year 2003.

CONCLUSIONS

While LOS shortened gradually since 1996, the absolute number of hip fractures in Taiwan continues to rise. There is still room for improvement in reducing mortality due to hip fractures.

Association between teriparatide treatment persistence and adherence, and fracture incidence in Taiwan: analysis using the National Health Insurance Research Database

Medication persistence and adherence are critical for osteoporosis outcomes. Using the Taiwan National Health Insurance Research Database, we found that persistence and adherence to teriparatide were low in Taiwanese patients with osteoporosis and that greater persistence and adherence were associated with a lower incidence of hip and other nonvertebral fractures.

INTRODUCTION

The purpose of this study was to determine the persistence and adherence to teriparatide treatment in Taiwanese patients with osteoporosis, and to examine the association between persistence and adherence to teriparatide with fracture risks.

METHODS

Medical and pharmacy claims for 4,692 patients with vertebral or hip fractures and teriparatide prescriptions between 2005 and 2008 were identified (Taiwan National Health Insurance Research Database). Persistence was the time from the start of treatment to the first 90-day gap between two teriparatide prescriptions. Adherence was the number of teriparatide pens (each pen is used over 1 month) prescribed over 24 months. Association of persistence and adherence to teriparatide with fracture incidence was assessed using adjusted Cox proportional hazards models.

RESULTS

The proportion of patients persisting with teriparatide for >6 months and >12 months was 44.6 and 24.9 %, respectively. Over 24 months, 53.6 % of patients were adherent for >6 months and 33.9 % were adherent for >12 months. Patients persisting for >12 months had a significantly lower incidence of hip (adjusted hazard ratio [HR], 0.61 [95 % confidence interval (CI), 0.40-0.93], P = 0.0229) and nonvertebral fracture (HR, 0.79 [95 % CI, 0.63-0.99], P = 0.0462) compared with those who persisted for ≤12 months. Patients adherent for >12 months had a lower incidence of hip (HR, 0.66 [95 % CI, 0.46-0.96], P = 0.0286) and nonvertebral fracture (HR, 0.81 [95 % CI, 0.66-0.99], P = 0.0377) compared with those adherent for ≤12 months.

CONCLUSIONS

Persistence and adherence to teriparatide over 24 months were low in Taiwanese patients with osteoporosis; greater adherence and persistence were associated with a lower incidence of nonvertebral fractures.

Prevalence of Osteoporosis and Low Bone Mass in Older Chinese Population Based on Bone Mineral Density at Multiple Skeletal Sites

Diagnosis of osteoporosis is based on bone mineral density (BMD) measurement, which is site dependent and commonly discordant between measurement sites. We aimed to determine the prevalence of osteoporosis diagnosed based on BMD T-scores measured by dual-energy x-ray absorptiometry (DXA) at different sites: the lumbar spine (LS) alone, femoral neck (FN) alone, or both. A total of 1712 women and 2028 men with LS and FN BMD measurements were enrolled. Over 50% discordance was found between osteoporosis classifications based on T-scores measured at the LS and FN. Use of the lowest T-scores measured at both the LS and right and left FN (rather than one site) significantly increased the prevalence of osteoporosis from 4.03 to 10.75% in postmenopausal women and 1.82 to 4.29% in men aged ≧50 years (p < 0.001). The trends of overall and age-adjusted prevalence of osteoporosis were similar in women and men. Osteoporosis was diagnosed at a higher rate if the USA reference rather than the Asia reference was used to calculate the T-score (26.64% vs. 10.75%). In conclusion, diagnosis based on the lowest T-score from multiple site BMD measurement can increase the prevalence of osteoporosis, demonstrating the higher sensitivity of the multiple site measurement strategy.

Epidemiology of fragility fractures in Sakaiminato, Japan: incidence, secular trends, and prognosis

We investigated the incidence of fragility fractures from 2010 to 2012 in Sakaiminato, Japan. The incidence rates of limb fractures in Sakaiminato were lower than in Caucasian populations but had increased relative to data obtained in Japan in the 1990s. Clinical vertebral fractures occurred at higher rates in Sakaiminato than in Caucasian populations.

