Phenotypes of disease severity in a cohort of hospitalized COVID-19 patients: Results from the IMPACC study

BACKGROUND

Better understanding of the association between characteristics of patients hospitalized with coronavirus disease 2019 (COVID-19) and outcome is needed to further improve upon patient management.

METHODS

Immunophenotyping Assessment in a COVID-19 Cohort (IMPACC) is a prospective, observational study of 1164 patients from 20 hospitals across the United States. Disease severity was assessed using a 7-point ordinal scale based on degree of respiratory illness. Patients were prospectively surveyed for 1 year after discharge for post-acute sequalae of COVID-19 (PASC) through quarterly surveys. Demographics, comorbidities, radiographic findings, clinical laboratory values, SARS-CoV-2 PCR and serology were captured over a 28-day period. Multivariable logistic regression was performed.

FINDINGS

The median age was 59 years (interquartile range [IQR] 20); 711 (61%) were men; overall mortality was 14%, and 228 (20%) required invasive mechanical ventilation. Unsupervised clustering of ordinal score over time revealed distinct disease course trajectories. Risk factors associated with prolonged hospitalization or death by day 28 included age ≥ 65 years (odds ratio [OR], 2.01; 95% CI 1.28-3.17), Hispanic ethnicity (OR, 1.71; 95% CI 1.13-2.57), elevated baseline creatinine (OR 2.80; 95% CI 1.63- 4.80) or troponin (OR 1.89; 95% 1.03-3.47), baseline lymphopenia (OR 2.19; 95% CI 1.61-2.97), presence of infiltrate by chest imaging (OR 3.16; 95% CI 1.96-5.10), and high SARS-CoV2 viral load (OR 1.53; 95% CI 1.17-2.00). Fatal cases had the lowest ratio of SARS-CoV-2 antibody to viral load levels compared to other trajectories over time (p=0.001). 589 survivors (51%) completed at least one survey at follow-up with 305 (52%) having at least one symptom consistent with PASC, most commonly dyspnea (56% among symptomatic patients). Female sex was the only associated risk factor for PASC.

INTERPRETATION

Integration of PCR cycle threshold, and antibody values with demographics, comorbidities, and laboratory/radiographic findings identified risk factors for 28-day outcome severity, though only female sex was associated with PASC. Longitudinal clinical phenotyping offers important insights, and provides a framework for immunophenotyping for acute and long COVID-19.

FUNDING

NIH.

Serum non-esterified fatty acid levels and hip fracture risk: The Cardiovascular Health Study

Among elderly participants from the Cardiovascular Health Study, we found that non-esterified trans fatty acid levels had a significant prospective association with hip fracture risk. Other non-esterified fatty acid classes were not associated with hip fracture risk.

INTRODUCTION

Serum non-esterified fatty acids (NEFAs) are bioactive metabolic intermediates that can be taken up by bone tissue. Their associations with hip fracture risk have not been previously examined.

METHODS

Thirty-five individual NEFAs in five classes (saturated [SFA], mono-un-saturated [MUFA], poly-unsaturated n-6 and n-3 [PUFA], and trans-FA) were measured in Cardiovascular Health Study participants (n = 2139, mean age 77.8 years) without known diabetes. The multivariable associations of NEFA levels with hip fracture risk were evaluated in Cox hazards models.

RESULTS

We documented 303 incident hip fractures during 11.1 years of follow-up. Among the five NEFA classes, total trans FA levels were positively associated with higher hip fracture risk (HR 1.17 [95% CI, 1.04, 1.31; p = 0.01] per one standard deviation higher level). The SFA lignoceric acid (24:0) was positively associated with higher risk (HR 1.09 [1.04, 1.1]; p < 0.001), while behenic (22:0) and docosatetraenoic (22:4 n6) acids were associated with lower risk (HR 0.76 [0.61, 0.94]; p = 0.01; 0.84 [0.70, 1.00]; p = 0.05, respectively).

CONCLUSION

Total plasma trans NEFA levels are related to hip fracture risk, suggesting an unrecognized benefit of their systematic removal from food. Novel associations of individual NEFAs with hip fracture risk require confirmation in other cohort studies.

The effect of insulin on bone mineral density among women with type 2 diabetes: a SWAN Pharmacoepidemiology study

This was a longitudinal study examining the effects of insulin use on bone mineral density loss. Insulin use was found to be associated with greater bone mineral density loss at the femoral neck among women with diabetes mellitus.

INTRODUCTION

Women with diabetes mellitus (DM) have higher bone mineral density (BMD) and experience slower BMD loss but have an increased risk of fracture. The data regarding the effect of insulin treatment on BMD remains conflicted. We examined the impact of insulin initiation on BMD.

METHODS

We investigated the annual changes in BMD associated with the new use of insulin among women with DM in the Study of Women's Health Across the Nation (SWAN). Propensity score (PS) matching, which is a statistical method that helps balance the baseline characteristics of women who did and did not initiate insulin, was used. Covariates with a potential impact on bone health were included in all models. Mixed model regression was used to test the change in BMD between the two groups. Median follow-up time was 5.4 years.

RESULTS

The cohort consisted of 110 women, mean age, 53.6 years; 49% white and 51% black. Women using insulin (n = 55) were similar on most relevant characteristics to the 55 not using insulin. Median diabetes duration for the user group was 10 vs. 5.0 years for the non-user group. There was a greater loss of BMD at the femoral neck among insulin users (- 1.1%) vs non-users (- 0.77%) (p = 0.04). There were no differences in BMD loss at the spine - 0.30% vs - 0.32% (p = 0.85) or at the total hip - 0.31% vs - 0.25 (p = 0.71), respectively.

CONCLUSIONS

Women with T2DM who initiated insulin experienced a more rapid BMD loss at the femoral neck as compared to women who did use insulin.

