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Wu Y, Chao J, Bao M, Zhang N. Predictive value of machine learning on fracture risk in osteoporosis: a systematic review and meta-analysis. BMJ Open 2023; 13:e071430. [PMID: 38070927 PMCID: PMC10728980 DOI: 10.1136/bmjopen-2022-071430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 11/06/2023] [Indexed: 12/18/2023] Open
Abstract
OBJECTIVES Early identification of fracture risk in patients with osteoporosis is essential. Machine learning (ML) has emerged as a promising technique to predict the risk, whereas its predictive performance remains controversial. Therefore, we conducted this systematic review and meta-analysis to explore the predictive efficiency of ML for the risk of fracture in patients with osteoporosis. METHODS Relevant studies were retrieved from four databases (PubMed, Embase, Cochrane Library and Web of Science) until 31 May 2023. A meta-analysis of the C-index was performed using a random-effects model, while a bivariate mixed-effects model was used for the meta-analysis of sensitivity and specificity. In addition, subgroup analysis was performed according to the types of ML models and fracture sites. RESULTS Fifty-three studies were included in our meta-analysis, involving 15 209 268 patients, 86 prediction models specifically developed for the osteoporosis population and 41 validation sets. The most commonly used predictors in these models encompassed age, BMI, past fracture history, bone mineral density T-score, history of falls, BMD, radiomics data, weight, height, gender and other chronic diseases. Overall, the pooled C-index of ML was 0.75 (95% CI: 0.72, 0.78) and 0.75 (95% CI: 0.71, 0.78) in the training set and validation set, respectively; the pooled sensitivity was 0.79 (95% CI: 0.72, 0.84) and 0.76 (95% CI: 0.80, 0.81) in the training set and validation set, respectively; and the pooled specificity was 0.81 (95% CI: 0.75, 0.86) and 0.83 (95% CI: 0.72, 0.90) in the training set and validation set, respectively. CONCLUSIONS ML has a favourable predictive performance for fracture risk in patients with osteoporosis. However, most current studies lack external validation. Thus, external validation is required to verify the reliability of ML models. PROSPERO REGISTRATION NUMBER CRD42022346896.
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Affiliation(s)
- Yanqian Wu
- Key Laboratory of Environmental Medicine Engineering of Ministry of Education/Health Management Research Center, School of Public Health, Southeast University, Nanjing, Jiangsu, China
| | - Jianqian Chao
- Key Laboratory of Environmental Medicine Engineering of Ministry of Education/Health Management Research Center, School of Public Health, Southeast University, Nanjing, Jiangsu, China
| | - Min Bao
- Key Laboratory of Environmental Medicine Engineering of Ministry of Education/Health Management Research Center, School of Public Health, Southeast University, Nanjing, Jiangsu, China
| | - Na Zhang
- Key Laboratory of Environmental Medicine Engineering of Ministry of Education/Health Management Research Center, School of Public Health, Southeast University, Nanjing, Jiangsu, China
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Leone GE, Shields DC, Haque A, Banik NL. Rehabilitation: Neurogenic Bone Loss after Spinal Cord Injury. Biomedicines 2023; 11:2581. [PMID: 37761022 PMCID: PMC10526516 DOI: 10.3390/biomedicines11092581] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 09/12/2023] [Accepted: 09/18/2023] [Indexed: 09/29/2023] Open
Abstract
Osteoporosis is a common skeletal disorder which can severely limit one's ability to complete daily tasks due to the increased risk of bone fractures, reducing quality of life. Spinal cord injury (SCI) can also result in osteoporosis and sarcopenia. Most individuals experience sarcopenia and osteoporosis due to advancing age; however, individuals with SCI experience more rapid and debilitating levels of muscle and bone loss due to neurogenic factors, musculoskeletal disuse, and cellular/molecular events. Thus, preserving and maintaining bone mass after SCI is crucial to decreasing the risk of fragility and fracture in vulnerable SCI populations. Recent studies have provided an improved understanding of the pathophysiology and risk factors related to musculoskeletal loss after SCI. Pharmacological and non-pharmacological therapies have also provided for the reduction in or elimination of neurogenic bone loss after SCI. This review article will discuss the pathophysiology and risk factors of muscle and bone loss after SCI, including the mechanisms that may lead to muscle and bone loss after SCI. This review will also focus on current and future pharmacological and non-pharmacological therapies for reducing or eliminating neurogenic bone loss following SCI.