INTRODUCTION

To elucidate the incidence and prognosis of fragility fractures in Sakaiminato, Japan.

METHODS

A survey of all hip, distal radius, proximal humerus, and clinical vertebral fractures was performed from 2010 to 2012 in patients aged 50 or older in Sakaiminato city, Tottori prefecture, Japan. The age- and gender-specific incidence rates (per 100,000 person-years) were calculated based on the population of Sakaiminato city each year. The incidence rates of hip, distal radius, and proximal humerus fractures were compared with previous reports. We conducted a follow-up study assessing patients within 1 year following their initial treatment at two Sakaiminato hospitals.

RESULTS

The age-adjusted incidence rates in population aged 50 years or older (per 100,000 person-years) of hip, distal radius, proximal humerus, and clinical vertebral fractures were, respectively, 217, 82, 26, and 412 in males and 567, 432, 96, and 1229 in females. Age-specific incidence rates of hip, distal radius, and proximal humerus fractures all increased since the 1990s. Our study also revealed that anti-osteoporotic pharmacotherapy was prescribed 1 year post-fracture at rates of 29, 20, 30, and 50 % for patients with hip, distal radius, proximal humerus, and clinical vertebral fractures, respectively.

CONCLUSIONS

The incidence rates of limb fractures in Sakaiminato were substantially lower than Caucasian populations in northern Europe but had increased relative to data obtained in Japan in the 1990s. Unlike upper and lower limb fractures, clinical vertebral fractures occurred at higher rates in our study population than in other Asian and North European countries.

Risk factors and incidence of repeat osteoporotic fractures among the elderly in Taiwan: a population-based cohort study

The incidence of osteoporotic fracture (OF), a condition that leads to higher morbidity and mortality in the elderly, is increasing yearly worldwide. However, most studies of OF have focused on the epidemiology of initial fractures, mainly in female and white populations. This study aimed to explore the incidence and the risk factors for repeat osteoporotic fracture (ROF) in Taiwan.We performed a retrospective cohort study using the Taiwan National Health Insurance Database (NHIRD) from 1995 through 2011. Individuals aged 65 years or older who experienced an initial OF were included. The patients were followed until death, the end of registration in the NHIRD, ROF occurrence, or the end of the study period (December 31, 2011), whichever occurred first. The incidence of ROF over ≥ 5 years after the initial fracture was analyzed, and the risk factors for ROF were assessed using Cox proportional hazards models. The incidence rates of ROF were 950.5, 321.4, 158.7, 92.8, and 70.2 per 1000 person-years among subjects in their first, second, third, fourth, and fifth years after the initial OF, respectively. Nearly 45% of the subjects sustained a ROF in the first year after OF. ROF risk increased with age and Charlson Comorbidity Index (CCI) score. Greater risk for ROF was observed among female subjects and those who had suffered from hip and vertebral fracture at the first OF, had undergone OF-related surgery, and had received bone-related medications. The incidence of ROF in the Taiwanese elderly is higher during the first year after the initial OF, and ROF risk increases with age, female sex, high CCI score, and in those who have undergone OF-related surgery, sustained hip or vertebral fracture, and used bone-related medications.

A systematic review on the use of daily subcutaneous administration of teriparatide for treatment of patients with osteoporosis at high risk for fracture in Asia

