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Inoue Y, Tokushige A, Kinjyo T, Ueda S. Association of schizophrenia with fracture-related femoral neck displacement: A cross-sectional retrospective study. PCN REPORTS : PSYCHIATRY AND CLINICAL NEUROSCIENCES 2024; 3:e195. [PMID: 38868087 PMCID: PMC11114322 DOI: 10.1002/pcn5.195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 03/30/2024] [Accepted: 04/09/2024] [Indexed: 06/14/2024]
Abstract
Aim Fracture-related femoral neck displacement is more likely in patients with schizophrenia because of delayed diagnosis, as these patients frequently have less severe fracture-associated subjective symptoms. This study aimed to investigate the association of schizophrenia with the risk of fracture-related femoral neck displacement in hospitalized patients. Methods We retrospectively analyzed the medical records of patients with femoral neck fractures treated between April 2013 and March 2018 at a single institution. Multivariate logistic regression was used to explore the relationship between schizophrenia and fracture-related femoral neck displacement after adjusting for risk factors. Results We compared 30 and 194 patients with and without schizophrenia, respectively. The prevalence of fracture-related displacement was 80.0% in patients with schizophrenia and 62.4% in the controls (p = 0.06). After adjusting for confounding variables, schizophrenia significantly correlated with fracture-related femoral neck displacement (odds ratio: 4.74, 95% confidence interval: 1.09-20.60, p = 0.0378). Conclusions Schizophrenia is associated with a higher risk of severe femoral neck fracture. To improve outcomes and alleviate the societal burden of femoral neck fractures, early radiographic assessment and surgical intervention for femoral fractures are essential for patients with schizophrenia, even in those without pain symptoms.
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Affiliation(s)
- Yukiyo Inoue
- Department of PsychiatryTakamatsu Red Cross HospitalTakamatsu‐ShiKagawaJapan
- Department of Clinical Research and ManagementUniversity of Ryukyus Graduate School of MedicineNishihara‐choOkinawaJapan
| | - Akihiro Tokushige
- Department of Clinical Pharmacology & TherapeuticsUniversity of Ryukyus Graduate School of MedicineNishihara‐choOkinawaJapan
| | - Takeshi Kinjyo
- Department of OrthopedicsOkinawa Prefectural Nanbu Medical Center & Children's Medical CenterHeabaru‐choOkinawaJapan
| | - Shinichiro Ueda
- Department of Clinical Research and ManagementUniversity of Ryukyus Graduate School of MedicineNishihara‐choOkinawaJapan
- Department of Clinical Pharmacology & TherapeuticsUniversity of Ryukyus Graduate School of MedicineNishihara‐choOkinawaJapan
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Dissaneewate K, Dissaneewate P, Orapiriyakul W, Kritsaneephaiboon A, Chewakidakarn C. Development and Validation of Two-Step Prediction Models for Postoperative Bedridden Status in Geriatric Intertrochanteric Hip Fractures. Diagnostics (Basel) 2024; 14:804. [PMID: 38667450 PMCID: PMC11049116 DOI: 10.3390/diagnostics14080804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 04/02/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024] Open
Abstract
Patients with intertrochanteric hip fractures are at an elevated risk of becoming bedridden compared with those with intraarticular hip fractures. Accurate risk assessments can help clinicians select postoperative rehabilitation strategies to mitigate the risk of bedridden status. This study aimed to develop a two-step prediction model to predict bedridden status at 3 months postoperatively: one model (first step) for prediction at the time of admission to help dictate postoperative rehabilitation plans; and another (second step) for prediction at the time before discharge to determine appropriate discharge destinations and home rehabilitation programs. Three-hundred and eighty-four patients were retrospectively reviewed and divided into a development group (n = 291) and external validation group (n = 93). We developed a two-step prediction model to predict the three-month bedridden status of patients with intertrochanteric fractures from the development group. The first (preoperative) model incorporated four simple predictors: age, dementia, American Society of Anesthesiologists physical status classification (ASA), and pre-fracture ambulatory status. The second (predischarge) model used an additional predictor, ambulation status before discharge. Model performances were evaluated using the external validation group. The preoperative model performances were area under ROC curve (AUC) = 0.72 (95%CI 0.61-0.83) and calibration slope = 1.22 (0.40-2.23). The predischarge model performances were AUC = 0.83 (0.74-0.92) and calibration slope = 0.89 (0.51-1.35). A decision curve analysis (DCA) showed a positive net benefit across a threshold probability between 10% and 35%, with a higher positive net benefit for the predischarge model. Our prediction models demonstrated good discrimination, calibration, and net benefit gains. Using readily available predictors for prognostic prediction can assist clinicians in planning individualized postoperative rehabilitation programs, home-based rehabilitation programs, and determining appropriate discharge destinations, especially in environments with limited resources.
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Affiliation(s)
- Kantapon Dissaneewate
- Department of Orthopedics, Faculty of Medicine, Prince of Songkhla University, Hat Yai 90110, Thailand; (P.D.); (W.O.); (A.K.); (C.C.)
- Department of Clinical Research and Medical Data Science, Faculty of Medicine, Prince of Songkla University, Hat Yai 90110, Thailand
| | - Pornpanit Dissaneewate
- Department of Orthopedics, Faculty of Medicine, Prince of Songkhla University, Hat Yai 90110, Thailand; (P.D.); (W.O.); (A.K.); (C.C.)
| | - Wich Orapiriyakul
- Department of Orthopedics, Faculty of Medicine, Prince of Songkhla University, Hat Yai 90110, Thailand; (P.D.); (W.O.); (A.K.); (C.C.)
| | - Apipop Kritsaneephaiboon
- Department of Orthopedics, Faculty of Medicine, Prince of Songkhla University, Hat Yai 90110, Thailand; (P.D.); (W.O.); (A.K.); (C.C.)
| | - Chulin Chewakidakarn
- Department of Orthopedics, Faculty of Medicine, Prince of Songkhla University, Hat Yai 90110, Thailand; (P.D.); (W.O.); (A.K.); (C.C.)
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Lakstein D, Oren N, Haimovich Y, Kharchenkov V. Evolving trends in hip fracture patterns among the elderly from 2001 to 2022. Injury 2024; 55:111279. [PMID: 38159332 DOI: 10.1016/j.injury.2023.111279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/28/2023] [Accepted: 12/10/2023] [Indexed: 01/03/2024]
Abstract
INTRODUCTION Hip fractures among the elderly exhibit diverse patterns. Differences regarding treatment and prognosis of displaced versus undisplaced intracapsular fractures are well established. Unstable extracapsular fractures are associated with considerably higher rates of complications than stable fractures, including cutout failures, non-unions, wound complications and hardware related problems. The purpose of this study was to identify trends in the distribution of various types of hip fractures and their complexity between 2001 and 2022. METHODS This retrospective study compared hip fractures treated in the years 2001, 2006, 2010, 2014, 2018, and 2022, excluding patients under 60 years old and those with pathological or peri‑prosthetic fractures. Radiographs were reviewed and fracture patterns were categorized as stable extracapsular, unstable extracapsular, subtrochanteric or intracapsular. RESULTS Out of 2646 patients admitted with proximal femoral fractures during these years, 2277 patients (69.5 % women) were available for analysis. Over the initial decade, the mean patient age gradually increased from 80 to 82, subsequently stabilizing. Gender distribution remained consistent, and the proportion of intracapsular fractures showed minimal variation (36-38 %). The most significant finding was the marked decrease in the proportion of stable-to-unstable extracapsular fractures during the first decade from 51 % to 31 %, followed by stabilization after 2010. Subgroup analysis by age revealed that while the proportion change between stable and unstable fractures remained insignificant in younger age groups (p = 0.41 for sexagenarians and 0.12 for septuagenarians), a significant change was observed in older patients (p = 0.002 for octogenarians and 0.04 for nonagenarians and older patients). DISCUSSION This study reveals a surge in unstable peritrochanteric fractures between 2001 and 2010, particularly pronounced in patients over 80. This trend plateaued in the following decade, aligning with the stabilization of the cohort's mean age at 82. Numerous factors, from bone morphology to systemic markers, influence hip fracture types. Evolutions in osteoporosis screening and treatment over the last three decades may have contributed to the observed shifts in fracture pattern distribution. CONCLUSION Understanding these trends enriches treatment strategies and underscores the need for further exploration of the interplay between demographic and anatomical factors in the etiology of specific fracture patterns.
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Affiliation(s)
- Dror Lakstein
- Orthopedic dept, E. Wolfson Medical Center, Israel; Faculty of Medicine, Tel Aviv University, Israel.
| | - Nugzar Oren
- Orthopedic dept, E. Wolfson Medical Center, Israel
| | - Yaron Haimovich
- Orthopedic dept, E. Wolfson Medical Center, Israel; Faculty of Medicine, Tel Aviv University, Israel
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Balziano S, Greenstein N, Apterman S, Fogel I, Baran I, Prat D. Subtype consideration in hip fracture research: patient variances in inter- and intra-classification levels highlight the need for future research deliberation. A 2-years follow-up prospective-historical cohort. Arch Osteoporos 2023; 18:123. [PMID: 37770694 DOI: 10.1007/s11657-023-01334-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/25/2023] [Indexed: 09/30/2023]
Abstract
Current research on elderly patients with hip fractures often neglects specific subtypes, either grouping all fracture types or overlooking them entirely. By categorizing elderly patients based on fracture subtypes, we observed diverse baseline characteristics but found no discrepancies in measured outcomes. This emphasizes the need for caution in future research dealing with different or broader measured outcomes that were not covered by the scope of this research. PURPOSE/INTRODUCTION Existing research in elderly patients with hip fractures often overlooks the distinct subtypes or lumps all fracture types together. We aim to examine the differences between hip fracture subtypes to assess if these differences are meaningful for clinical outcomes and should be considered in future research. METHODS Patients above 65 years who underwent hip fracture surgeries during a three-year period were retrospectively reviewed. Cases were grouped based on fracture subtype: non-displaced femoral neck (nDFN), displaced femoral neck (DFN), stable intertrochanteric (sIT), and unstable intertrochanteric (uIT). RESULTS Among the 1,285 included cases, the nDFN-group had lower ASA scores (p = 0.009) and younger patients (p < 0.001), followed by the DFN-group (p = 0.014). The uIT-group had a higher proportion of female patients (72.3%, p = 0.004). Differences in preoperative ambulation status were observed (p = 0.001). However, no significant associations were found between fracture type and postoperative outcomes, including ambulation, transfusions, complications, reoperations, or mortality. Gender and preoperative ambulation status were predictors of mortality across all time frames. ASA score predicted mortality only within the first year after surgery. Age and gender were predictors of postoperative blood transfusions, while age and preoperative ambulation status were predictors of postoperative complications. CONCLUSIONS Variations in baseline characteristics of hip fractures were observed, but no significant differences were found in measured outcomes. This indicates that the hip fracture group is not homogeneous, emphasizing the need for caution in research involving this population. While grouping all types of proximal femur fractures may be acceptable depending on the outcome being studied, it's essential not to extrapolate these results to outcomes beyond the study's scope. Therefore, we recommend consider hip fracture subtypes when researching different outcomes not covered by this study.