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Affiliation(s)
- Giovanna E. Leone
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, SC 29425, USA;
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC 29425, USA;
| | - Donald C. Shields
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC 29425, USA;
| | - Azizul Haque
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, SC 29425, USA;
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC 29425, USA;
- Ralph H. Johnson Veterans Administration Medical Center, Charleston, SC 29401, USA
| | - Narendra L. Banik
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, SC 29425, USA;
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC 29425, USA;
- Ralph H. Johnson Veterans Administration Medical Center, Charleston, SC 29401, USA
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Al-Rawaf HA, Gabr SA, Iqbal A, Alghadir AH. MicroRNAs as potential biopredictors for premenopausal osteoporosis: a biochemical and molecular study. BMC Womens Health 2023; 23:481. [PMID: 37689658 PMCID: PMC10493018 DOI: 10.1186/s12905-023-02626-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 08/29/2023] [Indexed: 09/11/2023] Open
Abstract
BACKGROUND Circulating micro-RNAs have been proposed as a new type of biomarker in several diseases, particularly those related to bone health. They have shown great potential due to their feasibility and simplicity of measurement in all body fluids, especially urine, plasma, and serum. AIM This study aimed to evaluate the expression of a set of mRNAs, namely miR-21, miR-24, mir-100, miR-24a, miR-103-3p, and miR-142-3p. Their proposed roles in the progression of osteoporosis were identified using a real-time polymerase chain reaction (RT-PCR) analysis in premenopausal women. In addition, their correlations with osteocalcin (OC), bone-specific alkaline phosphatase (BAP), and deoxypyridinoline (DPD) bone markers were explored. METHODS A total of 85 healthy premenopausal women aged 25-50 years old were included in this study. Based on a DXA scan (Z-score) analysis and calcaneus broadband ultrasound attenuation scores (c-BUAs), measured via quantitative ultrasound (QUS), the subjects were classified into three groups: normal group (n = 25), osteopenia (n = 30), and osteoporosis (n = 30). Real-time-PCR and immunoassay analyses were performed to determine miRNA expression levels and serum OC, s-BAP, and DPD, respectively, as biomarkers of bone health. RESULTS Among the identified miRNAs, only miR-21, miR-24, and mir-100 were significantly upregulated and increased in the serum of patients with osteopenia and osteoporosis, and miR-24a, miR-103-3p, and miR-142-3p were downregulated and significantly decreased in osteoporosis. Both upregulated and downregulated miRNAs were significantly correlated with BMD, c-BUA, OC, s-BAP, and DPD. CONCLUSION A group of circulating miRNAs was shown to be closely correlated with the parameters BMD, c-BUA, OC, s-BAP, and DPD, which are traditionally used for bone-health measurements. They could be identified as non-invasive biomarkers in premenopausal patients with osteoporosis. More studies with large sample sizes are recommended to estimate the mechanistic role of miRNAs in osteoporosis pathogenesis and to provide evidence for the use of these miRNAs as a non-invasive method of diagnosing clinical osteoporosis, especially in premenopausal patients.
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Affiliation(s)
- Hadeel A. Al-Rawaf
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, 11433 Saudi Arabia
| | - Sami A. Gabr
- Department of Rehabilitation Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, 11433 Saudi Arabia
| | - Amir Iqbal
- Department of Rehabilitation Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, 11433 Saudi Arabia
| | - Ahmad H. Alghadir
- Department of Rehabilitation Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, 11433 Saudi Arabia
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Park JW, Ha YC, Kim JW, Kim TY, Kim JW, Baek SH, Lee YK, Koo KH. The Korean hip fracture registry study. BMC Musculoskelet Disord 2023; 24:449. [PMID: 37268896 DOI: 10.1186/s12891-023-06546-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 05/18/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND The purpose of the Korean Hip Fracture Registry (KHFR) Study is to establish a nationwide, hospital-based prospective cohort study of adults with hip fracture to explore the incidence and risk factors of second osteoporotic fractures for a Fracture Liaison Service (FLS) model. METHODS The KHFR, a prospective multicenter longitudinal study, was launched in 2014. Sixteen centers recruited participants who were treated for hip fracture. The inclusion criteria were patients, who were treated for proximal femur fracture due to low-energy trauma and aged 50 or more at the time of injury. Until 2018, 5,841 patients were enrolled in this study. Follow-up surveys were conducted annually to determine occurrence of second osteoporotic fracture, and 4,803 participants completed at least one follow-up survey. DISCUSSION KHFR is a unique resource of individual level on osteoporotic hip fracture with radiological, medical, and laboratory information including DXA (dual energy x-ray absorptiometry), bone turnover marker, body composition, and hand grip strength for future analyses for FLS model. Modifiable factors for mortality after hip surgery is planned to be identified with nutritional assessment and multi-disciplinary interventions from hospitalization to follow-ups. The proportions of femoral neck, intertrochanteric, and subtrochanteric fractures were 517 (42.0%), 730 (53.6%), and 60 (4.4%), respectively, from 2014 to 2016, which was similar in other studies. Radiologic definition of atypical subtrochanteric fracture was adopted and 17 (1.2%) fractures among 1,361 proximal femoral fractures were identified. Internal fixation showed higher reoperation rate compared to arthroplasty in unstable intertrochanteric fractures (6.1% vs. 2.4%, p = 0.046) with no significant difference in mortality. The KHFR plans to identify outcomes and risk factors associated with second fracture by conducting a 10-year cohort study, with a follow-up every year, using 5,841 baseline participants. TRIAL REGISTRATION Present study was registered on Internet-based Clinical Research and Trial management system (iCReaT) as multicenter prospective observational cohort study (Project number: C160022, Date of registration: 22th, Apr, 2016).