Bone-muscle indices as risk factors for fractures in men: the Osteoporotic Fractures in Men (MrOS) Study

OBJECTIVE

To assess bone-muscle (B-M) indices as risk factors for incident fractures in men.

METHODS

Participants of the Osteoporotic Fractures in Men (MrOS) Study completed a peripheral quantitative computed tomography scan at 66% of their tibial length. Bone macrostructure, estimates of bone strength, and muscle area were computed. Areal bone mineral density (aBMD) and body composition were assessed with dual-energy X-ray absorptiometry. Four year incident non-spine and clinical vertebral fractures were ascertained. B-M indices were expressed as bone-to-muscle ratios for: strength, mass and area. Discriminative power and hazards ratios (HR) for fractures were reported.

RESULTS

In 1163 men (age: 77.2±5.2 years, body mass index (BMI): 28.0±4.0 kg/m(2), 4.1±0.9 follow-up years, 7.7% of men ⋝1 fracture), B-M indices were smaller in fractured men except for bending and areal indices. Smaller B-M indices were associated with increased fracture risk (HR: 1.30 to 1.74) independent of age and BMI. Strength and mass indices remained significant after accounting for lumbar spine but not total hip aBMD. However, aBMD correlated significantly with B-M indices.

CONCLUSION

Mass and bending B-M indices are risk factors for fractures in men, but may not improve fracture risk prediction beyond that provided by total hip aBMD.

Risk factors for nonvertebral fracture in obese older women

CONTEXT

A high prevalence of obesity has recently been reported in postmenopausal women with low trauma fracture, suggesting that higher bone mineral density (BMD) in obese individuals may not be protective against fracture.

OBJECTIVE

The aim of this study was to compare BMD and other risk factors for nonvertebral fracture in 1377 obese postmenopausal women.

DESIGN

Characteristics of obese women with and without incident nonvertebral fracture were investigated among the prospective cohort in the Study of Osteoporotic Fractures.

SETTING

The Study of Osteoporotic Fractures is a multicenter study of 9704 women (>99% Caucasian) aged 65 yr and over who were recruited between September 1986 and October 1988 from population-based listings at four U.S. clinical centers.

MAIN OUTCOME MEASURE

The main outcome measure was nonvertebral fracture.

RESULTS

BMD T-scores in the spine, femoral neck, and total hip were significantly lower in obese women who experienced fractures than in obese women without fracture: mean differences, -0.56 [95% confidence interval (CI) = -0.73 to -0.39], -0.46 (95% CI = -0.57 to -0.36), and -0.51 (95% CI = -0.62 to -0.39), respectively (P < 0.0001 for all). A previous history of fracture [odds ratio = 1.69 (95% CI = 1.33-2.14); P < 0.0001] and femoral neck BMD [1.62 (95% CI = 1.42-1.85) per sd decrease in BMD; P < 0.0001] were independently associated with incident nonvertebral fracture.

CONCLUSIONS

Obese postmenopausal women who sustain nonvertebral fractures have significantly lower BMD on average than obese women without fracture and are more likely to have a past history of fracture. Fractures in obese postmenopausal women thus exhibit some characteristics of fragility fractures.

Sex Hormones and Risk of Estrogen Receptor (ER)-Positive and ER-Negative Breast Cancer

Background: There is a need for improved breast cancer risk prediction by tumor estrogen receptor (ER) status. Endogenous sex hormone levels are associated with risk of overall breast cancer and the ER-positive subtype. However, the role of estradiol (E2) and testosterone (T) in the development of ER-negative tumors remains unclear. We investigated the associations of circulating levels of endogenous E2 and T with the risk of ER-positive as well as ER-negative breast cancer in postmenopausal women.Methods: We performed a case-cohort study within the Women's Health Initiative- Observational Study of postmenopausal women not taking exogenous hormones (age range: 50-79 years). Baseline endogenous levels of bioavailable E2 and T were measured using radioimmunoassays (University of Southern California, LA, CA) in 196 cases of invasive ER-positive breast cancer, 107 cases of invasive ER-negative cancer, and 560 randomly selected controls. The average follow-up time was 7.3 years.Results: After adjustment for putative risk factors, women with E2 levels in the upper three quartiles had an approximately 2-fold increased risk of ER-positive breast cancer, compared to those with E2 in the lowest quartile. These associations were only modestly decreased after adjustment for T. Higher T levels also indicated increased risk of ER-positive breast cancer; women in the third quartile of T had a 1.7-fold significantly higher risk, compared to those in the first quartile. However, this association was substantially diminished and not significant after controlling for E2.No association was observed between E2 levels and ER-negative cancer. However, women with T levels in the second, third, and fourth quartiles had lower risks of ER-negative cancer in the order of 54% (p= 0.018), 38% (p= 0.13), and 46% (p= 0.05), respectively, compared to women with T in the lowest quartile. These associations did not change materially after adjusting for E2.Table 1. Risk (Hazard Ratio (HR) and 95% CI) of ER-positive and ER-negative breast cancer by E2 and T quartiles ER-positive (HR (95% CI))ER-negative (HR (95% CI)) Model 1*Model 2**Model 1*Model 2*E2    Q11.001.001.001.00Q22.19 (1.25-3.84)2.12 (1.16-3.87)0.57 (0.29-1.12)0.72 (0.34-1.53)Q31.92 (1.10-3.35)1.74 (0.92-3.33)0.75 (0.40-1.42)1.09 (0.51-2.3)Q42.11 (1.21-3.68)1.86 (0.97-3.56)0.88 (0.48-1.62)1.36 (0.60-3.08)P for trend0.020.150.840.44T    Q11.001.001.001.00Q21.01 (0.57-1.78)0.82 (0.44-1.53)0.46 (0.24-0.88)0.45 (0.22-0.92)Q31.72 (1.04-2.84)1.36 (0.75-2.48)0.62 (0.34-1.15)0.56 (0.27-1.18)Q41.45 (0.85-2.46)1.16 (0.62-2.17)0.54 (0.29-1.00)0.44 (0.20-1.00)P for trend0.050.280.100.09*Model1: adjusted for age, race, age at menopause, alcohol use, physical activity, history of needle aspiration, lifetime use of estrogen+progestin, and time since quitting hormone therapy use. **Model2: adjusted for Model1 + sex hormones.Conclusion: Higher endogenous E2 levels were associated with increased risk of ER-positive breast cancer, independent of risk factors and T. In contrast, higher concentrations of endogenous T were related to lower risk of ER-negative breast cancer, independent of risk factors and E2. This is the first study to report an association of testosterone with ER-negative breast cancer. Further studies are needed to confirm this association.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 907.

