Lower risk of stress fractures in young adults with ADHD under chronic treatment with methylphenidate

A Nomogram for Predicting ADHD and ASD in Child and Adolescent Mental Health Services (CAMHS)

Objectives: To enhance the early detection of Attention Deficit/Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD) by leveraging clinical variables collected at child and adolescent mental health services (CAMHS). Methods: This study included children diagnosed with ADHD and/or ASD (n = 857). Three logistic regression models were developed to predict the presence of ADHD, its subtypes, and ASD. The analysis began with univariate logistic regression, followed by a multicollinearity diagnostic. A backward logistic regression selection strategy was then employed to retain variables with p < 0.05. Ethical approval was obtained from the local ethics committee. The models' internal validity was evaluated based on their calibration and discriminative abilities. Results: The study produced models that are well-calibrated and validated for predicting ADHD (incorporating variables such as physical activity, history of bone fractures, and admissions to pediatric/psychiatric services) and ASD (including disability, gender, special education needs, and Axis V diagnoses, among others). Conclusions: Clinical variables can play a significant role in enhancing the early identification of ADHD and ASD.

Musculoskeletal Injuries Among Females in the Military: A Scoping Review

INTRODUCTION

Musculoskeletal injuries (MSKi) are a common challenge for those in military careers. Compared to their male peers, reports indicate that female military members and recruits are at greater risk of suffering MSKi during training and deployment. The objectives of this study were to identify the types and causes of MSKi among female military personnel and to explore the various risk factors associated with MSKi.

MATERIALS AND METHODS

A scoping review was conducted over a 4-month time frame of English language, peer-reviewed studies published from 1946 to 2019. Search strategies for major biomedical databases (e.g., MEDLINE; Embase Classic + Embase; and the following EBM Reviews-Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Health Technology Assessment, and the NHS Economic Evaluation Database) were developed by a senior medical information specialist and included 2,891 titles/abstracts. Study selection and data collection were designed according to the Population, Concept, and Context framework. Studies were included if the study population provided stratified data for females in a military context.

RESULTS

From a total of 2,287 citations captured from the literature searches, 168 peer-reviewed publications (144 unique studies) were eligible for inclusion. Studies were identified from across 10 countries and published between 1977 and 2019. Study designs were primarily prospective and retrospective cohorts. Most studies assessed both prevalence/incidence and risk factors for MSKi (62.50%), with few studies assessing cause (13.69%). For MSKi of female recruits compared to active female members, the prevalence was higher (19.7%-58.3% vs. 5.5%-56.6%), but the incidence (0.02%-57.7% vs. 13.5%-71.9%) was lower. The incidence of stress fractures was found to be much higher in female recruits than in active members (1.6%-23.9% vs. 2.7%). For anthropometric risk factors, increased body fat was a predictor of MSKi, but not stress fractures. For physiological risk factors for both female military groups, being less physically fit, later menarche, and having no/irregular menses were predictors of MSKi and stress fractures. For biomechanical risk factors, among female recruits, longer tibial length and femoral neck diameter increased the risk of stress fractures, and low foot arch increased risk of an ankle sprain. For female active military members, differences in shoulder rotation and bone strength were associated with risk of MSKi. For biological sex, being female compared to male was associated with an increased risk of MSKi, stress fractures, and general injuries. The consequences of experiencing MSKi for active military included limited duties, time off, and discharge. For recruits, these included missed training days, limited duty days, and release.

CONCLUSIONS

This scoping review provides insight into the current state of the evidence regarding the types and causes of MSKi, as well as the factors that influence MSKi among females in the military. Future research endeavors should focus on randomized controlled trials examining training paradigms to see if women are more susceptible. The data presented in the scoping review could potentially be used to develop training strategies to mitigate some of the identified barriers that negatively impact women from pursuing careers in the military.

Prevalence of bone fractures among children and adolescents with attention-deficit/hyperactivity disorder: a systematic review and meta-analysis

Background

Attention-deficit/hyperactivity disorder (ADHD) is a significant neurodevelopment disorder among children and adolescents, with 5 % prevalence. Bone fractures account for 25 % of accidents and injuries among all children and adolescents. Considering the characteristics of inattention, hyperactivity, and impulsivity in children with ADHD, it is critical to examine bone fractures among these children. The objective of our meta-analysis was to determine the prevalence of bone fractures among children and adolescents with ADHD.

Methods

We completed a systematic review and meta-analysis using an electronic search of the following databases: CINAHL, EMBASE, PsycINFO, PubMed, and Scopus. The search terms used were: “attention deficit hyperactivity disorder OR attention deficit disorder” and “bone fracture*.” We included studies examining patients 18 years or younger who were diagnosed with ADHD and tracked (prospectively or retrospectively) for five or more years. Effect size (es), using a random effects model, was calculated. We registered the review protocol with PROSPERO (CRD42019119527).