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Affiliation(s)
- Jung-Wee Park
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Yong-Chan Ha
- Department of Orthopaedic Surgery, Seoul Bumin Hospital, Seoul, South Korea
| | - Jin-Woo Kim
- Department of Orthopaedic Surgery, Nowon Eulji Medical Center, Seoul, South Korea
| | - Tae-Young Kim
- Department of Orthopaedic Surgery, Konkuk University School of Medicine, Seoul, South Korea
| | - Ji Wan Kim
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Hoon Baek
- Department of Orthopedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Young-Kyun Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea.
| | - Kyung-Hoi Koo
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
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Validation of the Taiwan FRAX® calculator for the prediction of fracture risk. Arch Osteoporos 2022; 17:27. [PMID: 35094177 DOI: 10.1007/s11657-022-01068-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 01/20/2022] [Indexed: 02/03/2023]
Abstract
The Taiwan FRAX® calculator was validated to predict incident fractures preliminarily. Cutoffs of FRAX probability for predicting major osteoporotic fracture and hip fracture were proposed as 9.5% and 4% in Taiwanese individuals. PURPOSE FRAX® is an algorithm used to calculate fracture probabilities based on clinical risk factors (CRFs) and bone mineral density (BMD). The country-specific Taiwan FRAX calculator has not been validated since its establishment in 2010. The aim of the present study is to evaluate the predictive performance of the Taiwan FRAX calculator using longitudinal fracture data. METHODS A total of 1975 subjects, aged ≧ 40 years old, from Yunlin and Tianliao cohorts in Taiwan during the period 2009-2010, were identified and completely connected with the 2008-2016 National Health Insurance Research Database. RESULTS During the average 6.8 ± 1.1 years of follow-up, 160 incident major osteoporotic fractures (MOFs) were identified. The predictive ability assessing based on the observed to expected fractures (O/E) ratio calculated with the FRAX probability adjusted for 6.8 years were 1.19 (95%CI 1.02-1.39) for MOF, and 1.07 (95%CI 0.82-1.39) for hip fractures. In the discriminative statistics, the AUC for prediction of major osteoporotic fractures using FRAX was 0.75 without and 0.77 with BMD (AUC for hip fracture was 0.75 without and 0.77 with BMD). The optimal cutoff value was 9.5% of the FRAX score with BMD for all major osteoporotic fractures, with good sensitivity (76.9%) and specificity (65.3%). For hip fractures, the optimal cutoff point for the FRAX probability with BMD was 4.0%, and the sensitivity and specificity were 74.4% and 68.3%, respectively. CONCLUSION The Taiwan FRAX® calculator was validated to predict incident fractures preliminarily. Cutoffs are proposed for predicting fracture risk in Taiwanese individuals.
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Sun X, Chen Y, Gao Y, Zhang Z, Qin L, Song J, Wang H, Wu IXY. Prediction Models for Osteoporotic Fractures Risk: A Systematic Review and Critical Appraisal. Aging Dis 2022; 13:1215-1238. [PMID: 35855348 PMCID: PMC9286920 DOI: 10.14336/ad.2021.1206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/06/2021] [Indexed: 11/01/2022] Open
Abstract
Osteoporotic fractures (OF) are a global public health problem currently. Many risk prediction models for OF have been developed, but their performance and methodological quality are unclear. We conducted this systematic review to summarize and critically appraise the OF risk prediction models. Three databases were searched until April 2021. Studies developing or validating multivariable models for OF risk prediction were considered eligible. Used the prediction model risk of bias assessment tool to appraise the risk of bias and applicability of included models. All results were narratively summarized and described. A total of 68 studies describing 70 newly developed prediction models and 138 external validations were included. Most models were explicitly developed (n=31, 44%) and validated (n=76, 55%) only for female. Only 22 developed models (31%) were externally validated. The most validated tool was Fracture Risk Assessment Tool. Overall, only a few models showed outstanding (n=3, 1%) or excellent (n=32, 15%) prediction discrimination. Calibration of developed models (n=25, 36%) or external validation models (n=33, 24%) were rarely assessed. No model was rated as low risk of bias, mostly because of an insufficient number of cases and inappropriate assessment of calibration. There are a certain number of OF risk prediction models. However, few models have been thoroughly internally validated or externally validated (with calibration being unassessed for most of the models), and all models showed methodological shortcomings. Instead of developing completely new models, future research is suggested to validate, improve, and analyze the impact of existing models.
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Affiliation(s)
- Xuemei Sun
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan, China.
| | - Yancong Chen
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan, China.
| | - Yinyan Gao
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan, China.
| | - Zixuan Zhang
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan, China.
| | - Lang Qin
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan, China.
| | - Jinlu Song
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan, China.
| | - Huan Wang
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan, China.
| | - Irene XY Wu
- Department of Epidemiology and Biostatistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan, China.
- Hunan Provincial Key Laboratory of Clinical Epidemiology, Changsha 410000, China
- Correspondence should be addressed to: Dr. IXY Wu, Xiangya School of Public health, Central South University, Xiangya School of Public health, Changsha 410000, Hunan, China.