Predictors of adherence in the Women's Health Initiative Calcium and Vitamin D Trial

The authors analyzed data from the Women's Health Initiative (WHI) Calcium and Vitamin D Supplementation Trial (CaD) to learn more about factors affecting adherence to clinical trial study pills (both active and placebo). Most participants (36,282 postmenopausal women aged 50-79 years) enrolled in CaD 1 year after joining either a hormone trial or the dietary modification trial of WHI. The WHI researchers measured adherence to study pills by weighing the amount of remaining pills at an annual study visit; adherence was primarily defined as taking > or = 80% of the pills. The authors in this study examined a number of behavioral, demographic, procedural, and treatment variables for association with study pill adherence. They found that relatively simple procedures (ie, phone contact early in the study [4 weeks post randomization] and direct social contact) later in the trial may improve adherence. Also, at baseline, past pill-use experiences, personal supplement use, and relevant symptoms may be predictive of adherence in a supplement trial.

Endogenous sex hormone levels and risk of cognitive decline in an older biracial cohort

BACKGROUND

Older women treated with conjugated estrogens may have an increased risk of dementia, but the effect of naturally occurring sex hormones on cognition is not certain.

METHODS

Bioavailable estradiol and free testosterone level were obtained from 792 (55% men, 51% black) participants. We assessed cognition with the Modified Mini-Mental State Examination (3MS), Selective Reminding Test (SRT) and CLOX 1 at baseline and 2 years later.

RESULTS

Women in the lowest estradiol tertile were more likely than those in the highest tertile to decline (> or = 1.0 S.D. of change) on 3MS (25% versus 9%, adjusted odds ratio [OR] = 3.9; 95% confidence interval [CI] = 1.6-9.6) and on SRT (28% versus 12%, adjusted OR [95% CI] = 3.3 [1.4-7.9]) but not CLOX 1. There was a borderline association between low estradiol tertile and decline on SRT in men (22% versus 14%, adjusted OR [95% CI] = 1.9 [0.9-3.9]). Testosterone level was not associated with decline in cognition in either men or women. Findings did not differ by race.

CONCLUSIONS

Older women with low estradiol levels were more likely to experience decline in global cognitive function and verbal memory, and a similar trend was observed for verbal memory in men. This supports the hypothesis that endogenous sex hormones may play an important role in the maintenance of cognitive function in older adults.

The determinants of bone mineral density in Chinese men--results from Mr. Os (Hong Kong), the first cohort study on osteoporosis in Asian men

Mr. Os (Hong Kong) is the first study to address the risk factors for osteoporosis in Asian men. A standardized, structured interview and dual X-ray densitometry (DEXA) were performed on 2,000 Chinese men aged 65-92. By multiple regression, the following factors were found to be positively associated with BMD at both the total hip and the spine: body weight, grip strength and a history of diabetes mellitus. The following factors were found to be negatively associated with BMD at both the total hip and spine: cigarette smoking, a history of gastrectomy or bowel resection, current use of inhaled steroid and a history of fracture after 50 years. Moreover, a history of chronic obstructive pulmonary disease (COPD) was negatively associated with BMD at the total hip, and age, the use of an alpha-blocker, thiazide diuretic and nitrate were associated with a higher BMD at the spine. A total of 21.8% of the variance in total hip and 31.5% of the variance in total spine BMD was accounted for in the multivariate analysis.

Longitudinal study of periodontal disease and edentulism with rates of bone loss in older women

BACKGROUND

Previous cross-sectional studies have suggested a link between periodontal disease and osteoporosis. The purpose of the present study is to evaluate the association between changes in bone mineral density (BMD) and clinical signs of periodontal tissue destruction and tooth loss over a 2-year period.

METHODS

A total of 398 women (mean age 75.5 years) were randomly selected for an ancillary study of periodontal disease; osteoporosis in association with the presence or absence of teeth was evaluated. Osteoporosis in association with periodontal disease was also evaluated. All subjects were participants at the Pittsburgh Clinical Center for the Study of Osteoporotic Fractures (SOF), a prospective cohort study of women 65 years of age or older designed to determine risk factors for fractures. Oral health examinations, including periodontal probing and attachment loss, were performed at the fourth clinical visit, an average of 6 years after baseline. BMD of the total hip and its subregions was measured using dual energy x-ray absorptiometry at the time of dental examination and 2 years later. Results are expressed as annual percentage change.

RESULTS

A total of 145 (36.4%) women were edentulous and 163 (80.7%) of the dentate women (N = 253) had periodontal disease. Dentate women reported higher education (P <0.001) and a higher calcium intake (P= 0.002). Absolute BMD and percentage change in BMD were similar in dentate and edentulous women. We found no difference in BMD or in absolute or percentage change in BMD between women with or without periodontal disease.

CONCLUSION

Little evidence exists for an association between edentulousness, periodontal disease, and longitudinal changes in BMD.