Results

From 445 records retrieved, 31 full text articles were reviewed and 5 articles met inclusion criteria for meta-analysis. The summary es revealed the prevalence of bone fractures among children and adolescents with ADHD to be 4.83 % (95 % CI: 3.07–6.58 %). The location of bone fractures, using a subset of data, showed a distribution of 69.62 %, 22.85 %, and 7.53 % in the upper limbs, lower limbs, and other anatomical regions, respectively. Another subset of studies revealed a 2.55-fold increase in the prevalence of fractures among the children with ADHD compared to their counterparts.

Conclusions

Awareness of these findings is critical to physicians, parents, and policy makers to create safe environments and provide supports in order to optimize the health and safety of children and adolescents with ADHD.

ADHD, stimulant medication use, and the risk of fracture: a systematic review and meta-analysis

We performed a meta-analysis to quantify the relationships among a diagnosis of attention-deficit/hyperactivity disorder (ADHD), the use of stimulant medication, and the risk of fracture. There was a significant positive association between ADHD and the risk of fracture. However, stimulant ADHD medication therapy appears to be associated with a reduced risk of fracture in patients with ADHD.

INTRODUCTION

ADHD is associated with an increased fracture risk due to a lack of impulse control. ADHD medication may have a protective effect via behavior modification. However, previous research found an adverse effect of stimulant use on bone mass. Therefore, this meta-analysis study assessed the relationships among ADHD, the use of stimulant medication, and fracture risk.

METHODS

A literature search was conducted using PubMed and EMBASE from inception through December 2020. Random-effects models were used to determine overall pooled estimates and 95% confidence intervals (CIs).

RESULTS

The meta-analysis included 10 observational studies. Our results showed that ADHD diagnosis is associated with an increased risk of fracture (OR = 1.17; 1.01-1.35, p = 0.035). Notably, a higher risk of fracture (OR = 1.37, 95% CI 1.2-1.58, p < 0.001) was observed in non-stimulant-treated ADHD. However, no significant association, but a trend toward a lower risk, was observed for stimulant-treated ADHD patients compared with non-stimulant-treated ADHD patients (OR = 0.7, 95% CI 0.47-1.03, p = 0.073). In terms of fracture type, non-stimulant-treated ADHD was associated with traumatic fracture (OR = 1.79, 95% CI 1.54-2.08, p < 0.001) or stress fracture (OR = 1.12, 95% CI 1.04-1.2, p = 0.004) compared to healthy control (HC). In addition, further findings from our systematic review showed that the risk of traumatic (OR = 1, 95% CI 0.88-1.13, p = 0.954) or stress (OR = 0.84, 95% CI 0.62-1.14, p = 0.256) fracture was comparable between treated stimulant-ADHD patients and HC.

CONCLUSIONS

Individuals with ADHD are at higher risk of fracture than the general population. Stimulant ADHD medication appears to be associated with a lower risk of traumatic fracture but not with a higher risk of stress fracture.

The effects of methylphenidate on stress fractures in patients' ages 10-29: a national database study

Objectives: Current literature is divided on the effect of methylphenidate (MP) on stress fracture development and if this medication increases fracture, or is actually protective for it. This study further investigates this effect utilizing a large national database. We hypothesized that individuals on MP would have a reduced risk of SF compared against controls. Methods: This study utilized the Humana insurance data set within the PearlDiver Patient Records Database (PearlDiver Inc, Fort Wayne, Indiana). All patients' ages 10-29 were included and patients were identified without ADHD, with ADHD not on MP, and with ADHD on MP. ADHD and stress fracture diagnoses were identified by International Classification of Disease, Tenth Revision codes. Bivariate analysis of stress fracture occurrence was conducted using chi-square analysis. Multivariate logistic regression was used to calculate odds ratios, controlling for age, sex, race, and Charlson Comorbidity Index (CCI). Statistical analysis was performed using the PearlDiver software, which runs R, Version 1.1.442. An α value of .05 was set as the level of significance. Results: The study included 29,590 patients on MP and 831,439 patients not on MP from ages 10-29. The highest proportions of patients who filled MP prescriptions were in the age range 10 to 14 years old (51.2%), followed by 15 to 19 (41.0%). Patients rarely continue MP from years 20 to 24 (16.5%) or 25 to 29 (9.6%). ADHD patients on MP had the lowest calculated risk of stress fractures (0.45%) compared to patients without ADHD (0.54%) and ADHD patients not on methylphenidate (0.58%). In all three patient groups, most stress fractures occurred in 15 to 19-year olds. Patients with ADHD on MP conferred lower odds of stress fracture than ADHD patients not on MP and patients without ADHD (aOR = 0.64, p = 0.0002). The older age groups 20-24 and 25-29 involved less risk of stress fracture compared to the youngest age group 10-14 (p < 0.0001; p < 0.0001), as well as did male gender (p < 0.0001). Conclusions: This database-based study of the effect of MP on SF adds to the growing body of literature providing evidence that MP may offer protective benefit for stress fracture.