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Affiliation(s)
- Snir Balziano
- Department of Orthopedic Surgery, Chaim Sheba Medical Center, Tel Aviv University, Ramat Gan, Israel.
| | - Nechemia Greenstein
- Department of Orthopedic Surgery, Chaim Sheba Medical Center, Tel Aviv University, Ramat Gan, Israel
| | - Sagy Apterman
- Department of Orthopedic Surgery, Chaim Sheba Medical Center, Tel Aviv University, Ramat Gan, Israel
| | - Itay Fogel
- Department of Orthopedic Surgery, Chaim Sheba Medical Center, Tel Aviv University, Ramat Gan, Israel
| | - Isaac Baran
- Department of Orthopedic Surgery, Chaim Sheba Medical Center, Tel Aviv University, Ramat Gan, Israel
| | - Dan Prat
- Department of Orthopedic Surgery, Chaim Sheba Medical Center, Tel Aviv University, Ramat Gan, Israel
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Che SH, Cho MR, Quinn PM, Song SK. Risk factors affecting hip fracture patterns in an elderly Korean patient population. Medicine (Baltimore) 2023; 102:e34573. [PMID: 37603514 PMCID: PMC10443748 DOI: 10.1097/md.0000000000034573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 07/13/2023] [Indexed: 08/23/2023] Open
Abstract
Hip fracture in the elderly patient population, particularly the Korean patient cohort, is one of the most serious complications of osteoporosis and currently increasing alongside age. In this study, we attempted to identify various factors that could either indicate the risk for an intertrochanteric or femoral neck fracture in an osteoporotic Korean hip fracture patient cohort ≥ 65 years old. A retrospective analysis of 168 patients was performed for those who underwent surgical treatment for either an intertrochanteric or femoral neck fracture at Daegu Catholic University Medical Center from January 2013 to December 2015. Inclusion criteria included patients who sustained a intertrochanteric or femoral neck fracture between the designated time frame, ≥65 years old, and of Korean ethnicity. Differences between the T-score and Z-score regarding bone mineral density (BMD) and the relationship between BMD and subtype of the fracture for the intertrochanteric (n = 92) and femoral neck fracture (n = 76) groups were obtained. Demographical factors (age, sex, weight, height, and body mass index [BMI]) were analyzed as potential risk factors for intertrochanteric or femoral neck fractures using software. Of the total 168 patients, mean weight and BMI values were found to be lower in the intertrochanteric fracture group (P = .033) compared to the femoral neck fracture group (P = .044). Additionally, Z-scores for the intertrochanteric fracture group were lower in the trochanter (P = .030), intertrochanteric (P = .029), and Ward's triangle (P = .029) regions. Regarding the intertrochanteric fracture group, the A3 subgroup showed lower T-scores of the trochanteric region than the A1 fracture subgroup (P = .010). In an elderly Korean hip patient cohort, lower body weight, BMI, and BMD Z-scores are correlated with a higher incidence of intertrochanteric fractures when compared to femoral neck hip fractures.
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Affiliation(s)
- Sug Hun Che
- Department of Orthopaedic Surgery, Daegu Catholic University Medical Center, Daegu, Republic of Korea
| | - Myung-Rae Cho
- Department of Orthopaedic Surgery, Daegu Catholic University Medical Center, Daegu, Republic of Korea
| | - Patrick Michael Quinn
- Department of Orthopaedic Surgery, Wakamatsu Hospital, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Suk-Kyoon Song
- Department of Orthopaedic Surgery, Daegu Catholic University Medical Center, Daegu, Republic of Korea
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Ke Y, Hu H, Zhang J, Yuan L, Li T, Feng Y, Wu Y, Fu X, Wang M, Gao Y, Huo W, Chen Y, Zhang W, Wang L, Li X, Pang J, Zheng Z, Hu F, Zhang M, Sun L, Zhao Y, Lu J, Hu D. Alcohol Consumption and Risk of Fractures: A Systematic Review and Dose-Response Meta-Analysis of Prospective Cohort Studies. Adv Nutr 2023; 14:599-611. [PMID: 36966875 PMCID: PMC10334160 DOI: 10.1016/j.advnut.2023.03.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 02/27/2023] [Accepted: 03/21/2023] [Indexed: 04/11/2023] Open
Abstract
Alcohol consumption remains inconsistently correlated with fracture risk, and a dose-response meta-analysis for specific outcomes is lacking. The objective of this study was to quantitatively integrate the data on the relationship between alcohol consumption and fracture risk. Pertinent articles were identified in PubMed, Web of Science, and Embase databases up to 20 February 2022. Combined RRs and 95% CIs were estimated by random- or fixed-effects models. Restricted cubic splines were used to model linear or nonlinear relationships. Forty-four articles covering 6,069,770 participants and 205,284 cases of fracture were included. The combined RRs and 95% CIs for highest compared with lowest alcohol consumption were 1.26 (1.17-1.37), 1.24 (1.13-1.35), and 1.20 (1.03-1.40) for total, osteoporotic, and hip fractures, respectively. A linear positive relationship between alcohol consumption and total fracture risk was detected (Pnonlinearity = 0.057); the risk was correlated with a 6% increase (RR, 1.06; 95% CI: 1.02, 1.10) per 14 g/d increment of alcohol consumption. J-shaped relationships of alcohol consumption with risk of osteoporotic fractures (Pnonlinearity < 0.001) and hip fractures (Pnonlinearity < 0.001) were found. Alcohol consumption of 0 to 22 g/d was linked to a reduced risk of osteoporotic fractures and hip fractures. Our findings show that any level of alcohol consumption is a risk factor for total fractures. Moreover, this dose-response meta-analysis shows that an alcohol consumption level of 0 to 22 g/d is related to a reduction in the risk of osteoporotic and hip fractures. The protocol was registered in the International Prospective Register of Systematic Reviews (CRD42022320623).
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Affiliation(s)
- Yamin Ke
- Department of General Practice, The Affiliated Luohu Hospital of Shenzhen University Medical School, Shenzhen, Guangdong, China, 47 Youyi Road, Luohu District, Shenzhen, Guangdong, 518001, People's Republic of China
| | - Huifang Hu
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Jinli Zhang
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Lijun Yuan
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Tianze Li
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Yifei Feng
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Yuying Wu
- Department of General Practice, The Affiliated Luohu Hospital of Shenzhen University Medical School, Shenzhen, Guangdong, China, 47 Youyi Road, Luohu District, Shenzhen, Guangdong, 518001, People's Republic of China
| | - Xueru Fu
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Mengmeng Wang
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Yajuan Gao
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Weifeng Huo
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Yaobing Chen
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Wenkai Zhang
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Longkang Wang
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Xi Li
- Department of General Practice, The Affiliated Luohu Hospital of Shenzhen University Medical School, Shenzhen, Guangdong, China, 47 Youyi Road, Luohu District, Shenzhen, Guangdong, 518001, People's Republic of China
| | - Jinyuan Pang
- Department of Preventive Medicine, School of Public Health, Shenzhen University Medical School, ShenZhen, Guangdong, People's Republic of China
| | - Zeqiang Zheng
- Department of Preventive Medicine, School of Public Health, Shenzhen University Medical School, ShenZhen, Guangdong, People's Republic of China
| | - Fulan Hu
- Department of Biostatistics and Epidemiology, School of Public Health, Shenzhen University Medical School, Shenzhen, Guangdong, People's Republic of China
| | - Ming Zhang
- Department of Biostatistics and Epidemiology, School of Public Health, Shenzhen University Medical School, Shenzhen, Guangdong, People's Republic of China
| | - Liang Sun
- Department of Social Medicine and Health Management, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Yang Zhao
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Jie Lu
- Department of Epidemiology and Biostatistics, College of Public Health, Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Dongsheng Hu
- Department of General Practice, The Affiliated Luohu Hospital of Shenzhen University Medical School, Shenzhen, Guangdong, China, 47 Youyi Road, Luohu District, Shenzhen, Guangdong, 518001, People's Republic of China.
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Li N, Yuan Y, Yin L, Yang M, Liu Y, Zhang W, Ma K, Zhou F, Cheng Z, Wang L, Cheng X. Site-Specific Differences in Bone Mineral Density of Proximal Femur Correlate with the Type of Hip Fracture. Diagnostics (Basel) 2023; 13:diagnostics13111877. [PMID: 37296729 DOI: 10.3390/diagnostics13111877] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/24/2023] [Accepted: 05/25/2023] [Indexed: 06/12/2023] Open
Abstract
The aim of this study was to investigate whether site-specific differences in bone mineral density (BMD) of proximal femur correlate with the type of hip fracture using quantitative computed tomography. Femoral neck (FN) fractures were classified as nondisplaced or displaced subtypes. Intertrochanteric (IT) fractures were classified as A1, A2, or A3. The severe hip fractures were identified as displaced FN fractures or unstable IT fractures (A2 and A3). In total, 404 FN fractures (89 nondisplaced and 317 displaced) and 189 IT fractures (76 A1, 90 A2, and 23 A3) were enrolled. Areal BMD (aBMD) and volumetric BMD (vBMD) were measured in the regions of total hip (TH), trochanter (TR), FN, and IT of the contralateral unfractured femur. IT fractures exhibited lower BMD than FN fractures (all p ≤ 0.01). However, unstable IT fractures had higher BMD compared with stable ones (p < 0.01). After adjusting for covariates, higher BMD in TH and IT were associated with IT A2 (A1 vs. A2: odds ratios (ORs) from 1.47 to 1.69, all p < 0.01). Low bone measurements were risk factors for stable IT fractures (IT A1 vs. FN fracture subtypes: ORs from 0.40 to 0.65, all p < 0.01). There are substantial site-specific differences in BMD between IT fractures A1 and displaced FN fractures. Higher bone density was associated with unstable IT fracture when compared with stable ones. The understanding of biomechanics of various fracture types could help to improve the clinical management of these patients.