The prediction of visceral fat by dual-energy X-ray absorptiometry in the elderly: a comparison with computed tomography and anthropometry

INTRODUCTION

Effective methods for assessing visceral fat are important to investigate the role of visceral fat for the increased health risks in obesity. Techniques for direct measurement of soft tissue composition such as CT or MRI are expensive, time-consuming or require a relatively high radiation dose. Simple anthropometric methods, such as waist-to-hip ratio, waist circumference or sagittal diameter are widely used. However, these methods cannot differentiate between visceral and subcutaneous fat and are less accurate. The aim of the present study is to investigate whether the dual-energy X-ray absorptiometry (DXA) method, possibly combined with anthropometry, offers a good alternative to CT for the prediction of visceral fat in the elderly.

METHODS

Subjects were participants in the Health ABC-study, a cohort study of black and white men and women aged 70-79, investigating the effect of weight-related health conditions on disablement. Total body fat and trunk fat were measured by DXA using a Hologic QDR 1500. A 10 mm CT scan at the L4-L5 level was acquired to measure visceral fat and total abdominal fat. Weight, height, sagittal diameter and waist circumference were measured using standard methods. Fat in a manually defined DXA subregion (4 cm slice at the top of iliac crest) at the abdomen was calculated in a sub-group of participants (n=150; 50% male; 45.3% Afro-American/54.7% Caucasian, age 70-79 y). This subregion, the standard trunk region and total fat were used as indicators of visceral fat.

RESULTS

Total abdominal fat by DXA (subregion) was strongly correlated with total abdominal fat by CT (r ranging from 0.87 in white men to 0.98 in black women). The DXA subregion underestimated total abdominal fat by 10% compared to the CT slice. The underestimation by DXA was seen especially in people with less abdominal fat. The association of visceral fat by CT with the DXA subregion (r=0.66, 0.78, 0.79 and 0.65 for white and black men and women, respectively) was comparable with the association of the CT measure with the sagittal diameter (r=0.74, 0.70, 0.84 and 0.68). Combining DXA measurements with anthropometry gave only limited improvement for the prediction of visceral fat by CT compared to univariate models (maximal increase of r(2) 4%).

CONCLUSION

DXA is a good alternative to CT for predicting total abdominal fat in an elderly population. For the prediction of visceral fat the sagittal diameter, which has a practical advantage compared to DXA, is just as effective.

Association between the T29-->C polymorphism in the transforming growth factor beta1 gene and breast cancer among elderly white women: The Study of Osteoporotic Fractures

CONTEXT

Transgenic animal experiments suggest that increased expression of transforming growth factor beta1 (TGF-beta1) is protective against early tumor development, particularly in breast cancer. A T-->C (thymine to cytosine) transition in the 29th nucleotide in the coding sequence results in a leucine to proline substitution at the 10th amino acid and is associated with increased serum levels of TGF-beta1.

OBJECTIVE

To determine whether an association exists between this TGF-beta1 polymorphism and breast cancer risk.

DESIGN, SETTING, AND PARTICIPANTS

The Study of Osteoporotic Fractures, a prospective cohort study of white, community-dwelling women aged 65 years or older who were recruited at 4 US centers between 1986 and 1988. Three thousand seventy-five women who provided sufficient clinical information, buffy coat samples, and adequate consent for genotyping are included in this analysis.

MAIN OUTCOME MEASURE

Breast cancer cases during a mean (SD) follow-up of 9.3 (1.9) years, verified by medical chart review and compared by genotype.

RESULTS

Risk of breast cancer was similar in the 1124 women with the T/T genotype (56 cases; 5.4 per 1000 person-years) and the 1493 women with the T/C genotype (80 cases; 5.8 per 1000 person-years) but was significantly lower (P =.01) in the 458 women with the C/C genotype (10 cases; 2.3 per 1000 person-years). In analyses that adjusted for age, age at menarche, age at menopause, estrogen use, parity, body mass index, and bone mineral density, women with the C/C genotype had a significantly lower risk of developing breast cancer compared with women with the T/T or T/C genotype (hazard ratio [HR], 0.36; 95% confidence interval [CI], 0.17-0.75). There was no significant difference between the risk for women with the T/C genotype compared with women with the T/T genotype (adjusted HR, 1.04; 95% CI, 0.73-1.48).

CONCLUSIONS

Our findings suggest that TGF-beta1 genotype is associated with risk of breast cancer in white women aged 65 years or older. Because the T allele is the common variant and confers an increased risk, it may be associated with a large proportion of breast cancer cases.

The association of bone mineral density and depression in an older population

OBJECTIVE

To evaluate the association between bone mineral density (BMD) and measurements of depression in an older population.

DESIGN

Population-based, cross-sectional study.

SETTING

Study subjects were participants in the Cardiovascular Health Study (CHS), a longitudinal, long-term, follow-up study, at the University of California Davis (Sacramento, California) and the University of Pittsburgh (Pittsburgh, Pennsylvania) clinical centers.

PARTICIPANTS

A random sample of 1,566 Medicare enrollees age 65 and older enrolled in the CHS.

MEASUREMENTS

Total hip BMD, measured using dual energy x-ray absorptiometry (DEXA), after adjustment for multiple covariates, was compared with depression evaluated with the Center for Epidemiological Studies 10-item Depression Scale (CES-Dm). Risk factors for osteoporosis were compared in depressed and nondepressed participants. Potential correlates were entered into a regression model. Depression scores were compared in normal, osteopenic, and osteoporotic individuals.

RESULTS

Sixteen percent of participants were clinically depressed; 9% had BMDs in the osteoporotic range. Mean BMD was 40 mg/cm2 lower in those with clinical depression. High CES-Dm scores were associated with lower BMD (P < .001) when adjusted for body mass index (BMI), age, kilocalories of activity, estrogen use, gender, race, smoking and drinking. When stratified by race, this remained true for all Caucasians (P < .01), all African Americans (P < .05), and when stratified by race and gender the association remained only for all Caucasian women (P < .001). In women and Caucasian men there was an increase in depression scores among individuals with osteoporotic-range BMDs.