This systematic review aimed to examine the evidence for teriparatide in Asia for osteoporosis with a high fracture risk and for exploratory (unapproved) bone-related indications. MEDLINE (1946+), EMBASE (1966+), and ClinicalTrials.gov (2008+) were searched (16 August 2013); all studies of daily subcutaneous teriparatide 20 μg for bone-related conditions from China, Hong Kong, Japan, Republic of Korea, Philippines, Singapore, and Taiwan were included. Evidence on efficacy/safety was retrieved primarily from randomized controlled trials (10 publications) of postmenopausal women from Japan and China. In these studies, teriparatide was well tolerated; subjects had significantly greater increases in lumbar spine bone mineral density (BMD) from baseline compared with placebo, antiresorptive agents, or elcatonin/calcitonin; bone turnover markers increased from baseline and were sustained at elevated levels during teriparatide treatment. Few studies reported fracture risk, pain, or quality of life; one study showed a lower incidence of new-onset vertebral fracture with teriparatide versus antiresorptive agents. Nonrandomized studies (nine publications, one unpublished trial) conducted mainly in Taiwan, Japan, and the Republic of Korea provided supporting data for efficacy. The exploratory (unapproved) use of teriparatide (17 publications) for fracture healing and osteonecrosis of the jaw was described primarily in case reports. The clinical effectiveness of teriparatide for treatment of postmenopausal women with osteoporosis who are at high risk of fracture in Asia is focused primarily on improvements in BMD and tolerability. Recommended additional studies may include assessment of fracture risk and the effect of teriparatide on pain, quality of life, and mortality in Asia.

Geriatric hospitalizations in fall-related injuries

BACKGROUND

To investigate the injury pattern, severity, and mortality of elderly patients hospitalized for treatment of trauma following fall accidents.

METHODS

Data obtained from the Trauma Registry System were retrospectively reviewed for trauma admissions between January 1, 2009 and December 31, 2013 in a Level I trauma center. Of 16,548 registered patients, detailed information was retrieved from the 2,403 elderly patients (aged 65 years and above) with fall accidents and was compared with information from 1,909 adult patients (aged 20-64) with fall accidents.

RESULTS

Falls presented the major mechanism for admission (59.9%) in the elderly patients. The number of elderly patients who fell from a height <1 m was greater than that of the adult patients (91.9% vs. 62.5%, respectively, p <0.001). The Injury Severity Score (ISS) (9.3 ± 4.4 vs. 8.3 ± 6.1, respectively, p =0.007) and New Injury Severity Score (NISS) (10.3 ± 6.8 vs. 9.5 ± 8.2, respectively, p <0.001) were significantly higher in the elderly than the adult patients. A significantly larger proportion of the elderly patients were admitted to the ICU (16.2% vs. 13.4%, respectively, p =0.009), and the elderly were found to have longer stays in the intensive care unit (ICU) (8.6 days vs. 7.6 days, respectively, p =0.034) but not in the hospital in general (9.6 days vs. 8.5 days, respectively, p =0.183). Additionally, a significantly higher percentage of the elderly patients sustained subdural hematoma (10.1% vs. 8.2%, respectively, p =0.032) and femoral fracture (50.6% vs. 14.1%, respectively, p <0.001). There were significant differences in in-hospital mortality (18.2% vs. 10.3%, respectively, p =0.031) and length of stay in the hospital (11.6 days vs. 14.9 days, respectively, p =0.037) between the elderly and adult patients with subdural hematoma, but not between those with femoral fracture.

CONCLUSIONS

Analysis of the data indicates that elderly patients hospitalized for treatment of trauma following fall accidents present with a bodily injury pattern that differs from that of adult patients and have a higher severe injury score, worse outcome, and higher mortality than those of adult patients.