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Affiliation(s)
- Ning Li
- Department of Traumatic Orthopedics, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Yi Yuan
- Department of Radiology, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Lu Yin
- Medical Research and Biometrics Center, National Center for Cardiovascular Disease, Beijing 100037, China
| | - Minghui Yang
- Department of Traumatic Orthopedics, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Yandong Liu
- Department of Radiology, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Wenshuang Zhang
- Department of Radiology, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Kangkang Ma
- Department of Radiology, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Fengyun Zhou
- Department of Radiology, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Zitong Cheng
- Department of Radiology, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Ling Wang
- Department of Radiology, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Xiaoguang Cheng
- Department of Radiology, Beijing Jishuitan Hospital, Beijing 100035, China
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8
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Tomita Y, Yamamoto N, Inoue T, Ichinose A, Noda T, Kawasaki K, Ozaki T. Preoperative and perioperative factors are related to the early postoperative Barthel Index score in patients with trochanteric fracture. Int J Rehabil Res 2022; 45:154-160. [PMID: 35170497 DOI: 10.1097/mrr.0000000000000522] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Previous studies have shown that preoperative factors predict the postoperative Barthel Index score in patients with trochanteric fractures, while there is less evidence on the effects of perioperative factors on the prediction. This study aimed to assess the effects of preoperative and perioperative factors on the early postoperative Barthel Index score in patients with trochanteric fractures. Consecutive 288 patients aged ≥60 years with trochanteric fractures who could independently walk before injury were included. Patients were grouped according to the Barthel Index score measured after 2 weeks of surgery; the cut-off value was 20 points. Two logistic regression models were created to assess the effects of preoperative (model 1: dementia, walking ability before injury, and nutrition status) and perioperative (model 2: independent variables in model 1, reduction quality, and basic mobility function) factors on the Barthel Index score. Sensitivity and specificity were used to assess the predicative accuracy of the models. Poor preoperative (model 1: χ2 = 34.626, P < 0.01) and perioperative (model 2: χ2 = 43.956, P < 0.01) characteristics were significantly related to lower Barthel Index score. Sensitivity and specificity were similar between the models (model 1: 83.3% and 38.9% and model 2: 82.2% and 42.6%, respectively). Both preoperative and perioperative factors were significantly related to the early postoperative Barthel Index score after trochanteric fracture. However, only minimal increase in predictive accuracy was observed when perioperative predictors were analyzed along with preoperative factors. Both baseline characteristics and basic postoperative mobility should be considered when treating patients with trochanteric fractures.
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Affiliation(s)
- Yosuke Tomita
- Department of Physical Therapy, Faculty of Health Care, Takasaki University of Health and Welfare, Gunma
| | - Norio Yamamoto
- Department of Orthopedic Surgery, Kagawa Prefectural Central Hospital
- Systematic Review Workshop Peer Support Group (SRWS-PSG), Osaka
| | - Tomoo Inoue
- Department of Orthopedic Surgery, Kagawa Prefectural Central Hospital
| | - Arisa Ichinose
- Department of Physical Therapy, Kagawa Prefectural Central Hospital, Kagawa
| | - Tomoyuki Noda
- Department of Orthopaedic Surgery and Traumatology, Kawasaki Medical School General Medical Center
| | - Keisuke Kawasaki
- Department of Orthopedic Surgery, Kagawa Prefectural Central Hospital
| | - Toshifumi Ozaki
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
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Jadzic J, Milovanovic P, Cvetkovic D, Ivovic M, Tomanovic N, Bracanovic M, Zivkovic V, Nikolic S, Djuric M, Djonic D. Mechano-structural alteration in proximal femora of individuals with alcoholic liver disease: Implications for increased bone fragility. Bone 2021; 150:116020. [PMID: 34044170 DOI: 10.1016/j.bone.2021.116020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/14/2021] [Accepted: 05/19/2021] [Indexed: 02/06/2023]
Abstract
Although increased hip fracture risk is noted in patients with alcoholic liver disease (ALD), their femoral microstructural and mechanical properties were not investigated previously. The present study aimed to analyze the associations between subregional deteriorations in femoral mechano-structural properties and clinical imaging findings to explain increased femoral fracture risk among ALD patients. This study analyzed proximal femora of 33 male cadaveric donors, divided into ALD (n = 13, 57 ± 13 years) and age-matched control group (n = 20, 54 ± 13 years). After pathohistological verification of ALD stage, DXA and HSA measurements of the proximal femora were performed, followed by micro-CT and Vickers microindentation of the superolateral neck, inferomedial neck, and intertrochanteric region. Bone mineral density and cross sectional area of the femoral neck were deteriorated in ALD donors, compared with healthy controls (p < 0.05). Significant ALD-induced degradation of trabecular and cortical microstructure and Vickers microhardness reduction were noted in the analyzed femoral regions (p < 0.05). Still, the most prominent ALD-induced mechano-structural deterioration was noted in intertrochanteric region. Additionally, more severe bone alterations were observed in individuals with an irreversible stage of ALD, alcoholic liver cirrhosis (ALC), than in those with an initial ALD stage, fatty liver disease. Observed osteodensitometric and mechano-structural changes illuminate the basis for increased femoral fracture risk in ALD patients. Additionally, our data suggest bone strength reduction that may result in increased susceptibility to intertrochanteric femoral fracture in men with ALD. Thus, femoral fracture risk assessment should be advised for all ALD patients, especially in those with ALC.
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Affiliation(s)
- Jelena Jadzic
- Laboratory for Anthropology and Skeletal biology, Institute for Anatomy, Faculty of Medicine, University of Belgrade, Dr. Subotica no. 4/2, Belgrade, Serbia
| | - Petar Milovanovic
- Laboratory for Anthropology and Skeletal biology, Institute for Anatomy, Faculty of Medicine, University of Belgrade, Dr. Subotica no. 4/2, Belgrade, Serbia
| | - Danica Cvetkovic
- Institute of Forensic Medicine, Faculty of Medicine, University of Belgrade, Deligradska no. 31a, Belgrade, Serbia
| | - Miomira Ivovic
- Institute for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Dr. Subotica no. 13, Belgrade, Serbia
| | - Nada Tomanovic
- Institute of Pathology, Faculty of Medicine, University of Belgrade, Dr. Subotica no. 1, Belgrade, Serbia
| | - Milos Bracanovic
- Clinic for Emergency Surgery, Clinical Center of Serbia, Pasterova no. 2, Belgrade, Serbia
| | - Vladimir Zivkovic
- Institute of Forensic Medicine, Faculty of Medicine, University of Belgrade, Deligradska no. 31a, Belgrade, Serbia
| | - Slobodan Nikolic
- Institute of Forensic Medicine, Faculty of Medicine, University of Belgrade, Deligradska no. 31a, Belgrade, Serbia
| | - Marija Djuric
- Laboratory for Anthropology and Skeletal biology, Institute for Anatomy, Faculty of Medicine, University of Belgrade, Dr. Subotica no. 4/2, Belgrade, Serbia
| | - Danijela Djonic
- Laboratory for Anthropology and Skeletal biology, Institute for Anatomy, Faculty of Medicine, University of Belgrade, Dr. Subotica no. 4/2, Belgrade, Serbia.
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Tomita Y, Yamamoto N, Inoue T, Noda T, Kawasaki K, Ozaki T. Clinical prediction model for postoperative ambulatory ability outcomes in patients with trochanteric fractures. Injury 2021; 52:1826-1832. [PMID: 33931207 DOI: 10.1016/j.injury.2021.04.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 04/10/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Regaining independent ambulatory ability is one of the primary goals of treatment in patients with trochanteric fractures. This study aimed to develop and evaluate the discriminative accuracy of a clinical prediction model for ambulatory ability outcomes 3 months after surgery for trochanteric fractures. METHODS This retrospective cohort study included 346 patients treated with intramedullary nailing for trochanteric fractures who had independent ambulatory ability before their injury. Multiple regression models with preoperative and postoperative factors were used to predict ambulatory ability outcomes at 3 months. A clinical prediction model (CPM) was created based on a decision tree developed using a chi-square automatic interaction detector technique. RESULTS Three months after surgery, 263 (76.0%) and 83 (24.0%) patients regained and lost independent ambulatory ability, respectively. Univariate analysis showed that the Barthel index (BI) total score at 2 weeks predicted the ambulatory ability outcome at 3 months with good discriminative accuracy (area under the receiver operating characteristic curve [AUROC]: 0.819; 95% confidence interval [CI]: [0.769, 0.868], cut-off value: 22.5; sensitivity: 69.5%; specificity: 82.3%). Multiple logistic regression analysis showed that preoperative factors (residence before injury, diagnosis of dementia, and serum albumin at admission) and postoperative factors (BI total score at 2 weeks) predicted ambulatory ability outcomes at 3 months (AUROC: 0.710; 95%CI: [0.636, 0.783]; sensitivity: 91.3%; specificity: 41.8%). The CPM with the BI total score at 2 weeks (≤10; 10<, ≤50; >50 points) and dementia status (present; absent) had a moderate discriminative accuracy (AUROC: 0.676; 95%CI: [0.600, 0.752]; sensitivity: 94.7%; specificity: 40.5%). CONCLUSIONS We developed a CPM with moderate accuracy to predict ambulatory ability outcomes in patients 3 months after surgery for trochanteric fractures. Our results demonstrate the importance of the BI score measured soon after surgery and dementia status for the prediction of postoperative ambulation.