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Wei CC, Yue LF, You FT, Tao C. Panax notoginseng saponins alleviate osteoporosis and joint destruction in rabbits with antigen-induced arthritis. Exp Ther Med 2021; 22:1302. [PMID: 34630657 PMCID: PMC8461612 DOI: 10.3892/etm.2021.10737] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 05/17/2021] [Indexed: 12/20/2022] Open
Abstract
Although a number of anti-rheumatic drugs and biologics may be used to alleviate the symptoms of rheumatoid arthritis (RA), these compounds have been associated with bone loss and joint destruction; thus, alternative treatment approaches are required. In the present study, various plant extracts were evaluated for their capacity to inhibit joint destruction, and Panax notoginseng saponins (PNS), obtained from the Traditional Chinese Medicine Panax notoginseng, was identified as such a compound. Therefore, a rabbit antigen-induced arthritis (AIA) model was generated by immunization with ovalbumin in Freund's complete adjuvant, followed by treatment with PNS for 3 months. The morphology of the quadriceps femoris muscle, cartilage chondrocytes and skeletal elements was histologically observed by transmission electron microscopy (TEM), as well as micro-computed tomography. The results revealed that PNS significantly reduced the histopathological alterations associated with arthritic muscular atrophy and inflammation. In addition, TEM demonstrated that PNS protected chondrocytes from RA-associated damage. Furthermore, the bone density and microarchitecture in rabbits treated with PNS were markedly improved compared with those of the model group. Collectively, these data indicated that treatment with PNS may relieve osteoporosis and prevent joint and bone destruction in AIA.
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Affiliation(s)
- Chen Chao Wei
- Department of Orthopaedics and Traumatology, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of TCM, Shanghai 200071, P.R. China
| | - Li Fei Yue
- Department of Traumatology, Rui Jin Hospital Shanghai Jiao Tong University School of Medicine, Shanghai 200025, P.R. China
| | - Fan Tian You
- Department of Orthopaedics and Traumatology, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of TCM, Shanghai 200071, P.R. China
| | - Che Tao
- Department of Orthopaedics and Traumatology, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of TCM, Shanghai 200071, P.R. China
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Zhou Y, Liu S, Wang X, Fu Y, Su F, Cao L, Zha X, Wen Y. Implications of gender-based variabilities in bone mineral density and hemoglobin levels. BMC Musculoskelet Disord 2021; 22:645. [PMID: 34330237 PMCID: PMC8323312 DOI: 10.1186/s12891-021-04536-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 07/22/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Studies reported that there is a relationship between volumetric bone mineral density (vBMD) and hemoglobin (HGB) in sickle cell anemia, chronic obstructive pulmonary disease, inflammatory bowel disease, and chronic kidney disease, it is not clear whether this association exists in normal populations or different genders. In order to further clarify the relationship between vBMD and HGB, and provide the basis for the diagnosis of related diseases, this study was conducted in the physical examination population. METHODS A cross-sectional study was conducted on a health check-up population from Wannan area of China from January to December 2018. The study involved 1238 individuals aged 23 to 85 years. Linear regression analysis and smooth curve were applied to determine the relationship of HGB and vBMD. RESULTS The average level of vBMD in the population was 130.11 ± 79.51 mg/cm3, after adjusting for age, body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), total cholesterol (TC), triglycerides (TG), glucose (GLU), high-density lipoprotein (HDL) and low-density lipoprotein (LDL). A U-shape relationship was established between vBMD and HGB, the cut off value of HGB was 130 g/L. After gender stratification, the results showed a U-shaped curve relationship between vBMD and HGB in male group, and a linear relationship between vBMD and HGB in female group. The vBMD decreased with HGB when HGB < 120 g/L, and increased when HGB ≥ 120 g/L in male group. CONCLUSION The relationship between vBMD and HGB in the male physical examination population presents a U-shaped curve.
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Affiliation(s)
- Yumei Zhou
- School of Public Health, Wannan Medical College, 22 West Wenchang Road, Wuhu, Anhui Province, 241002, People's Republic of China
| | - Shengjun Liu
- Institute of Quantitative Pharmacology Department of Pharmacology, Wannan Medical College, 22 West Wenchang Road, Wuhu, Anhui Province, 241002, People's Republic of China
| | - Ximei Wang
- School of Public Health, Wannan Medical College, 22 West Wenchang Road, Wuhu, Anhui Province, 241002, People's Republic of China
| | - Yuhan Fu
- School of Public Health, Wannan Medical College, 22 West Wenchang Road, Wuhu, Anhui Province, 241002, People's Republic of China
| | - Fan Su
- School of Public Health, Wannan Medical College, 22 West Wenchang Road, Wuhu, Anhui Province, 241002, People's Republic of China
| | - Lei Cao
- School of Public Health, Wannan Medical College, 22 West Wenchang Road, Wuhu, Anhui Province, 241002, People's Republic of China
| | - Xiaojuan Zha
- First Affiliated Hospital, Wannan Medical College, 2 West Zheshan Road, Wuhu, Anhui Province, 241004, People's Republic of China
| | - Yufeng Wen
- School of Laboratory Medicine, Wannan Medical College, 22 West Wenchang Road, Wuhu, Anhui Province, 241002, People's Republic of China.