Secular trends in hip fractures worldwide: opposing trends East versus West

Despite wide variations in hip rates fractures worldwide, reasons for such differences are not clear. Furthermore, secular trends in the age-specific hip fracture rates are changing the world map of this devastating disease, with the highest rise projected to occur in developing countries. The aim of our investigation is to systematically characterize secular trends in hip fractures worldwide, examine new data for various ethnic groups in the United States, evidence for divergent temporal patterns, and investigate potential contributing factors for the observed change in their epidemiology. All studies retrieved through a complex Medline Ovid search between 1966 and 2013 were examined. For each selected study, we calculated the percent annual change in age-standardized hip fracture rates de-novo. Although occurring at different time points, trend breaks in hip fracture incidence occurred in most Western countries and Oceania. After a steep rise in age-adjusted rates in these regions, a decrease became evident sometimes between the mid-seventies and nineties, depending on the country. Conversely, the data is scarce in Asia and South America, with evidence for a continuous rise in hip fracture rates, with the exception of Hong-Kong and Taiwan that seem to follow Western trends. The etiologies of these secular patterns in both the developed and the developing countries have not been fully elucidated, but the impact of urbanization is at least one plausible explanation. Data presented here show close parallels between rising rates of urbanization and hip fractures across disparate geographic locations and cultures. Once the proportion of the urban population stabilized, hip fracture rates also stabilize or begin to decrease perhaps due to the influence of other factors such as birth cohort effects, changes in bone mineral density and BMI, osteoporosis medication use and/or lifestyle interventions such as smoking cessation, improvement in nutritional status and fall prevention.

Geographic and ethnic disparities in osteoporotic fractures

Osteoporotic fractures are a major worldwide epidemic. Here, we review global variability, ethnic differences and secular changes in osteoporotic fractures. Worldwide, age-standardized incidence rates of hip fracture vary >200-fold in women and >140-fold in men when comparing the country in which incidence rates are the highest with that in which they are the lowest. Median age-standardized rates are highest in North America and Europe, followed by Asia, Middle East, Oceania, Latin America and Africa. Globally, rates of hip fracture are greater in women than in men, with an average ratio of ∼2:1. The incidence of radiographic vertebral fractures is much higher than that of hip fractures, whereas the incidence rates of clinical vertebral fractures mirror hip fracture rates in most countries. Methodological challenges of defining and ascertaining vertebral fractures limit the interpretation of these data. Secular declines in hip fracture rates have been reported in populations from North America, Europe and Oceania. These declines are especially notable in women, suggesting that reproductive factors might contribute to this reduction. By contrast, hip fracture rates are increasing in parts of Asia and Latin America. Global indicators of health, education and socioeconomic status are positively correlated with fracture rates suggesting that lifestyles in developed countries might contribute to hip fracture. Improvements in fracture assessment, in particular for nonhip fractures, and identification of factors that contribute to this variability might substantially influence our understanding of osteoporotic fracture aetiology and provide new avenues for prevention.

Impact of changes in mortality on FRAX-derived fracture probabilities

BACKGROUND

Accurate hip fracture incidence and mortality rates are two essential requirements for FRAX calculators.

PURPOSE

To investigate the effects of change in mortality on FRAX-derived fracture estimates.

METHODS

Lebanese FRAX calculator was updated in 2012 from version 3.00 utilizing WHO mortality data from year 1999, and hip fracture incidence rates from 2007, to version 3.05 utilizing mortality data from 2009, but with identical hip fracture data. FRAX-derived estimates from 679 patients were computed using both FRAX versions and compared. Numbers presented as median [25th-75th] percentiles.

RESULTS

The 10-year FRAX-derived probability of major osteoporotic fracture and hip fracture increased substantially. Changes were most pronounced in high risk sub-groups. The relative increase in probability of major osteoporotic fracture in individuals with a baseline risk of 10-20% was 79% [19%-127%], and in individuals with a baseline risk >20% it was 125% (N=3). The numbers for relative increase in hip fracture probability were 98% [33%-135%], and 129%, respectively. Similarly, individuals older than 70 years had a 125% [89%-150%] relative increase in probability of major osteoporotic fracture and a 122% [95%-145%] relative increase in hip fracture probability. Using the FRAX-based Lebanese guidelines, FRAX 3.05 led to an additional increase in treatment qualification of 3.8 patients per 100 patients, or a relative increase of 24%.

CONCLUSIONS

Updates in mortality values increased FRAX-derived estimates, most substantially in older patients, and those at high risk for fracture. The update results in altering individuals' treatment decisions and modifying country wide osteoporosis management. Our results are relevant to the development and update of FRAX models for countries worldwide, and more importantly those with increasing longevity and possible increase in fracture rates.