CONCLUSIONS

A significant association was found between BMD and depressive symptoms after adjustment for osteoporosis risk factors. In Caucasians, depressive symptoms were associated with both osteoporotic and osteopenic levels of BMD. Causality cannot be ascribed, with only one measurement of BMD. We postulate that there may be an unmeasured third factor, such as an endogenous steroid, that is responsible for both low BMD and depression.

Assessment of physical activity with a single global question in a large, multiethnic sample of midlife women

This study compared responses from 13,621 African-American, Chinese, Hispanic, Japanese, and White women to a single, global physical activity question. Respondents aged 40-55 years were randomly selected from seven geographic locations in the United States for the 1996-1997 cross-sectional survey of the Study of Women's Health Across the Nation, a longitudinal, observational study of the menopause transition. Respondents rated their activity level as much less, less, the same as, more, or much more than other women their age. Physical activity rating varied minimally by race/ethnicity. The proportions of women who rated themselves much less active and much more active ranged from 3.1% for Whites to 4.8% for Japanese and from 13.6% for Japanese to 16.4% for African Americans, respectively. Multiple logistic regression models, stratified by race/ethnicity, showed independent associations between a low level of activity and higher body mass index, poor health, functional impairment, perceived stress, difficulty sleeping, and not being employed. A high level of activity was associated with excellent health, single marital status, higher education, lower body mass index, and older age. These findings suggest that a comparative rating of physical activity may rank women by activity level within a specific racial/ethnic group but may not capture differences across racial/ethnic groups.

Cognitive decline in women in relation to non-protein-bound oestradiol concentrations

BACKGROUND

Previous studies have found no association between serum concentrations of total oestradiol and cognitive function, but these measurements may not reflect concentrations of hormone available to the brain. We tested the hypothesis that concentrations of non-protein-bound (free) and loosely bound (bioavailable) sex hormones are associated with cognitive function in older women.

METHODS

We measured cognitive performance with a modified mini mental status examination (mMMSE) at baseline (1986-88) and 6 years later in 425 women (65 years or older). Concentrations of non-protein-bound and bioavailable oestradiol and total and non-protein-bound testosterone were measured by RIA in serum samples taken at baseline.

FINDINGS

Initial cognitive scores did not differ by tertile of non-protein-bound oestradiol, bioavailable oestradiol, or testosterone. Cognitive impairment (a decrease of 3 points or more in mMMSE score) occurred in five (5%) of 94 women in the high tertile for non-protein-bound oestradiol and in 17 (16%) of 106 in the low tertile (odds ratio 0.3 [95% CI 0.1-0.8]). After adjustment for age, years of education, body-mass index, current oestrogen use, history of surgical menopause, and baseline mMMSE score, the odds ratio was 0.3 (0.1-0.9). The results were similar for bioavailable oestradiol (five [5%] vs 15 [15%]; adjusted odds ratio 0.3 [0.1-1.0]). There was no association between risk of cognitive impairment and serum testosterone.

INTERPRETATION

Women with high serum concentrations of non-protein-bound and bioavailable oestradiol, but not testosterone, were less likely to develop cognitive impairment than women with low concentrations. This finding supports the hypothesis that higher concentrations of endogenous oestrogens prevent cognitive decline.

Evaluation of a new body composition phantom for quality control and cross-calibration of DXA devices

This study evaluated a new body composition phantom and its use for quality control and cross-calibration of dual-energy X-ray absorptiometry (DXA) instruments for measurements of body composition. We imaged the variable composition phantom (Lunar, Madison, WI) on eight different DXA devices. Deviations of up to 7% fat were observed when we compared the percent fat values measured by the different devices with the nominal values provided by the manufacturer. Absolute precision error of percent fat measurements for the phantom ranged from 0.6 to 0.8%. The phantom's percent fat values were also compared with whole body composition measurements from 130 female and male volunteers. The phantom detected differences in percent fat values that were similar to those found by comparing in vivo measurements with values from different DXA scanner models from the same manufacturer. When comparing different models of scanners from different manufacturers, such as the Hologic QDR-4500 and the Lunar DPX-IQ, the phantom showed a different relationship than was seen for patients. Therefore, corrections or comparisons based on the phantom data alone would be incorrect. In conclusion, the Lunar variable composition phantom is capable of accurately measuring the fat calibration of DXA devices and may be suitable for cross-sectional cross-calibration between scanners from the same manufacturer; however, for comparison of DXA scanners from different manufacturers, in vivo cross-calibration is still the only accurate method. The phantom may be used in longitudinal quality control to verify an instrument's temporal stability.

Evaluation of a new body composition phantom for quality control and cross-calibration of DXA devices

This study evaluated a new body composition phantom and its use for quality control and cross-calibration of dual-energy X-ray absorptiometry (DXA) instruments for measurements of body composition. We imaged the variable composition phantom (Lunar, Madison, WI) on eight different DXA devices. Deviations of up to 7% fat were observed when we compared the percent fat values measured by the different devices with the nominal values provided by the manufacturer. Absolute precision error of percent fat measurements for the phantom ranged from 0.6 to 0.8%. The phantom's percent fat values were also compared with whole body composition measurements from 130 female and male volunteers. The phantom detected differences in percent fat values that were similar to those found by comparing in vivo measurements with values from different DXA scanner models from the same manufacturer. When comparing different models of scanners from different manufacturers, such as the Hologic QDR-4500 and the Lunar DPX-IQ, the phantom showed a different relationship than was seen for patients. Therefore, corrections or comparisons based on the phantom data alone would be incorrect. In conclusion, the Lunar variable composition phantom is capable of accurately measuring the fat calibration of DXA devices and may be suitable for cross-sectional cross-calibration between scanners from the same manufacturer; however, for comparison of DXA scanners from different manufacturers, in vivo cross-calibration is still the only accurate method. The phantom may be used in longitudinal quality control to verify an instrument's temporal stability.