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The effects of falls on the prediction of osteoporotic fractures: epidemiological cohort study. Arch Osteoporos 2021; 16:110. [PMID: 34245374 DOI: 10.1007/s11657-021-00977-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 06/18/2021] [Indexed: 02/03/2023]
Abstract
UNLABELLED Fall is the major risk factor of fracture that has not been included in FRAX®. Whether different age may determine the effect of falls on FRAX® is still uncertain. This epidemiological cohort study reveals that history of fall is a significant predictor of incident fracture independent of FRAX probability, especially in subjects < 75 years old. INTRODUCTION The Fracture Risk Assessment Tool (FRAX) calculates 10-year fracture risk using 11 clinical risk factors and bone mineral density (BMD); however, it does not include fall history in its risk assessment. Here, we investigated whether fall history is an independent risk factor on fracture prediction after adjustment of FRAX scores in two age subgroups (40-75 and ≥ 75 years). METHODS Beginning in 2009 to 2010, 1975 people (914 men) from Taiwan were followed for 6.8 ± 1.1 years by matching them with their records in the 2008-2016 National Health Insurance databank. We validated FRAX predictive accuracy with or without fall history by Cox proportional hazards regression. RESULTS After adjusting for FRAX risk, a history of falling was still a significant predictor of major osteoporotic fractures (MOFs) (using BMD, hazard ratio [HR], 1.47; p = 0.03; without using BMD, HR, 1.54; p = 0.01). A history of recurrent falls was also a significant predictor of both incident MOFs and hip fractures. However, when the subjects were stratified based on age group, a history of falling and recurrent falls were strong predictors of MOFs and hip fractures in the younger but not the older subgroup. CONCLUSION A fall history can predict incident fracture independently of FRAX probability, particularly in subjects younger than 75 years old.
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Xie X, Huang R, Li X, Li N, Zhang H, Xu S, Li D, Xi S, Yang K. Association between hepatitis B virus infection and risk of osteoporosis: a systematic review and meta-analysis: A protocol for systematic review. Medicine (Baltimore) 2020; 99:e19719. [PMID: 32311959 PMCID: PMC7220488 DOI: 10.1097/md.0000000000019719] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The potential association between hepatitis B virus (HBV) infection and development of osteoporosis has drawn significant attention from clinicians and researchers in recent years due to the increasing prevalence of HBV infection. This study aims to perform a systematic review and meta-analysis of the literature to show whether HBV infection is associated with an increased risk of osteoporosis. METHODS Case-control, cohort, and cross-sectional studies that report the incidence of osteoporosis, osteoporotic fracture, osteopenia, and bone mineral density level in populations with HBV infection will be selected. Four databases from their inception to October 2019 will be searched. All data were assessed and extracted by 2 authors independently. The Newcastle-Ottawa scale and (Agency for Healthcare Research and Quality) Agency for Healthcare Research and Quality checklist will be used to assess the quality of the selected studies. Stata 15.1 (Stata Corp, College Station, TX) will be used to conduct meta-analysis. RESULT The results of this systemic review and meta-analysis will be submitted to a recognized journal for publication. CONCLUSION This systemic review and meta-analysis will determine whether HBV infection is associated with an increased risk of osteoporosis. We hope this review can provide a reliable evidence. REGISTRATION PROSPERO (registration number CRD42020140522).
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Affiliation(s)
- Xingwen Xie
- Department of Orthopaedics, Affiliated Hospital of Northwest Minzu University
- Department of Orthopaedics, Gansu Second Provincial People's Hospital
| | - Rui Huang
- Clinical Medical College of Traditional Chinese Medicine, Gansu University of Chinese Medicine
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province
| | - Xiuxia Li
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province
| | - Ning Li
- Clinical Medical College of Traditional Chinese Medicine, Gansu University of Chinese Medicine
| | - Haijun Zhang
- Department of Orthopaedics, Affiliated Hospital of Northwest Minzu University
- Department of Orthopaedics, Gansu Second Provincial People's Hospital
| | - Shihong Xu
- Department of Bone Oncology, Gansu Provincial Hospital of Tradition Chinese Medicine, Lanzhou, Gansu
| | - Dingpeng Li
- Department of Orthopaedics, Affiliated Hospital of Northwest Minzu University
| | - Shanshan Xi
- Department of Endocrinology and Nephrology, Hengshui Hospital of Traditional Chinese Medicine, Hengshui, Hebei
| | - Kehu Yang
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province
- Institute of Clinical Research and Evidence Based Medicine, Gansu Provincial People's Hospital
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, China
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Hsu CY, Wu CH, Yu SF, Su YJ, Chiu WC, Chen YC, Lai HM, Chen JF, Ko CH, Chen JF, Cheng TT. Novel algorithm generating strategy to identify high fracture risk population using a hybrid intervention threshold. J Bone Miner Metab 2020; 38:213-221. [PMID: 31583541 DOI: 10.1007/s00774-019-01046-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 09/02/2019] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The aim of this study was to develop an algorithm to identify high-risk populations of fragility fractures in Taiwan. MATERIALS AND METHODS A total of 16,539 postmenopausal women and men (age ≥ 50 years) were identified from the Taiwan Osteoporosis Survey database. Using the Taiwan FRAX® tool, the 10-year probability of major osteoporotic fracture (MOF) and hip fracture (HF) and the individual intervention threshold (IIT) of each participant were calculated. Subjects with either a probability above the IIT or those with MOF ≥ 20% or HF ≥ 9% were included as group A. Subjects with a bone mineral density (BMD) T-score at femoral neck based on healthy subjects of ≤ - 2.5 were included in group B. We tested several cutoff points for MOF and HF so that the number of patients in group A and group B were similar. A novel country-specific hybrid intervention threshold along with an algorithm was generated to identify high fracture risk individuals. RESULTS 3173 (19.2%) and 3129 (18.9%) participants were categorized to groups A and B, respectively. Participants in group B had a significantly lower BMD (p < 0.001), but clinical characteristics, especially the 10-year probability of MOF (p < 0.001) or HF (p < 0.001), were significantly worse in group A. We found the algorithm generated from the hybrid intervention threshold is practical. CONCLUSION The strategy of generating an algorithm for fracture prevention by novel hybrid intervention threshold is more efficient as it identifies patients with a higher risk of fragility fracture and could be a template for other country-specific policies.