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Affiliation(s)
- Yosuke Tomita
- Department of Physical Therapy, Faculty of Health Care, Takasaki University of Health and Welfare, Gunma, Japan
| | - Norio Yamamoto
- Department of Orthopedic Surgery, Kagawa Prefectural Central Hospital, Kagawa, Japan.
| | - Tomoo Inoue
- Department of Orthopedic Surgery, Kagawa Prefectural Central Hospital, Kagawa, Japan
| | - Tomoyuki Noda
- Department of Musculoskeletal Traumatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Keisuke Kawasaki
- Department of Orthopedic Surgery, Kagawa Prefectural Central Hospital, Kagawa, Japan
| | - Toshifumi Ozaki
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
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11
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Asoudeh F, Salari-Moghaddam A, Larijani B, Esmaillzadeh A. A systematic review and meta-analysis of prospective cohort studies on the association between alcohol intake and risk of fracture. Crit Rev Food Sci Nutr 2021; 62:5623-5637. [PMID: 33596741 DOI: 10.1080/10408398.2021.1888691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Previous studies on the association between alcohol intake and risk of fracture have reached conflicting findings. The aim of this systematic review and meta-analysis of prospective cohort studies was to summarize earlier studies on the association of alcohol intake with risk of fracture. A systematic search of PubMed, Scopus, and ISI Web of Science was conducted up to November 2020. Prospective cohort studies that had considered alcohol consumption as the exposure variable and fracture as the main outcome or as one of the outcome variables were included in this systematic review. Publications in which odds ratios (ORs), rate or risk ratios (RRs), or hazard ratios (HRs) and 95% confidence intervals (CIs) were reported, were included in the meta-analysis. In total, 40 prospective cohort studies including 5,084,303 participants and 170,916 subjects with fracture were included in this systematic review; of them 38 studies with a total sample size of 5,053,117 participants and 169,560 cases of fracture were included in the meta-analysis. Using a random-effects meta-analysis, we found a significant positive association between alcohol consumption and risk of total fractures (RR: 1.35; 95% CI: 1.01, 1.81) and any fractures (RR: 1.24; 95% CI: 1.11, 1.38). However, no significant association was observed between alcohol intake and risk of hip fractures (RR: 1.19; 95% CI: 0.96, 1.48), osteoporotic fractures (RR: 2.01; 95% CI: 0.76, 5.34), vertebral fractures (RR: 0.98; 95% CI: 0.68, 1.40), and wrist fractures (RR: 0.99; 95% CI: 0.85, 1.16). In conclusion, we found that alcohol consumption was positively associated with risk of total fractures and any fractures. However, we did not observe any significant association between alcohol consumption and risk of hip, osteoporotic, vertebral, and wrist fractures.
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Affiliation(s)
- Farzaneh Asoudeh
- Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - Asma Salari-Moghaddam
- Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmad Esmaillzadeh
- Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran.,Obesity and Eating Habits Research Center, Endocrinology and Metabolism Molecular-Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.,Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
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12
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Zhao J, Cai Q, Jiang D, Wang L, Chen S, Jia W. The Associations of Serum Vitamin D and Bone Turnover Markers with the Type and Severity of Hip Fractures in Older Women. Clin Interv Aging 2020; 15:1971-1978. [PMID: 33116451 PMCID: PMC7574903 DOI: 10.2147/cia.s271904] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 09/17/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose Vitamin D (25[OH]D) status and bone turnover markers (BTMs) are considered important determinants of bone quality, which is associated with the risk of hip fractures, including both femoral neck and intertrochanteric fractures, in older adults; however, the exact relationship of 25(OH)D and BTMs with the type and severity of hip fractures remains unclear and the present study aimed to identify any specific associations. Patients and Methods According to the inclusion and exclusion criteria, 441 older female patients with hip fractures from 2015 to 2020 and 215 women without hip fractures were included in this cross-sectional study. According to Garden and AO/OTA classifications for femoral neck and intertrochanteric fractures, patients were divided into less severe (Garden I and Garden II; 31A1) and more severe (Garden III and Garden IV; 31A2 and 31A3) fracture groups. Levels of the serum osteoblast indicator, N-terminal/mid region (N-MID); the osteoclast indicator, beta-carboxy terminal telopeptide (β-CTX); and 25(OH)D were analyzed. Results For patients with less severe fractures, mean 25(OH)D levels were significantly higher than those with more severe fractures (17.67 vs 15.30 ng/mL, p = 0.006). Higher 25(OH)D levels were also observed in patients with less severe intertrochanteric fractures (p = 0.01). After adjustments for confounders, 25(OH)D remained a risk factor for patients with more severe fractures (p = 0.01), particularly those with intertrochanteric fractures (p = 0.011). No significant differences in BTMS were found between patients with less severe and more severe fractures. Conclusion Levels of 25(OH)D were significantly associated with the severity of intertrochanteric, but not femoral neck, fractures. Neither 25(OH)D nor BTMs were associated with the type of hip fracture in older women. Separate consideration of intertrochanteric and femoral neck fractures may be appropriate when investigating the clinical association between 25(OH)D and the severity of hip fractures in older women.
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Affiliation(s)
- Jinhui Zhao
- Department of Orthopedic Surgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai 200233, People's Republic of China
| | - Qianying Cai
- Department of Orthopedic Surgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai 200233, People's Republic of China
| | - Dajun Jiang
- Department of Orthopedic Surgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai 200233, People's Republic of China
| | - Lingtian Wang
- Department of Orthopedic Surgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai 200233, People's Republic of China
| | - Shengbao Chen
- Department of Orthopedic Surgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai 200233, People's Republic of China
| | - Weitao Jia
- Department of Orthopedic Surgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai 200233, People's Republic of China
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13
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Wang SM, Han KD, Kim NY, Um YH, Kang DW, Na HR, Lee CU, Lim HK. Association of Alcohol Intake and Fracture Risk in Elderly Varied by Affected Bones: A Nationwide Longitudinal Study. Psychiatry Investig 2020; 17:1013-1020. [PMID: 33059395 PMCID: PMC7596281 DOI: 10.30773/pi.2020.0143] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 08/20/2020] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE Previous studies investigating association of alcohol intake and fracture risk in elderly yielded conflicting results. We first examined the association between alcohol intake and total fracture risk in elderly subjects and further analyzed whether the association varied by fracture locations. METHODS This is a nationwide population-based cohort study which included all people aged 66 (n=1,431,539) receiving the National Screening Program during 2009-2014. Time-to-event were defined as duration from study recruitment, the day they received health screening, to the occurrence of fracture. RESULTS Total fracture was significantly lower in mild drinkers [adjusted hazard ratio (aHR)=0.952; 95% confidence interval (95% CI) =0.931-0.973] and higher in heavy drinkers (aHR=1.246; 95% CI=1.201-1.294) than non-drinkers. Risk pattern of alcohol consumption and fracture differed according to affected bones. Similar J-shaped trends were observed for vertebra fractures, but risk of limb fracture showed a linear relationship with alcohol intake. For hip fracture, risk decrement was more pronounced in mild and moderate drinkers, and significant increment was noted only in very severe drinkers [≥60 g/day; (aHR)=1.446; 1.162-1.801]. CONCLUSION Light to moderate drinking generally lowered risk of fractures, but association between alcohol and fracture risk varied depending on the affected bone lesions.
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Affiliation(s)
- Sheng-Min Wang
- Department of Psychiatry, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kyung-Do Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - Nak-Young Kim
- Department of Psychiatry, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yoo Hyun Um
- Department of Psychiatry, St. Vincent Hospital, College of Medicine, The Catholic University of Korea, Suwon, Republic of Korea
| | - Dong Woo Kang
- Department of Psychiatry, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hae-Ran Na
- Department of Psychiatry, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chang Uk Lee
- Department of Psychiatry, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyun Kook Lim
- Department of Psychiatry, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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14
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Dretakis K, Igoumenou VG. The role of parathyroid hormone (PTH) and vitamin D in falls and hip fracture type. Aging Clin Exp Res 2019; 31:1501-1507. [PMID: 30701437 DOI: 10.1007/s40520-019-01132-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 01/16/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Fragility fractures of the hip are associated with high morbidity and mortality, and represent a rather devastating consequence of osteoporosis. Hip fractures are traditionally investigated as a whole, although it has been recently implied that distinct pathogenic mechanisms may lead either to trochanteric or subcapital fractures. AIMS To investigate whether differences exist by hip fracture type with respect to serum 25(OH)D (vitamin D) and parathyroid hormone (PTH) levels, in addition to epidemiological and demographic data, including history of falls. METHODS The inclusion criteria were met by 116 patients [48 men and 68 women; mean age 80.8 ± 8.5 (range 62-94) years]. Patients were analyzed according to hip fracture type, history of falls, and vitamin D and PTH status. RESULTS Older age, recurrent falls, serum levels of PTH > 65 pg/ml, and severe vitamin D deficiency were found to be associated with trochanteric fractures. Additionally, older age, female gender, PTH > 65 pg/ml, and severe vitamin D deficiency were related to recurrent falls. Meanwhile, patients with absence of PTH response to low vitamin D levels, were not repeated fallers and suffered mostly from subcapital fractures. DISCUSSION AND CONCLUSION Elevated PTH levels predispose both to falls and trochanteric fractures, while vitamin D-deficient patients with normal PTH levels are mostly related to subcapital fractures. It is thereby indicated that different pathophysiological processes lie behind subcapital and trochanteric fractures. A better understanding of these mechanisms may assist in the development of prevention strategies for individuals recognized at risk for falls and either type of hip fracture.
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Affiliation(s)
| | - Vasilios G Igoumenou
- First Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
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15
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Farhang M, Mukka S, Bergström U, Svensson O, Sayed-Noor AS. The trend of radiological severity of hip fractures over a 30 years period: a cohort study. BMC Musculoskelet Disord 2019; 20:358. [PMID: 31391031 PMCID: PMC6686553 DOI: 10.1186/s12891-019-2739-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 07/25/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite advances in operative techniques and preoperative care, proximal femur fractures (PFF) still represent a great public health problem. Displacement and fracture stability have been assumed as important determinants of treatment modality and outcome in such fractures. Purpose of this study was to determine whether the radiological severity of PFF fractures has increased over time. METHODS In a cohort study, the plain radiographs of all patients with PFF aged over 50 years who were admitted to Umeå University Hospital in 1981/82, 2002 and 2012 were recruited to examine the types of fractures. RESULTS The ratio of undisplaced to displaced femoral neck (FN) fractures was 30 to 70% in 1981/82, 28 to 72% in 2002 and 25 to 75% in 2012. The ratio of stable to unstable intertrochanteric (IT) fractures was 64 to 36% in 1981/82, 68 to 32% in 2002 and 75 to 25% in 2012. The ratio of simple to comminute subtrochanteric fractures was 35 to 65% in 1981/82, 16 to 84% in 2002 and 12 to 88% in 2012. In both FN and IT fractures we found no statistical difference among these 3 study periods, p = 0.67 and p = 0.40. In subtrochanteric fractures we saw a tendency towards more comminute subtrochanteric fractures (1981/82 to 2012), p = 0.09. CONCLUSIONS We found no significant increment in the radiological severity of FN and IT over a 30 years' period. However, there was tendency towards an increase in comminute subtrochanteric fractures.