Waist circumference and sagittal diameter reflect total body fat better than visceral fat in older men and women. The Health, Aging and Body Composition Study

The validity of waist circumference and sagittal diameter as surrogate measures of visceral fat were assessed using preliminary cross-sectional data from the Health, Aging and Body Composition Study, a cohort of 3,075 men and women aged 70-79. Weight, body mass index, waist circumference, waist/thigh ratio, and sagittal diameter were compared by correlation, graphical analysis, and regression to total body fat as measured by dual-energy X-ray absorptiometry (Hologic 4500A), and to visceral fat area as measured by computerized tomography. We included 2,830 persons, 1,439 women and 1,391 men with complete data on all measurements. For both men and women, all measurements were strongly correlated with both total body fat and visceral fat except the waist/thigh ratio. However, waist circumference, sagittal diameter, weight, and body mass index were more closely related to total body fat than to visceral fat area (R2 for the linear regression of waist circumference on total body fat was 0.69 in women and men; R2 for linear regression of waist circumference on visceral fat area was 0.40 in women, and 0.49 in men). These data suggest that the contribution of visceral fat to health risks will be better assessed by directly measuring this fat depot.

Association between bone mineral density and cognitive decline in older women

OBJECTIVE

To test the hypothesis that bone mineral density (BMD), a marker of cumulative estrogen exposure, is associated with cognitive function in nondemented older women.

DESIGN

A prospective cohort study.

SETTING

Clinical centers in Baltimore, Maryland, Minneapolis, Minnesota, the Monongahela Valley near Pittsburgh, Pennsylvania, and Portland, Oregon.

PARTICIPANTS

We evaluated 8333 older community-dwelling women enrolled in the Study of Osteoporotic Fractures who were not taking estrogen replacement.

MEASUREMENTS

Calcaneal and hip BMD were measured at baseline and at follow-up (4-6 years later); vertebral fractures were ascertained radiologically at year 6. Women were administered a modified Mini-Mental State Exam, Trails B, and Digit Symbol at baseline and at follow-up.

RESULTS

Compared with women with higher bone mineral density, women with low baseline BMD had up to 8% worse baseline cognitive scores (P = .001) and up to 6% worse repeat cognitive scores (P = .001), even after multivariate adjustments. For 1 SD decrease in baseline hip BMD or calcaneal BMD, women had a 32% (95% CI, 19-47%) or a 33% (95% CI, 20-48%) greater odds of cognitive deterioration (worst 10th percentile of change). Women with vertebral fractures had lower cognitive test scores and a greater odds of cognitive deterioration than those without fractures (OR = 1.29; 95% CI, 1.03-1.60).

CONCLUSIONS

Women with osteoporosis, whether measured by baseline BMD, reductions in BMD, or vertebral fractures, have poorer cognitive function and greater risk of cognitive deterioration. Our findings suggest a link between two of the most common conditions affecting older women. Further understanding of this association may be important for new treatment and prevention directions.

Estrogen replacement therapy and cognitive decline in older community women

BACKGROUND

The purpose of this study was to evaluate the cross-sectional and longitudinal association of oral estrogen replacement therapy (ERT) and cognitive function in an older, nondemented sample of women.

METHODS

In a prospective cohort of 9651 white women aged 65 years and older enrolled in the Study of Osteoporotic Fractures, a modified Mini-Mental Status Exam (mMMSE), and digit symbol substitution and Trails B tests were administered twice, 4 to 6 years apart. History and current use of oral ERT was documented. Age, educational attainment, and activity limitations were the primary covariates in the analyses; in addition, stroke and depression scores were adjusted in subsets of women with available data.

RESULTS

Current and past users of ERT had better initial scores on the mMMSE than did never users, P < .05 and .001, respectively, with better scores for current estrogen hormone users being most apparent among the older and less educated women. The percentages of women scoring < or = 23 of a possible 26 on the mMMSE were 14.3 for current users, 14.5 for past users, and 20.5 for never users, P < .001. However, only past users exhibited smaller declines upon retesting in mMMSE and Trails B performance, P < .05, than did never users. Educational attainment predicted both initial test scores and change scores and was, next to age, the most powerful predictor of cognitive function.

CONCLUSIONS

Current oral ERT does not protect against age-related declines in cognitive function in older nondemented women, whereas formal education does protect, even though it had been completed many years earlier. The influence of education in late-life on cognitive function should be tested.

Apolipoprotein E phenotype and cognitive decline in a prospective study of elderly community women

OBJECTIVE

To determine whether apolipoprotein E (Apo E) phenotype is associated with cognitive decline in community-dwelling nondemented elderly women.

DESIGN

Prospective cohort study.

SETTING

A university-affiliated clinic near Pittsburgh, Pa.

PATIENTS

A total of 1750 nondemented community-dwelling women, aged 65 years and older, who were enrolled in the Study of Osteoporotic Fractures.

MAIN OUTCOME MEASURES

The women completed a baseline interview and performed 3 cognitive tests: the modified Mini-Mental State Examination, Trials B, and Digit Symbol. Serum samples were obtained for Apo E typing. Baseline cognitive scores and repeated scores approximately 6 years after study enrollment were compared in women with and without Apo E epsilon 4. Cognitive decline, defined as the worst 10th percentile change scores, was assessed for each test and by phenotype group.