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Affiliation(s)
- Chung-Yuan Hsu
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Road, Kaohsiung, 833, Taiwan
| | - Chih-Hsing Wu
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Shan-Fu Yu
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Road, Kaohsiung, 833, Taiwan
| | - Yu-Jih Su
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Road, Kaohsiung, 833, Taiwan
| | - Wen-Chan Chiu
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Road, Kaohsiung, 833, Taiwan
| | - Ying-Chou Chen
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Road, Kaohsiung, 833, Taiwan
| | - Han-Ming Lai
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Road, Kaohsiung, 833, Taiwan
| | - Jia-Feng Chen
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Road, Kaohsiung, 833, Taiwan
| | - Chi-Hua Ko
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Road, Kaohsiung, 833, Taiwan
| | - Jung-Fu Chen
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Tien-Tsai Cheng
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, No. 123, Ta-Pei Road, Kaohsiung, 833, Taiwan.
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Huang R, Xu S, Li D, Xie X. Acupoint injection treatment for primary osteoporosis: A systematic review and meta-analysis of randomized controlled trials protocol. Medicine (Baltimore) 2019; 98:e16735. [PMID: 31393383 PMCID: PMC6709080 DOI: 10.1097/md.0000000000016735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 07/15/2019] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Acupoint injection has currently received increasing attention as a treatment for primary osteoporosis (POP). A number of randomized controlled trials (RCTs) have reported that acupoint injection have some advantages in treatment of POP. However, no article has summarized the existing evidence. This study will evaluate the efficacy and safety of acupoint injection as a clinical treatment for POP, so as to provide an important reference for clinical decision-making. METHODS RCTs of acupoint injection compared with conventional non-acupoint injection for POP were identified in searches of 7 databases from their inception to March 2019. All data were assessed and extracted by 2 authors independently. The risk of bias assessment recommended by the Cochrane Collaboration was used to assess the quality of the selected studies. Review Manager 5.3 (Cochrane Collaboration) was used to conduct meta-analysis for the efficacy and safety of acupoint injection. RESULT The results of this systemic review and meta-analysis will be submitted to a recognized journal for publication. CONCLUSION This systemic review and meta-analysis will evaluate the efficacy and safety of acupoint injection as a clinical treatment for POP. We hope this study can make a definitive conclusion for acupoint injection in the treatment of POP. REGISTRATION PROSPERO (registration number CRD42019130890).
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Affiliation(s)
- Rui Huang
- Clinical Medical College of Traditional Chinese Medicine, Gansu University of Chinese Medicine
| | - Shihong Xu
- Institute of Osteopathy Gansu Institute of Traditional Chinese Medicine
- Department of Bone Oncology, Gansu Provincial Hospital of Traditional Chinese Medicine, Lanzhou, Gansu, China
| | - Dingpeng Li
- Institute of Osteopathy Gansu Institute of Traditional Chinese Medicine
- Department of Bone Oncology, Gansu Provincial Hospital of Traditional Chinese Medicine, Lanzhou, Gansu, China
| | - Xingwen Xie
- Institute of Osteopathy Gansu Institute of Traditional Chinese Medicine
- Department of Bone Oncology, Gansu Provincial Hospital of Traditional Chinese Medicine, Lanzhou, Gansu, China
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Oh YH, Moon JH, Cho B. Association between Hemoglobin Level and Bone Mineral Density in Korean Adults. J Bone Metab 2017; 24:161-173. [PMID: 28955692 PMCID: PMC5613021 DOI: 10.11005/jbm.2017.24.3.161] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 08/01/2017] [Accepted: 08/02/2017] [Indexed: 01/17/2023] Open
Abstract
Background Low bone mineral density (BMD) increases fracture risk. Anemia is highly prevalent. Some studies suggested that anemia is an independent risk factor for osteoporosis. The aim of this study was to evaluate the association between hemoglobin (Hb) level and BMD in Korean adults. Methods This study was based on data from the Korea National Health and Nutrition Examination Survey 2008 to 2011. Propensity score-matching was performed to establish a dataset for analysis. Regression analyses were used to evaluate the association between Hb and BMD. Mean BMD scores were compared between normal and anemia groups, and among normal, anemia with low ferritin, and anemia without low ferritin groups. Results There were partial positive associations between Hb and BMD in men, but negative associations in women. The normal group had lower mean BMD scores than the anemia group in men. However, the anemia group had higher whole-body and lumbar-spine BMD scores than the normal group in women. In a comparison of the three groups, the anemia without low ferritin group had the lowest all-site BMD scores in men and women. However, the anemia with low ferritin group had the highest all-site BMD scores in women. In postmenopausal women, the anemia without low ferritin group had the lowest all-site BMD scores. In premenopausal women, the anemia with low ferritin group had the highest whole-body BMD scores. Conclusions This study found that Hb and anemia status were associated with BMD scores. However, the associations were different according to sex. This may be due to the etiology of anemia or low Hb levels.