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Affiliation(s)
- Mehdy Farhang
- 0000 0001 1034 3451grid.12650.30Department of Surgical and Perioperative Sciences, Umeå University, 90187 Umeå, Sweden
| | - Sebastian Mukka
- 0000 0001 1034 3451grid.12650.30Department of Surgical and Perioperative Sciences, Umeå University, 90187 Umeå, Sweden
| | - Ulrica Bergström
- 0000 0001 1034 3451grid.12650.30Department of Surgical and Perioperative Sciences, Umeå University, 90187 Umeå, Sweden
| | - Olle Svensson
- 0000 0001 1034 3451grid.12650.30Department of Surgical and Perioperative Sciences, Umeå University, 90187 Umeå, Sweden
| | - Arkan S. Sayed-Noor
- 0000 0001 1034 3451grid.12650.30Department of Surgical and Perioperative Sciences, Umeå University, 90187 Umeå, Sweden
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16
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Altai Z, Qasim M, Li X, Viceconti M. The effect of boundary and loading conditions on patient classification using finite element predicted risk of fracture. Clin Biomech (Bristol, Avon) 2019; 68:137-143. [PMID: 31202100 DOI: 10.1016/j.clinbiomech.2019.06.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 05/28/2019] [Accepted: 06/04/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Osteoporotic proximal femoral fractures associated to falls are a major health burden in the ageing society. Recently, bone strength estimated by finite element models emerged as a feasible alternative to areal bone mineral density as a predictor of fracture risk. However, previous studies showed that the accuracy of patients' classification under their risk of fracture using finite element strength when simulating posterolateral falls is only marginally better than that of areal bone mineral density. Patients tend to fall in various directions: since the predicted strength is sensitive to the fall direction, a prediction based on certain fall directions might not be fully representative of the physical event. Hence, side fall boundary conditions may not be completely representing the physical event. METHODS The effect of different side fall boundary and loading conditions on a retrospective cohort of 98 postmenopausal women was evaluated to test models' ability to discriminate fracture and control cases. Three different boundary conditions (Linear, Multi-point constraints and Contact model) were investigated under various anterolateral and posterolateral falls. FINDINGS The stratification power estimated by the area under the receiver operating characteristic curve was highest for Contact model (0.82), followed by Multi-point constraints and Linear models with 0.80. Both Contact and MPC models predicted high strains in various locations of the proximal femur including the greater trochanter, which has rarely reported previously. INTERPRETATION A full range of fall directions and less restrictive displacement constraints can improve the finite element strength ability to classify patients under their risk of fracture.
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Affiliation(s)
- Zainab Altai
- Department of Mechanical Engineering, University of Sheffield, Sheffield, UK; INSIGNEO Institute for in silico Medicine, University of Sheffield, Sheffield, UK
| | - Muhammad Qasim
- Faculty of Health, Education, Medicine and Social Care, Medical Technology Research Centre, Anglia Ruskin University, Chelmsford, UK
| | - Xinshan Li
- Department of Mechanical Engineering, University of Sheffield, Sheffield, UK; INSIGNEO Institute for in silico Medicine, University of Sheffield, Sheffield, UK.
| | - Marco Viceconti
- Department of Industrial Engineering, Alma Mater Studiorum - University of Bologna, Italy; Laboratorio di Tecnologia Medica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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17
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Irving D, Hinkley J, Marquart M. The Relationship Between BMI and Stability of Intertrochanteric Fracture Following Low-Energy Falls. A Retrospective Cohort Study. Geriatr Orthop Surg Rehabil 2019; 10:2151459319857555. [PMID: 31245169 PMCID: PMC6582282 DOI: 10.1177/2151459319857555] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 05/03/2019] [Accepted: 05/25/2019] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Intertrochanteric proximal femur fractures are common injuries in the elderly. Certain patterns are considered unstable and confer increased risks. Risk factors for these patterns are not well defined. We sought to determine whether increased body mass index (BMI) was associated with increased risk of sustaining an unstable pattern intertrochanteric (IT) fracture following low-energy trauma. Materials and methods: Retrospective case review of all patients presenting to a level-2 trauma center between October 2010 and August 2014 with Intertrochanteric fracture. Fracture pattern (stable or unstable) and BMI were analyzed using odds ratios and age was controlled for. RESULTS Four hundred fifty-two patients were identified. No difference was found between fracture stability when BMI of 25 was used as a cutoff. However, when a BMI of 30 was used as a cutoff, there was a trend of difference (relative difference 30%) in rates of fracture type favoring unstable patterns in the obese group. This difference approached but did not reach statistical significance (P = .08). When adjusted for age, the difference remained but still did not reach statistical significance (P = .11). DISCUSSION Unstable type IT fractures were found more frequently in the obese cohort (BMI >30) than those who were not obese.
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Affiliation(s)
- Devan Irving
- Altru Health System, Genesys Regional Medical Center, Grand Blanc, MI, USA
| | - Jacob Hinkley
- Altru Health System, Genesys Regional Medical Center, Grand Blanc, MI, USA
| | - Matthew Marquart
- Altru Health System, Genesys Regional Medical Center, Grand Blanc, MI, USA
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18
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Greer JB, Greer P, Sandhu BS, Alkaade S, Wilcox CM, Anderson MA, Sherman S, Gardner TB, Lewis MD, Guda NM, Muniraj T, Conwell D, Cote GA, Forsmark CE, Banks PA, Tang G, Stello K, Gelrud A, Brand RE, Slivka A, Whitcomb DC, Yadav D. Nutrition and Inflammatory Biomarkers in Chronic Pancreatitis Patients. Nutr Clin Pract 2018; 34:387-399. [PMID: 30101991 DOI: 10.1002/ncp.10186] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Chronic pancreatitis (CP) patients frequently experience malabsorption and maldigestion, leading to micronutrient and macronutrient deficiencies. Comorbid diabetes and lifestyle habits, such as alcohol consumption, may impact nutrition status. METHODS We compared micronutrient antioxidant, bone metabolism, serum protein, and inflammatory marker levels in 301 CP patients and 266 controls with no known pancreatic disease. We analyzed serum prealbumin and retinol binding protein; vitamins A, D, E, and B12; osteocalcin; tumor necrosis factor-α; and C-reactive protein (CRP). We also evaluated biomarkers among subsets of patients, examining factors including time since diagnosis, body mass index, alcohol as primary etiology, diabetes mellitus, vitamin supplementation, and pancreatic enzyme replacement. RESULTS After correcting for multiple comparisons, CP patients had significantly lower levels than controls of the following: vitamin A (40.9 vs 45.4 μg/dL) and vitamin E (α-tocopherol [8.7 vs 10.3 mg/L] and γ-tocopherol [1.8 vs 2.2 mg/L]), as well as osteocalcin (7.9 vs 10 ng/mL) and serum prealbumin (23 vs 27 mg/dL). Both patients and controls who took vitamin supplements had higher serum levels of vitamins than those not taking supplements. Compared with controls, in controlled analyses, CP patients had significantly lower levels of vitamins A, D, and E (both α-tocopherol and γ-tocopherol). CP patients also had significantly lower levels of osteocalcin, serum prealbumin, and retinol binding protein, and higher CRP. CONCLUSIONS CP patients demonstrated lower levels of selected nutrition and bone metabolism biomarkers than controls. Diabetes and alcohol did not impact biomarkers. Vitamin supplements and pancreatic enzyme replacement therapy improved nutrition biomarkers in CP patients.
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Affiliation(s)
- Julia B Greer
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Phil Greer
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Samer Alkaade
- Department of Medicine, Saint Louis University, St. Louis, Missouri
| | - C Mel Wilcox
- Department of Medicine, University of Alabama Birmingham, Birmingham, Alabama
| | | | - Stuart Sherman
- Department of Medicine, Indiana University, Indianapolis, Indiana
| | - Timothy B Gardner
- Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Nalini M Guda
- GI Associates LLC, Aurora Health Care, St. Luke's Medical Center, Milwaukee, Wisconsin
| | | | - Darwin Conwell
- Department of Medicine, The Ohio State University, Columbus, Ohio
| | - Gregory A Cote
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | | | - Peter A Banks
- Department of Medicine, Brigham and Women's Hospital, Boston Massachusetts
| | - Gong Tang
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kim Stello
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Andres Gelrud
- GastroHealth and Miami Cancer Institute, Baptist Hospital, Miami, Florida
| | - Randall E Brand
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Adam Slivka
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David C Whitcomb
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dhiraj Yadav
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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19
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Hosseinzadeh A, Khalili M, Sedighi B, Iranpour S, Haghdoost AA. Parkinson's disease and risk of hip fracture: systematic review and meta-analysis. Acta Neurol Belg 2018; 118:201-210. [PMID: 29767373 DOI: 10.1007/s13760-018-0932-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 04/21/2018] [Indexed: 01/09/2023]
Abstract
The relationship between Parkinson's disease (PD) and risk of hip fracture yielded inconsistent results. Therefore, we conducted the present systematic review and meta-analysis of published observational studies to assess the association between PD and risk of hip fracture. PubMed, ISI, EMBASE, and Cochrane databases were searched systematically to identify studies assessing the relationship between PD and the risk of hip fracture up to July 01, 2017. In addition, to find related articles, the reference section of retrieved articles was checked. Random-effects model was used for calculation of pooled hazard ratio (HR) and 95% confidence intervals (CI). Thirteen independent studies containing 564,947 participants were included in the meta-analysis. The overall results of included studies showed PD to be associated with the risk of hip fracture (HRoverall = 3.13, 95% CI 2.53-3.87) in women 3.11 (2.51-3.86) and men 2.60 (2.19-3.09). Our meta-analysis showed the direct association between PD and the risk of hip fracture in both men and women. However, due to the limitations of this study, further well-designed studies are required to confirm our findings.
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Affiliation(s)
- Ali Hosseinzadeh
- Research Center for Modeling in Health, Institute for Future Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Malahat Khalili
- Research Center for Modeling in Health, Institute for Future Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Behnaz Sedighi
- Department of Neurology, Shafa Hospital, Kerman University of Medical Science, Kerman, Iran
| | - Sohrab Iranpour
- Department of Epidemiology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Akbar Haghdoost
- Research Center for Modeling in Health, Institute for Future Studies in Health, Kerman University of Medical Sciences, Kerman, Iran.