RESULTS

After adjustment for age, education, presence of severe tremor, and depression, baseline scores did not differ by Apo E epsilon 4 status except for lower scores on Trails B in the homozygous epsilon 4 group (mean score, 159.7 compared with 127.7 for the heterozygous epsilon 4 group and 125.4 for the no epsilon 4 group; P = .01). However, repeated test performance on follow-up examination was worse on all tests in those women with 1 or more epsilon 4. Reduction on the modified Mini-Mental State Examination was 0% for no epsilon 4 allele, 1.9% for 1 epsilon 4 allele, and 3.7% for 2 epsilon 4 alleles (P < .001); reduction on Digit Symbol was 6.2% for no epsilon 4 allele, 9.0% for 1 epsilon 4 allele, and 17.5% for 2 epsilon 4 alleles (P = .04); and reduction on Trials B was 5.9% for no epsilon 4 allele, 25.0% for 1 epsilon 4 allele, and 10.9% for 2 epsilon 4 alleles (P = .002). Women with at least 1 epsilon 4 had an odds ratio of 1.6 (95% confidence interval, 1.1-2.3) of having cognitive decline during the study period.

CONCLUSION

Apolipoprotein E epsilon 4 is associated with cognitive decline in community-dwelling nondemented women.

Weight change and fractures in older women. Study of Osteoporotic Fractures Research Group

BACKGROUND

The effect of change in weight in later years on risk of osteoporotic fractures in uncertain. Prior studies have assessed the relationship between weight change and risk of hip fracture only and have not examined whether the association between weight loss and increased risk of hip fracture is because of voluntary or involuntary weight loss.

OBJECTIVES

To determine the association between weight change in later years and the risk of fractures in elderly women and to assess the effect of weight loss intention on this relationship.

METHODS

The association between weight change and fracture risk was assessed in 6754 ambulatory, non-black women aged 65 years or older enrolled in the Study of Osteoporotic Fractures who had measurements of weight performed at both the baseline and fourth examinations (mean, 5.7 years between examinations). These 6754 women were followed up for all incident nonspine fractures and frailty fractures (defined as fractures of the proximal femur, pelvis, and proximal humerus) occurring after the fourth examination (average follow-up, 19.5 months). All incident fractures were confirmed by radiographic report.

RESULTS

During an average of 19.5 months after the fourth examination, 264 women (4%) had at least 1 nonspine fracture, including 83 women who suffered frailty fractures. After adjustment for age, women who lost weight between the baseline and fourth examinations had an increased risk of subsequent nonspine fracture (relative risk [RR] per 10% decrease in weight, 1.32; 95% confidence interval [CI], 1.11-1.55). This observed increase in the risk of nonspine fracture was entirely caused by an increase in the risk of frailty fracture (age-adjusted RR per 10% decrease in weight, 1.86; 95% CI, 1.42-2.43). Weight change was not significantly related to other types of nonspine fractures (age-adjusted RR per 10% decrease in weight, 1.09; 95% CI, 0.90-1.33). Further adjustment for cigarette smoking, physical activity, estrogen use, medical conditions, health status, body weight, femoral neck bone mass, and rate of change in calcaneal bone mass did not substantially alter the association between weight change and frailty fracture (multivariate RR per 10% decrease in weight 1.68; 95% CI, 1.17-2.41). Weight change was an even stronger predictor of risk of frailty fracture in those women who were not trying to lose weight (multivariate RR per 10% decrease in weight, 1.81; 95% CI, 1.26-2.61).

CONCLUSIONS

Involuntary weight loss in later years substantially increases the risk of frailty fracture including hip fracture in elderly women. Weight change is not related to risk of other nonspine fractures in older women.

Hip and calcaneal bone loss increase with advancing age: longitudinal results from the study of osteoporotic fractures

It is uncertain whether or how rapidly elderly women continue to lose bone with advancing age. To determine rates of change in bone mass at the hip and at the calcaneus in elderly women and to compare these rates of change among estrogen users and nonusers, we prospectively measured rates of change in bone mineral density (BMD) at the total hip and its four subregions (mean +/- SD, 3.55 +/- 0.29 years between examinations) and at the calcaneus (mean +/- SD, 5.69 +/- 0.33 years between examinations) in 5689 community-dwelling white women aged 65 years or older at the baseline examination. The rate of decline in total hip BMD steadily increased from 2.5 mg/cm 2/year (95% confidence interval 2.0 to 2.9) in women 67-69 years old to 10.4 mg/cm 2/year in those aged 85 or older (95% confidence interval 8.4 to 12.4). The rate of bone loss also increased with aging at all subregions of the hip and at the calcaneus. The average loss of bone from the total hip is sufficient to increase the risk of hip fracture by 21% per 5 years in women aged 80 years or older. Compared with nonusers, current estrogen users had a 33% lower age-adjusted mean rate of loss at the total hip (2.9 vs 4.3 mg/cm 2/year, p < or = 0.0001) and a 35% lower age-adjusted mean rate of loss at the calcaneus (3.9 vs 6.0 mg/cm 2/year, p < or = 0.0001). The rate of bone loss in the hip and calcaneus steadily increases with advancing age in older women. Estrogen therapy may significantly decrease this loss. Efforts to understand and prevent bone loss should include elderly women.

Risk factors for hip fracture in white women. Study of Osteoporotic Fractures Research Group

BACKGROUND

Many risk factors for hip fractures have been suggested but have not been evaluated in a comprehensive prospective study.

METHODS

We assessed potential risk factors, including bone mass, in 9516 white women 65 years of age or older who had had no previous hip fracture. We then followed these women at 4-month intervals for an average of 4.1 years to determine the frequency of hip fracture. All reports of hip fractures were validated by review of x-ray films.