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Affiliation(s)
- Yun Hwan Oh
- Department of Family Medicine, Jeju National University Hospital, Jeju, Korea
| | - Ji Hyun Moon
- Department of Family Medicine, Jeju National University Hospital, Jeju, Korea
| | - Belong Cho
- Department of Family Medicine, Center for Health Promotion and Optimal Aging, Seoul National University College of Medicine & Hospital, Seoul, Korea.,Advanced Institutes of Convergence Technology, Seoul National University, Suwon, Korea.,Institute on Aging, Seoul National University College of Medicine, Seoul, Korea
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Xu F, Huang M, Jin Y, Kong Q, Lei Z, Wei X. Moxibustion treatment for primary osteoporosis: A systematic review of randomized controlled trials. PLoS One 2017; 12:e0178688. [PMID: 28591176 PMCID: PMC5462379 DOI: 10.1371/journal.pone.0178688] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 05/17/2017] [Indexed: 12/14/2022] Open
Abstract
Primary osteoporosis (POP) has a serious impact on quality of life for middle-aged and elderly, which particularly increase the risk of fracture. We conducted the systematic review to evaluate the effects of moxibustion for POP in randomized controlled trials (RCTs).Eight databases were searched from their inception to July 30, 2016. The RCTs reporting the moxibustion as a monotherapy or in combination with conventional therapy for POP were enrolled. The outcomes might be fracture incidence, quality of life, clinical symptoms, death attributed to osteoporosis, adverse effect, bone mineral density (BMD), and biochemical indicators. Literature selection, data abstraction, quality evaluation, and data analysis were in accordance with Cochrane standards.Thirteen trials including 808 patients were included. Meta-analysis was not conducted because of the obvious clinical or statistical heterogeneity. Limited evidence suggested that moxibustion plus anti-osteoporosis medicine might be more effective in relieving the pain (visual analogue scale scores average changed 2 scores between groups, 4 trials), increasing the BMD of femoral neck (average changed 0.4 g/cm2 between groups, 3 trials), and improving the level of bone gla protein, osteoprotegerin and bone alkaline phosphatase (2 trials) compared with anti-osteoporosis medicine alone. However, the quality of previous studies was evaluated as generally poor. The safety evidence of moxibustion was still insufficient. Due to the paucity of high-quality studies, there was no definite conclusion about the efficacy and safety of moxibustion treating POP although parts of positive results were presented. Future research should pay attention to the dose-response relation and fracture incidence of moxibustion for POP.
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Affiliation(s)
- Fanping Xu
- Department of Orthopaedics, Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China
| | - Minghua Huang
- Department of Orthopaedics, Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China
| | - Yi Jin
- Department of Orthopaedics, Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China
| | - Qingzhe Kong
- Department of Orthopaedics, Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China
| | - Zhongmin Lei
- Department of Orthopaedics, Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China
- * E-mail: (ZL); (XW)
| | - Xu Wei
- Department of Scientific Research, Wangjing hospital, China Academy of Chinese Medical Sciences, Beijing, China
- * E-mail: (ZL); (XW)
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Wang J, Wang X, Fang Z, Lu N, Han L. The Effect of FRAX on the Prediction of Osteoporotic Fractures in Urban Middle-aged and Elderly Healthy Chinese Adults. Clinics (Sao Paulo) 2017; 72:289-293. [PMID: 28591341 PMCID: PMC5439115 DOI: 10.6061/clinics/2017(05)06] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Accepted: 02/24/2017] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE: We aimed to analyze the applicability of a fracture risk assessment tool for the prediction of osteoporotic fractures in middle-aged and elderly healthy Chinese adults. METHODS: A standard questionnaire was administered, and bone mineral density was measured in residents visiting the Dongliu Street Community Health Service Center. Paired t-tests were used to compare the FRAX-based probabilities of fractures estimated with and without consideration of bone mineral density. Risk stratification and partial correlation analyses were applied to analyze the associations between FRAX-based probabilities and body mass index or bone mineral density at different sites. RESULTS: A total of 444 subjects were included in this study. Of these subjects, 175 (39.59%) were diagnosed as osteoporotic, and 208 (47.06%) were diagnosed as osteopenic. The Kappa value for the detection of osteoporosis at the L1-L4 lumbar spine and femoral neck was 0.314. The FRAX-based 10-year major osteoporotic fracture probability and hip osteoporotic fracture probability estimated without considering bone mineral density were 4.93% and 1.64%, respectively; when estimated while considering bone mineral density, these probabilities were 4.97% and 1.54%, respectively. A significant positive association was observed between the FRAX-based fracture probabilities estimated with and without consideration of bone mineral density, while significant negative associations between body mass index and the estimated FRAX-based fracture probabilities after adjustment for age and the estimated FRAX-based fracture probabilities and femoral neck bone mineral density were identified. These results remained the same after controlling for lumbar spine bone mineral density. CONCLUSIONS: The Chinese FRAX model could predict osteoporotic fracture risk regardless of whether bone mineral density was considered and was especially appropriate for predicting osteoporotic fractures of the femoral neck.