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Lin ZL, Li PF, Pang ZH, Zheng XH, Huang F, Xu HH, Li QL. Influence of Regional Difference in Bone Mineral Density on Hip Fracture Site in Elderly Females by Finite Element Analysis. Cell Biochem Biophys 2017; 73:405-412. [PMID: 27352330 DOI: 10.1007/s12013-015-0650-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Hip fracture is a kind of osteoporotic fractures in elderly patients. Its important monitoring indicator is to measure bone mineral density (BMD) using DXA. The stress characteristics and material distribution in different parts of the bones can be well simulated by three-dimensional finite element analysis. Our previous studies have demonstrated a linear positive correlation between clinical BMD and the density of three-dimensional finite element model of the femur. However, the correlation between the density variation between intertrochanteric region and collum femoris region of the model and the fracture site has not been studied yet. The present study intends to investigate whether the regional difference in the density of three-dimensional finite element model of the femur can be used to predict hip fracture site in elderly females. The CT data of both hip joints were collected from 16 cases of elderly female patients with hip fractures. Mimics 15.01 software was used to reconstruct the model of proximal femur on the healthy side. Ten kinds of material properties were assigned. In Abaqus 6.12 software, the collum femoris region and intertrochanteric region were, respectively, drawn for calculating the corresponding regional density of the model, followed by prediction of hip fracture site and final comparison with factual fracture site. The intertrochanteric region/collum femoris region density was [(1.20 ± 0.02) × 10(6)] on the fracture site and [(1.22 ± 0.03) × 10(6)] on the non-fracture site, and the difference was statistically significant (P = 0.03). Among 16 established models of proximal femur on the healthy side, 14 models were consistent with the actual fracture sites, one model was inconsistent, and one model was unpredictable, with the coincidence rate of 87.5 %. The intertrochanteric region or collum femoris region with lower BMD is more prone to hip fracture of the type on the corresponding site.
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Affiliation(s)
- Z L Lin
- Department of Orthopedics, The First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou, 510405, Guangdong, China.
| | - P F Li
- Guangzhou University of Chinese Medicine, Guangzhou, 510405, Guangdong, China
| | - Z H Pang
- Department of Orthopedics, The First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou, 510405, Guangdong, China
| | - X H Zheng
- Department of Orthopedics, The First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou, 510405, Guangdong, China
| | - F Huang
- Department of Orthopedics, The First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou, 510405, Guangdong, China
| | - H H Xu
- Guangzhou University of Chinese Medicine, Guangzhou, 510405, Guangdong, China
| | - Q L Li
- Guangzhou University of Chinese Medicine, Guangzhou, 510405, Guangdong, China
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Li PF, Lin ZL, Pang ZH, Zeng YR. Does serum calcium relate to different types of hip fracture? A retrospective study. Chin J Traumatol 2016; 19:275-277. [PMID: 27780507 PMCID: PMC5068212 DOI: 10.1016/j.cjtee.2016.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
PURPOSE To investigate the potential correlation between two different types of hip fractures and serum calcium levels. METHODS We consecutively studied 101 cases of femoral neck fracture and 95 cases of femoral inter- trochanteric fracture between January 2011 and December 2013. Fasting blood samples were taken and serum calcium measurements were performed respectively in three periods: the time of admission, postoperation, and discharge. Creatinine, alkaline phosphatase and albumin were also analyzed. RESULTS Considering the levels of serum calcium between two groups at the time of admission, post- operation and discharge, there was significant difference at admission and discharge (p <0.05), while there was no significant difference at the time of postoperation (p > 0.05). The magnitude of serum calcium fluctuation was larger in femoral neck group than femoral intertrochanteric group. Concerning alkaline phosphatase and albumin levels at admission, there was no significant difference between two groups (p > 0.05). CONCLUSION The capability of reservation and restoration of serum calcium in patients with femoral neck fracture is better than that in patients with femoral intertrochanteric fracture. A low serum calcium level may be susceptible to femoral intertrochanteric fracture.
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Affiliation(s)
- Peng-Fei Li
- First Clinic Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510405, China
| | - Zi-Ling Lin
- Department of Orthopedics, First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510405, China,Corresponding author. Tel.: +86 13600460045.
| | - Zhi-Hui Pang
- Department of Orthopedics, First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510405, China
| | - Yi-Rong Zeng
- Department of Orthopedics, First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou 510405, China
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Abstract
Vertebral fractures are one of the most common fractures associated with skeletal fragility and can cause as much morbidity as hip fractures. However, the epidemiology of vertebral fractures differs from that of osteoporotic fractures at other skeletal sites in important ways, largely because only one quarter to one-third of vertebral fractures are recognized clinically at the time of their occurrence and otherwise require lateral spine imaging to be recognized. This article first reviews the prevalence and incidence of clinical and radiographic vertebral fractures in populations across the globe and secular trends in the incidence of vertebral fracture over time. Next, associations of vertebral fractures with measures of bone mineral density and bone microarchitecture are reviewed followed by associations of vertebral fracture with various textural measures of trabecular bone, including trabecular bone score. Finally, the article reviews clinical risk factors for vertebral fracture and the association of vertebral fractures with morbidity, mortality, and other subsequent adverse health outcomes.
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Affiliation(s)
- John T Schousboe
- Park Nicollet Osteoporosis Center, Park Nicollet Clinic, HealthPartners, Minneapolis, MN, USA; Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MD, USA.
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Minimally invasive surgery for femoral neck fractures using bone cement infusible hollow-perforated screw in high-risk patients with advanced cancer. Surg Oncol 2015; 24:226-31. [DOI: 10.1016/j.suronc.2015.05.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 04/22/2015] [Accepted: 05/19/2015] [Indexed: 10/23/2022]
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Leavy B, Byberg L, Michaëlsson K, Melhus H, Åberg AC. The fall descriptions and health characteristics of older adults with hip fracture: a mixed methods study. BMC Geriatr 2015; 15:40. [PMID: 25887407 PMCID: PMC4428087 DOI: 10.1186/s12877-015-0036-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Accepted: 03/24/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In light of the multifactorial etiology of fall-related hip fracture, knowledge of fall circumstances may be especially valuable when placed in the context of the health of the person who falls. We aimed to investigate the circumstances surrounding fall-related hip fractures and to describe fall circumstances in relation to participants' health and functional characteristics. METHODS The fall circumstances of 125 individuals (age ≥ 50 years) with hip fracture were investigated using semi-structured interviews. Data concerning participants' health (comorbidities and medications) and function (self-reported performance of mobility, balance, personal activities of daily living and physical activity, previous falls and hand grip strength) were collected via medical records, questionnaires and dynamometry. Using a mixed methods design, both data sets were analysed separately and then merged in order to provide a comprehensive description of fall events and identify eventual patterns in the data. RESULTS Fall circumstances were described as i) Activity at the time of the fall: Positional change (n = 24, 19%); Standing (n = 16, 13%); Walking (n =71, 57%); Balance challenging (n = 14, 11%) and ii) Nature of the fall: Environmental (n = 32, 26%); Physiological (n = 35, 28%); Activity-related indoor (n = 8, 6%) and outdoor (n = 8, 6%); Trips and slips on snow (n = 20, 16%) and in snow-free conditions (n = 12, 10%) and Unknown (n = 10, 8%). We observed the following patterns regarding fall circumstances and participants' health: those who fell i) during positional change had the poorest functional status; ii) due to environmental reasons (indoors) had moderate physical function, but high levels of comorbidity and fall risk increasing medications; iii) in snow-free environments (outdoors) appeared to have a poorer health and functional status than other outdoor groups. CONCLUSIONS Our findings indicate that patterns exist in relation to the falls circumstances and health characteristics of people with hip fracture which build upon that previously reported. These patterns, when verified, can provide useful information as to the ways in which fall prevention strategies can be tailored to individuals of varying levels of health and function who are at risk for falls and hip fracture.
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Affiliation(s)
- Breiffni Leavy
- Department of Surgical Sciences, Orthopedics, Uppsala University, Uppsala, Sweden.
| | - Liisa Byberg
- Department of Surgical Sciences, Orthopedics, Uppsala University, Uppsala, Sweden.
| | - Karl Michaëlsson
- Department of Surgical Sciences, Orthopedics, Uppsala University, Uppsala, Sweden.
| | - Håkan Melhus
- Department of Medical Sciences, Osteoporosis and Clinical Pharmacogenetics, Uppsala University, Uppsala, Sweden.
| | - Anna Cristina Åberg
- Department of Public Health and Caring Sciences, Geriatrics, Uppsala University, Uppsala, Sweden. .,School of Education, Health and Society, Dalarna University, Falun, Sweden.
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Zhang X, Yu Z, Yu M, Qu X. Alcohol consumption and hip fracture risk. Osteoporos Int 2015; 26:531-42. [PMID: 25266483 DOI: 10.1007/s00198-014-2879-y] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Accepted: 08/27/2014] [Indexed: 01/22/2023]
Abstract
SUMMARY The present meta-analysis shows that a nonlinear association between alcohol consumption and the risk of hip fracture was observed. Light alcohol consumption was inversely significantly associated with hip fracture risk, whereas heavy alcohol consumption was associated with an elevated hip fracture risk. INTRODUCTION Previous studies examining the association between alcohol consumption and the risk of hip fracture have reported conflicting findings. Therefore, we conducted a meta-analysis of prospective cohort studies to assess the association between alcohol consumption and the risk of hip fracture. METHODS PubMed and EMBASE were searched for prospective cohort studies on the relationship between alcohol consumption and the risk of hip fractures. Relative risks (RR) with 95% confidence intervals (CI) were derived using random-effects models throughout the whole analysis. RESULTS Eighteen prospective cohort studies were included with 3,730,424 participants and 26,168 hip fracture cases. Compared with non-drinkers, the pooled RR of hip fractures for alcohol consumption was 1.03 (95% CI, 0.91-1.15), with high heterogeneity between studies (P<0.001, I2=72.6%). A nonlinear relationship between alcohol consumption and the risk of hip fracture was identified (P nonlinearity=0.003). Compared with non-drinkers, the pooled RRs of hip fractures were 0.88 (95% CI, 0.83-0.89) for light alcohol consumption (0.01-12.5 g/day), 1.00 (95% CI, 0.85-1.14) for moderate alcohol consumption (12.6-49.9 g/day), and 1.71 (95% CI, 1.41-2.01) for heavy alcohol consumption (≥50 g/day). CONCLUSIONS There was no evidence of publication bias. In conclusion, a nonlinear association between alcohol consumption and the risk of hip fracture was observed in this meta-analysis. Further, light alcohol consumption was inversely significantly associated with hip fracture risk, whereas heavy alcohol consumption was associated with an elevated hip fracture risk.