RESULTS

During the follow-up period, 192 women had first hip fractures not due to motor vehicle accidents. In multivariable age-adjusted analyses, a maternal history of hip fracture doubled the risk of hip fracture (relative risk, 2.0; 95 percent confidence interval, 1.4 to 2.9), and the increase in risk remained significant after adjustment for bone density. Women who had gained weight since the age of 25 had a lower risk. The risk was higher among women who had previous fractures of any type after the age of 50, were tall at the age of 25, rated their own health as fair or poor, had previous hyperthyroidism, had been treated with long-acting benzodiazepines or anticonvulsant drugs, ingested greater amounts of caffeine, or spent four hours a day or less on their feet. Examination findings associated with an increased risk included the inability to rise from a chair without using one's arms, poor depth perception, poor contrast sensitivity, and tachycardia at rest. Low calcaneal bone density was also an independent risk factor. The incidence of hip fracture ranged from 1.1 (95 percent confidence interval, 0.5 to 1.6) per 1,000 woman-years among women with no more than two risk factors and normal calcaneal bone density for their age to 27 (95 percent confidence interval, 20 to 34) per 1,000 woman-years among those with five or more risk factors and bone density in the lowest third for their age.

CONCLUSIONS

Women with multiple risk factors and low bone density have an especially high risk of hip fracture. Maintaining body weight, walking for exercise, avoiding long-acting benzodiazepines, minimizing caffeine intake, and treating impaired visual function are among the steps that may decrease the risk.

Bone density at various sites for prediction of hip fractures. The Study of Osteoporotic Fractures Research Group

Women with low bone density in the radius or calcaneus are at increased risk of hip fracture. To see whether bone density of the hip measured by dual X-ray absorptiometry is a better predictor of hip fracture than measurements of other bones, we assessed bone density at several sites in 8134 women aged 65 years or more. 65 women had hip fractures during a mean follow-up of 1.8 years. Each SD decrease in femoral neck bone density increased the age-adjusted risk of hip fracture 2.6 times (95% CL 1.9, 3.6). Women with bone density in the lowest quartile had an 8.5-fold greater risk of hip fracture than those in the highest quartile. Bone density of the femoral neck was a better predictor than measurements of the spine (p < 0.0001), radius (p < 0.002), and moderately better than the calcaneus (p = 0.10). Low hip bone density is a stronger predictor of hip fracture than bone density at other sites. Efforts to prevent hip fractures should focus on women with low hip bone density.

Design of the Fracture Intervention Trial

The Fracture Intervention Trial (FIT) is a randomized, double-masked, placebo-controlled trial designed to test the hypothesis that alendronate, an amino-bisphosphonate, will reduce the rate of fractures in women aged 55-80 years with low hip bone marrow density (< 0.68 gm/cm2 at the femoral neck). It is being conducted at 11 clinical centers around the United States with a coordinating center at UC San Francisco. The goal was to randomize 6000 women. When recruitment was completed (in May 1993), 6457 women had been randomized, amounting to 108% of goal. The women were assigned to one of two substudies. The first (Vertebral Deformity study) includes 2023 women who have at least one vertebral deformity, and will test the hypothesis that alendronate reduces the rate of new vertebral deformities during 3 years of follow-up. This substudy has a power of 0.90 to detect a 32% reduction in the incidence of new vertebral deformities, assuming a 6.5% annual incidence of new vertebral deformities in the placebo group. The second study (Clinical Fracture study) includes 4434 women without vertebral deformities at baseline and will test the hypothesis that alendronate reduces the rate of clinically recognized fractures of all types over an average of 4.25 years of follow-up. This substudy has a 0.90 power to detect a 25% reduction in the rate of all clinical fractures, assuming 4% annual incidence in the placebo group. To our knowledge, this is the largest prospective, randomized, controlled study undertaken to determine the effectiveness of a treatment in reducing the risk of fractures in postmenopausal women.

Premenopausal determinants of menopausal estrogen use

METHODS

Characteristics related to subsequent use of estrogen replacement therapy were evaluated prospectively in a cohort of 541 healthy premenopausal women being followed through the menopausal transition.

RESULTS

Among women who became menopausal during the follow-up period, the most striking premenopausal baseline differences between menopausal estrogen users and never users were that users tended to be thinner and more likely to report past oral contraceptive use than never users (P less than or equal to 0.05). Nonsignificant trends were also observed, with menopausal estrogen users having higher total high-density lipoprotein cholesterol and lower fasting insulin prior to estrogen use than the menopausal never users (P less than or equal to 0.10). Weaker trends included greater alcohol intake and past week kilocalorie expenditure and lower blood pressure levels among menopausal estrogen users than never users.

CONCLUSIONS

Although these findings do not preclude the probable protective effect of estrogen therapy on coronary heart disease morbidity and mortality, they do suggest that slightly healthier women may take menopausal hormones.

Hormone replacement therapy and lipoprotein changes during early menopause

The relationship of postmenopausal hormone replacement therapy to lipoproteins was assessed in a cohort of 211 healthy premenopausal women followed during the menopausal transition. Both estrogen and estrogen-progestogen users had minimal increases in low-density lipoprotein (LDL) cholesterol levels, whereas non-users had significant increases in LDL cholesterol over time. Estrogen users had a nonsignificant increase in high-density lipoprotein (HDL) cholesterol, estrogen-progestogen users maintained premenopausal HDL cholesterol levels, and non-users had decreases in HDL cholesterol. Both estrogen and estrogen-progestogen users had increases in apolipoprotein AI, apolipoprotein AII, and triglycerides relative to the changes observed among the menopausal non-users. In summary, estrogen, whether administered with or without medroxyprogesterone acetate, could provide cardiovascular benefits to postmenopausal women by protecting against the atherogenic changes in LDL and HDL cholesterol observed among the non-users. With the exception of the hormone-related increases in triglycerides, the results are consistent with a beneficial effect of hormone replacement therapy on coronary heart disease risk.