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Affiliation(s)
- Jun Wang
- Director’s Office, Minglou Street Community Health Service Center, Jiangdong District, Ningbo, China
| | - Xuejun Wang
- Director’s Office, Dongliu Street Community Health Service Center, Jiangdong District, Ningbo, China
| | - Zhen Fang
- Director’s Office, Dongliu Street Community Health Service Center, Jiangdong District, Ningbo, China
| | - Nanjia Lu
- Department of Preventive Medicine, Zhejiang Provincial Key Laboratory of Pathophysiology, School of Medicine, Ningbo University, Ningbo, China
| | - Liyuan Han
- Department of Preventive Medicine, Zhejiang Provincial Key Laboratory of Pathophysiology, School of Medicine, Ningbo University, Ningbo, China
- *Corresponding author. E-mail:
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Wang G, Yang J, Zheng X, Zhu J, Shi W, Chen A, Chen G, Zhou F. Association of genetic polymorphisms of GALNT3 and VDR with osteoporosis in postmenopausal women. Exp Ther Med 2016; 12:2629-2633. [PMID: 27698765 PMCID: PMC5038359 DOI: 10.3892/etm.2016.3665] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 08/23/2016] [Indexed: 01/31/2023] Open
Abstract
The correlation of genetic polymorphisms of GALNT3 and vitamin D receptor (VDR) with osteoporosis in postmenopausal women was investigated. A total of 1,212 cases of postmenopausal patients diagnosed with osteoporosis (observation group) and 404 cases of postmenopausal women without osteoporosis (control group) were selected. Dual-energy X-ray absorptiometry was used for measurement of bone mineral density (BMD) of lumbar vertebrae L2–4, proximal femoral neck and total hip, and classifications were made. TaqMan genotyping technology was employed to examine tag single-nucleotide polymorphism (tagSNP) of GALNT3 and VDR and the correlation of tagSNP with bone turnover markers (BTMs) and serum calcium and phosphorous levels was analyzed. The multiple logistic regression analysis was used to screen risk factors for osteoporosis. A comparison of age and menopause time of the two groups, yielded no statistical significance difference (P>0.05). BMD and T values of the lumbar vertebrae, femoral neck and total hip in the observation group were significantly lower than those in the control group, and the differences were statistically significant (P<0.05). A comparison of the degree of osteoporosis, yielded statistically significant differences (P<0.05). The proportion of tagSNP of 5 loci in GALNT3 and 3 loci in VDR in the observation group was significantly higher than that in the control group, and the differences were of statistical significance (P<0.05). Levels of 25-OHD3, β-CTX, P1NP and serum calcium in the observation group were lower than those in the control group and the level of serum phosphorus in the observation group was higher than that in the control group, and all of these results were statistically significant (P<0.05). The result of the correlation analysis revealed that rs1425000 and rs757343 were negatively correlated with BTM and serum calcium and phosphorus levels (P<0.05). The result of the regression analysis revealed that 8 tagSNPs were independent risk factors for osteoporosis. Genetic polymorphisms of GALNT3 and VDR were closely associated with osteoporosis in postmenopausal women.
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Affiliation(s)
- Guorong Wang
- Fujian Medical University Teaching Hospital, The First Hospital of Putian, Putian, Fujian 351100, P.R. China
| | - Junhua Yang
- Fujian Medical University Teaching Hospital, The First Hospital of Putian, Putian, Fujian 351100, P.R. China
| | - Xun Zheng
- Fujian Medical University Teaching Hospital, The First Hospital of Putian, Putian, Fujian 351100, P.R. China
| | - Jiahua Zhu
- Fujian Medical University Teaching Hospital, The First Hospital of Putian, Putian, Fujian 351100, P.R. China
| | - Wangqing Shi
- Fujian Medical University Teaching Hospital, The First Hospital of Putian, Putian, Fujian 351100, P.R. China
| | - Aimin Chen
- Fujian Medical University Teaching Hospital, The First Hospital of Putian, Putian, Fujian 351100, P.R. China
| | - Guoxian Chen
- Fujian Medical University Teaching Hospital, The First Hospital of Putian, Putian, Fujian 351100, P.R. China
| | - Fangye Zhou
- Fujian Medical University Teaching Hospital, The First Hospital of Putian, Putian, Fujian 351100, P.R. China
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