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Affiliation(s)
- X Zhang
- Department of Clinical Medicine, Shanghai Medical College, Fudan University, Shanghai, China
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West SL, Lok CE, Jamal SA. Osteoprotegerin and fractures in men and women with chronic kidney disease. J Bone Miner Metab 2014; 32:428-33. [PMID: 24122248 DOI: 10.1007/s00774-013-0506-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 08/07/2013] [Indexed: 10/26/2022]
Abstract
Fractures are common in men and women with chronic kidney disease (CKD) but the best tool to identify those at high risk is unknown. Increased circulating osteoprotegerin(OPG) is associated with fractures in postmenopausal women. We determined if serum OPG was associated with prevalent fractures (self-reported low trauma fractures since 40 years of age and/or prevalent vertebral fractures identified by radiographs) in men (n = 97) and women (n = 67) with stage 3–5 CKD. Analyses were performed unadjusted and adjusted for stage of CKD. Results are expressed as mean ± standard deviation(SD), and as odds ratio (OR) per SD increase in OPG with 95 % confidence intervals (CI). The mean age was 62.7 ± 16.3 years, and mean weight was 78.9 ± 18.7 kg. Compared to those without fractures, those with fractures(n = 55) were older (p < 0.01). Serum OPG increased as kidney function decreased, and OPG was higher in those with fractures compared to those without (9.42 ± 4.08 vs 8.06 ± 3.11 pmol/L, p = 0.02). After adjusting for stage of CKD, increased OPG was associated with an increased fracture risk (OR 1.13, 95 % CI 1.02–1.25); however, OPG did not discriminate fracture status well (area under the receiver operating characteristic curve 0.61, 95 % CI 0.52–0.70). OPG is associated with fractures in men and women with stage 3–5 CKD; however, the ability of OPG to discriminate fracture status is poor and cannot be used in isolation to assess fracture risk. Further studies should examine the ability of OPG in combination with other risk factors to better discriminate fracture status in men and women with CKD.
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Gilchrist S, Guy P, Cripton PA. Development of an Inertia-Driven Model of Sideways Fall for Detailed Study of Femur Fracture Mechanics. J Biomech Eng 2013; 135:121001. [DOI: 10.1115/1.4025390] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 09/12/2013] [Indexed: 11/08/2022]
Abstract
A new method for laboratory testing of human proximal femora in conditions simulating a sideways fall was developed. Additionally, in order to analyze the strain state in future cadaveric tests, digital image correlation (DIC) was validated as a tool for strain field measurement on the bone of the femoral neck. A fall simulator which included models for the body mass, combined lateral femur and pelvis mass, pelvis stiffness, and trochanteric soft tissue was designed. The characteristics of each element were derived and developed based on human data from the literature. The simulator was verified by loading a state-of-the-art surrogate femur and comparing the resulting force-time trace to published, human volunteer experiments. To validate the DIC, 20 human proximal femora were prepared with a strain rosette and speckle paint pattern, and loaded to 50% of their predicted failure load at a low compression rate. Strain rosettes were taken as the gold standard, and minimum principal strains from the DIC and the rosettes were compared using descriptive statistics. The initial slope of the force-time curve obtained in the fall simulator matched published human volunteer data, with local peaks superimposed in the model due to internal vibrations of the spring used to model the pelvis stiffness. Global force magnitude and temporal characteristics were within 2% of published volunteer experiments. The DIC minimum principal strains were found to be accurate to 127±239μɛ. These tools will allow more biofidelic laboratory simulation of falls to the side, and more detailed analysis of proximal femur failure mechanisms using human cadaver specimens.
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Affiliation(s)
- Seth Gilchrist
- Department of Mechanical Engineering, University of British Columbia, Vancouver, BC V6T-1Z4, Canada e-mail:
| | - Pierre Guy
- Department of Orthopeadics, University of British Columbia, Vancouver, BC V5Z-1M9, Canada e-mail:
| | - Peter A Cripton
- Department of Mechanical Engineering, University of British Columbia, Vancouver, BC V6T-1Z4, Canada e-mail:
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Napoli N, Schwartz AV, Palermo L, Jin JJ, Wustrack R, Cauley JA, Ensrud KE, Kelly M, Black DM. Risk factors for subtrochanteric and diaphyseal fractures: the study of osteoporotic fractures. J Clin Endocrinol Metab 2013; 98:659-67. [PMID: 23345099 PMCID: PMC3565107 DOI: 10.1210/jc.2012-1896] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Patients on long-term bisphosphonate therapy may have an increased incidence of low-energy subtrochanteric and diaphyseal (SD) femoral fractures. However, the incidence and risk factors associated with these fractures have not been well defined. OBJECTIVE The objective of the study was to determine the incidence of and risk factors for low-energy SD fractures in the Study of Osteoporotic Fractures (SOF). DESIGN Low-energy SD fractures were identified from a review of radiographic reports obtained between 1986 and 2010 in women in the SOF. Among the SD fractures, pathological, periprosthetic, and traumatic fractures were excluded. We assessed risk factors for SD fractures as well as risk factors for femoral neck (FN) and intertrochanteric (IT) hip fractures using both age-adjusted and multivariate time-dependent proportional hazards models. During this follow-up, only a small minority had ever used bisphosphonates. RESULTS Forty-five women sustained low-energy subtrochanteric/diaphyseal femoral fractures over a total follow-up of 140 000 person-years. The incidence of SD fracture was 3.2 per 10 000 person-years compared with a total hip fracture incidence of 110 per 10 000 person-years. A total of about 12% of women reported bisphosphonate use at 1 or more visits. In multivariate analyses, age, total hip bone mineral density (BMD), bisphosphonate use, and history of diabetes emerged as independent risk factors for SD fractures. Risk factors for FN and IT fractures included age, BMD, and history of falls or prior fractures. Bisphosphonate use was protective against FN fractures, whereas there was an increased risk of SD fractures (hazard ratio 2.58, P = .049) with bisphosphonate use after adjustment for other risk factors for fracture. CONCLUSIONS In SOF, low-energy SD fractures were rare occurrences, far outnumbered by FN and IT fractures. Typical risk factors were associated with FN and IT fractures, whereas only age, total hip BMD, and history of diabetes were independent risk factors for SD fractures. In addition, bisphosphonate use was a marginally significantly predictor although the SOF study has limited ability to assess this association.
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Affiliation(s)
- Nicola Napoli
- Università Campus Bio-Medico di Roma, 83-00155 Rome, Italy
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Abstract
The association between hip fracture and reduced bone mineral density is well documented, with reduced bone mineral density predisposing to fracture. However, it is unknown whether an association exists between the magnitude of bone density lost and the severity of the hip fracture sustained. One hundred forty-two patients (96 women, 46 men) with a mean age of 74 years (range, 49-92 years) who sustained a hip fracture following a simple ground-level fall and were treated for this injury were reviewed. All patients had undergone dual-energy x-ray absorptiometry bone scanning of the contralateral hip and lumbar spine. Fractures were classified as intra- or extracapsular or subtrochanteric and then subclassified by degree of severity as simple (stable) or multifragmentary (unstable) fracture patterns.Although a low hip bone mineral density (T- or Z score <2.5) was associated with an increased risk of extracapsular fracture (P=.025) compared with other fracture types, no association existed between bone mineral density and the severity of the resultant hip fracture. Although an association exists between bone mineral density and the risk of fragility fractures, the results of the current study suggest that the severity of hip fractures does not follow this correlation. Therefore, no assumption can be made about bone mineral density of the proximal femur based on the severity of the fracture observed on plain radiographs.
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Affiliation(s)
- Simon J Spencer
- Department of Trauma & Orthopaedic Surgery, Southern General Hospital, Glasgow G51 4TF, United Kingdom.
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Fisher AA, Srikusalanukul W, Davis MW, Smith PN. Clinical profiles and risk factors for outcomes in older patients with cervical and trochanteric hip fracture: similarities and differences. J Trauma Manag Outcomes 2012; 6:2. [PMID: 22333003 PMCID: PMC3295722 DOI: 10.1186/1752-2897-6-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Accepted: 02/15/2012] [Indexed: 02/08/2023]
Abstract
Background Data on clinical characteristics and outcomes in regard to hip fracture (HF) type are controversial. This study aimed to evaluate whether clinical and laboratory predictors of poorer outcomes differ by HF type. Methods Prospective evaluation of 761 consecutively admitted patients (mean age 82.3 ± 8.8 years; 74.9% women) with low-trauma non-pathological HF. Clinical characteristics and short-term outcomes were recorded. Haematological, renal, liver and thyroid status, C-reactive protein, cardiac troponin I, serum 25(OH) vitamin D, PTH, leptin, adiponectin and resistin were determined. Results The cervical compared to the tronchanteric HF group was younger, have higher mean haemoglobin, albumin, adiponectin and resistin and lower PTH levels (all P < 0.05). In-hospital mortality, length of hospital stay (LOS), incidence of post-operative myocardial injury and need of institutionalisation were similar in both groups. Multivariate analysis revealed as independent predictors for in-hospital death in patient with cervical HF male sex, hyperparathyroidism and lower leptin levels, while in patients with trochanteric HF only hyperparathyroidism; for post-operative myocardial injury dementia, smoking and renal impairment in the former group and coronary artery disease (CAD), hyperparathyroidism and hypoleptinaemia in the latter; for LOS > 20 days CAD, and age > 75 years and hyperparathyroidism, respectively. Need of institutionalisation was predicted by age > 75 years and dementia in both groups and also by hypovitaminosis D in the cervical and by hyperparathyroidism in the trochanteric HF. Conclusions Clinical characteristics and incidence of poorer short-term outcomes in the two main HF types are rather similar but risk factors for certain outcomes are site-specific reflecting differences in underlying mechanisms.
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Affiliation(s)
- Alexander A Fisher
- Department of Geriatric Medicine, The Canberra Hospital, PO Box 11, Woden, ACT 2606, Australia.
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Larrosa M, Gomez A, Casado E, Moreno M, Vázquez I, Orellana C, Berlanga E, Ramon J, Gratacos J. Hypovitaminosis D as a risk factor of hip fracture severity. Osteoporos Int 2012; 23:607-14. [PMID: 21394494 DOI: 10.1007/s00198-011-1588-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Accepted: 02/09/2011] [Indexed: 10/18/2022]
Abstract
SUMMARY In a cross-sectional study including 324 patients older than 65 years admitted to our hospital for osteoporotic hip fracture, we found that those patients with a more severe vitamin D deficiency had more severe osteoporotic hip fractures (Garden grades III-IV and Kyle III-IV). INTRODUCTION To identify possible differences in baseline characteristics of patients with different types of osteoporotic hip fracture. METHODS Cross-sectional study including consecutive individuals over 65 admitted to our hospital for osteoporotic hip fracture over a year. Demographic data, fracture type, comorbidities, history of osteoporosis, functional capacity, nutritional status and vitamin D storage were evaluated. RESULTS We included 324 patients (83 ± 7 years, 80% women). Two hundred sixteen patients (67%) had vitamin D deficiency (25OHD3 <25 ng/ml). In patients with severe femoral neck or intertrochanteric fractures (Garden III-IV and Kyle III-IV), vitamin D deficiency was more frequent (74%) and severe (25OHD3 20 ± 15 ng/ml) than in patients with less severe fractures (57%, 25OHD3 26 ± 21 ng/ml). Forty-three percent of patients had previous fractures. Only 15% of patients had been previously diagnosed with osteoporosis and 10% were receiving treatment. Patients receiving vitamin D supplements have higher 20OHD3 levels and less severe fractures. CONCLUSIONS Although vitamin D levels are not different between patients with intracapsular or extracapsular hip fractures, a more severe vitamin D deficiency seems to be associated to more severe osteoporotic hip fractures. A prior vitamin D supplementation could avoid a higher severity of these fractures.
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Affiliation(s)
- M Larrosa
- Rheumatology Department, University Institute Parc Taulí (UAB), Parc Tauli s/n, 08208 Sabadell, Barcelona, Spain.
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Sambrook PN, Silverman SL, Cauley JA, Recknor C, Olson M, Su G, Boonen S, Black D, Adachi JD. Health-related quality of life and treatment of postmenopausal osteoporosis: results from the HORIZON-PFT. Bone 2011; 48:1298-304. [PMID: 21421092 DOI: 10.1016/j.bone.2011.03.719] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Revised: 03/14/2011] [Accepted: 03/14/2011] [Indexed: 01/08/2023]
Abstract
Osteoporosis-related fractures are associated with reductions in health-related quality of life (HRQL). We examined the benefits of zoledronic acid (ZOL) on HRQL in patients sustaining vertebral and clinical fractures from HORIZON-Pivotal Fracture Trial using mini-Osteoporosis quality of life Questionnaire (OQLQ). In this multicenter, double-blind, placebo-controlled trial, 1434 patients from a cohort of postmenopausal women with osteoporosis (mean age 73years) were randomized to receive annual infusions of ZOL 5mg or placebo for 3years. Baseline HRQL scores were comparable between ZOL and placebo groups based on the presence or absence of fractures, with exception of prevalent vertebral fractures where patients (irrespective of the treatment group) had lower baseline HRQL scores than those without prevalent vertebral fractures. Greater number of prevalent vertebral fractures was associated with lower baseline HRQL (p<0.001). No significant difference between ZOL and placebo in the overall summary score was observed but a significant benefit was noted in certain domains with ZOL, especially in patients sustaining incident clinical fractures. Improvements in HRQL were marked at first assessment after a morphometric vertebral fracture with significant differences favouring ZOL in pain (p=0.0115), standing pain (p=0.0125)), physical (lifting, p=0.0333) and emotional function (fear of fractures, p=0.0243; fear of falls, p=0.0075) but not for activities of daily living or leisure domains. HRQL is reduced in patients with vertebral fractures. Treatment with ZOL over 3years was associated with improvements in specific domains of quality of life vs. placebo, particularly in patients sustaining incident fractures.
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Feehan LM, Beck CA, Harris SR, MacIntyre DL, Li LC. Exercise prescription after fragility fracture in older adults: a scoping review. Osteoporos Int 2011; 22:1289-322. [PMID: 20967425 PMCID: PMC5438255 DOI: 10.1007/s00198-010-1408-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2010] [Accepted: 08/20/2010] [Indexed: 10/18/2022]
Abstract
The purpose of this study is to identify and chart research literature on safety, efficacy, or effectiveness of exercise prescription following fracture in older adults. We conducted a systematic, research-user-informed, scoping review. The population of interest was adults aged ≥45 years with any fracture. "Exercise prescription" included post-fracture therapeutic exercise, physical activity, or rehabilitation interventions. Eligible designs included knowledge synthesis studies, primary interventional studies, and observational studies. Trained reviewers independently evaluated citations for inclusion. A total of 9,415 citations were reviewed with 134 citations (119 unique studies) identified: 13 knowledge syntheses, 95 randomized or controlled clinical trials, and 11 "other" designs, representing 74 articles on lower extremity fractures, 34 on upper extremity, eight on vertebral, and three on mixed body region fractures. Exercise prescription characteristics were often missing or poorly described. Six general categories emerged describing exercise prescription characteristics: timing post-fracture, person prescribing, program design, functional focus, exercise script parameters, and co-interventions. Upper extremity and ankle fracture studies focused on fracture healing or structural impairment outcomes, whereas hip fracture studies focused more on activity limitation outcomes. The variety of different outcome measures used made pooling or comparison of outcomes difficult. There was insufficient information to identify evidence-informed parameters for safe and effective exercise prescription for older adults following fracture. Key gaps in the literature include limited numbers of studies on exercise prescription following vertebral fracture, poor delineation of effectiveness of different strategies for early post-fracture mobilization following upper extremity fracture, and inconsistent details of exercise prescription characteristics after lower extremity fracture.
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Affiliation(s)
- L M Feehan
- Department of Physical Therapy, University of British Columbia, 2177 Wesbrook Mall, Vancouver, BC V6T 1Z3, Canada.
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Meknas K, Johansen O, Steigen SE, Olsen R, Jørgensen L, Kartus J. Could tendinosis be involved in osteoarthritis? Scand J Med Sci Sports 2011; 22:627-34. [DOI: 10.1111/j.1600-0838.2010.01287.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Yoon TS, Yoon JJ, Han SJ, Kim JO. Analysis of Stroke Patients with Hip Fracture. BRAIN & NEUROREHABILITATION 2011. [DOI: 10.12786/bn.2011.4.2.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Tae Sik Yoon
- Department of Rehabilitation Medicine, School of Medicine, Ewha Womans University, Korea
| | - Jung Joong Yoon
- Department of Rehabilitation Medicine, School of Medicine, Ewha Womans University, Korea
| | - Soo Jeong Han
- Department of Rehabilitation Medicine, School of Medicine, Ewha Womans University, Korea
| | - Jong Oh Kim
- Department of Orthopaedic Surgery, School of Medicine, Ewha Womans University, Korea
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Tang DZ, Hou W, Zhou Q, Zhang M, Holz J, Sheu TJ, Li TF, Cheng SD, Shi Q, Harris SE, Chen D, Wang YJ. Osthole stimulates osteoblast differentiation and bone formation by activation of beta-catenin-BMP signaling. J Bone Miner Res 2010; 25:1234-45. [PMID: 20200936 PMCID: PMC3153131 DOI: 10.1002/jbmr.21] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Osteoporosis is defined as reduced bone mineral density with a high risk of fragile fracture. Current available treatment regimens include antiresorptive drugs such as estrogen receptor analogues and bisphosphates and anabolic agents such as parathyroid hormone (PTH). However, neither option is completely satisfactory because of adverse effects. It is thus highly desirable to identify novel anabolic agents to improve future osteoporosis treatment. Osthole, a coumarin-like derivative extracted from Chinese herbs, has been shown to stimulate osteoblast proliferation and differentiation, but its effect on bone formation in vivo and underlying mechanism remain unknown. In this study, we found that local injection of Osthole significantly increased new bone formation on the surface of mouse calvaria. Ovariectomy caused evident bone loss in rats, whereas Osthole largely prevented such loss, as shown by improved bone microarchitecture, histomorphometric parameters, and biomechanical properties. In vitro studies demonstrated that Osthole activated Wnt/beta-catenin signaling, increased Bmp2 expression, and stimulated osteoblast differentiation. Targeted deletion of the beta-catenin and Bmp2 genes abolished the stimulatory effect of Osthole on osteoblast differentiation. Since deletion of the Bmp2 gene did not affect Osthole-induced beta-catenin expression and the deletion of the beta-catenin gene inhibited Osthole-regulated Bmp2 expression in osteoblasts, we propose that Osthole acts through beta-catenin-BMP signaling to promote osteoblast differentiation. Our findings demonstrate that Osthole could be a potential anabolic agent to stimulate bone formation and prevent estrogen deficiency-induced bone loss.
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Affiliation(s)
- De-Zhi Tang
- Spine Research Institute, Shanghai University of Traditional Chinese Medicine, Shanghai, People's Republic of China
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Marks R. Hip fracture epidemiological trends, outcomes, and risk factors, 1970-2009. Int J Gen Med 2010; 3:1-17. [PMID: 20463818 PMCID: PMC2866546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Indexed: 11/20/2022] Open
Abstract
Hip fractures - which commonly lead to premature death, high rates of morbidity, or reduced life quality - have been the target of a voluminous amount of research for many years. But has the lifetime risk of incurring a hip fracture decreased sufficiently over the last decade or are high numbers of incident cases continuing to prevail, despite a large body of knowledge and a variety of contemporary preventive and refined surgical approaches? This review examines the extensive hip fracture literature published in the English language between 1980 and 2009 concerning hip fracture prevalence trends, and injury mechanisms. It also highlights the contemporary data concerning the personal and economic impact of the injury, plus potentially remediable risk factors underpinning the injury and ensuing disability. The goal was to examine if there is a continuing need to elucidate upon intervention points that might minimize the risk of incurring a hip fracture and its attendant consequences. Based on this information, it appears hip fractures remain a serious global health issue, despite some declines in the incidence rate of hip fractures among some women. Research also shows widespread regional, ethnic and diagnostic variations in hip fracture incidence trends. Key determinants of hip fractures include age, osteoporosis, and falls, but some determinants such as socioeconomic status, have not been well explored. It is concluded that while more research is needed, well-designed primary, secondary, and tertiary preventive efforts applied in both affluent as well as developing countries are desirable to reduce the present and future burden associated with hip fracture injuries. In this context, and in recognition of the considerable variation in manifestation and distribution, as well as risk factors underpinning hip fractures, well-crafted comprehensive, rather than single solutions, are strongly indicated in early rather than late adulthood.
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Affiliation(s)
- Ray Marks
- Correspondence: Ray Marks, Columbia University, Teachers College, Department of Health and Behavior Studies, Box 114, 525W 120th Street, New York, NY 10027, USA, Tel +1 212 678 3445, Fax +1 212 678 8259, Email
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