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Lorentzon M, Litsne H, Axelsson KF. The significance of recent fracture location for imminent risk of hip and vertebral fractures-a nationwide cohort study on older adults in Sweden. Osteoporos Int 2024:10.1007/s00198-024-07072-x. [PMID: 38521820 DOI: 10.1007/s00198-024-07072-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 03/15/2024] [Indexed: 03/25/2024]
Abstract
The role of recent fracture site in predicting the most detrimental subsequent fractures, hip and vertebral, is unclear. This study found that most recent fracture sites were associated with an increased risk of both hip and vertebral fracture, a finding that may impact the design of secondary prevention programs. BACKGROUND Hip and vertebral fractures are the most serious in terms of associated morbidity, mortality, and societal costs. There is limited evidence as to which fracture types are associated with the highest risk for subsequent hip and vertebral fractures. This study aims to explore the dependency of imminent hip and vertebral fracture risk on the site of the recent index fracture. METHODS Conducted as a nationwide retrospective cohort study, we utilized Swedish national registers to assess the risk of hip and vertebral fractures based on the site of the recent (≤ 2 years) index fracture and an old (> 2 years) prevalent fracture. This risk was compared to that observed in individuals without any prevalent fractures. This study encompassed all Swedes aged 50 years and older between 2007 and 2010. Patients with a recent fracture were categorized into specific groups based on the type of their previous fracture and were followed until December 2017, with censoring for death and migration. The study assessed the risk of hip and vertebral fractures during the follow-up period. RESULTS The study included a total of 3,423,320 individuals, comprising 145,780 with a recent fracture, 293,051 with an old fracture, and 2,984,489 without a previous fracture. The median follow-up times for the three groups were 7.6 years (IQR 4.0-9.1), 7.9 years (5.8-9.2), and 8.5 years (7.4-9.7), respectively. Patients with a recent fracture at almost all sites exhibited a significantly increased risk of hip fracture and an elevated risk of vertebral fracture compared to controls. Patients with recent fractures had an increased risk of subsequent hip and vertebral fractures, regardless of the index fracture site. These results strengthen the notion that all patients with a recent fracture, regardless of fracture site, should be included in secondary prevention programs, to improve the prevention of the clinically most serious fractures.
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Affiliation(s)
- Mattias Lorentzon
- Sahlgrenska Osteoporosis Centre, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Litsne
- Sahlgrenska Osteoporosis Centre, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kristian F Axelsson
- Sahlgrenska Osteoporosis Centre, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Region Västra Götaland, Närhälsan Norrmalm Health Centre, Skövde, Sweden.
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Jaiswal R, Johansson H, Axelsson KF, Magnusson P, Harvey NC, Vandenput L, McCloskey E, Kanis JA, Litsne H, Johansson L, Lorentzon M. Hemoglobin Levels Improve Fracture Risk Prediction in Addition to FRAX Clinical Risk Factors and Bone Mineral Density. J Clin Endocrinol Metab 2023; 108:e1479-e1488. [PMID: 37406247 PMCID: PMC10655535 DOI: 10.1210/clinem/dgad399] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 06/26/2023] [Accepted: 07/03/2023] [Indexed: 07/07/2023]
Abstract
CONTEXT Anemia and decreasing levels of hemoglobin (Hb) have previously been linked to increased fracture risk, but the added value to FRAX, the most utilized fracture prediction tool worldwide, is unknown. OBJECTIVE To investigate the association between anemia, Hb levels, bone microstructure, and risk of incident fracture and to evaluate whether Hb levels improve fracture risk prediction in addition to FRAX clinical risk factors (CRFs). METHODS A total of 2778 community-dwelling women, aged 75-80 years, and part of a prospective population-based cohort study in Sweden were included. At baseline, information on anthropometrics, CRFs, and falls was gathered, blood samples were collected, and skeletal characteristics were investigated using dual-energy x-ray absorptiometry and high-resolution peripheral quantitative computed tomography. At the end of follow-up, incident fractures were retrieved from a regional x-ray archive. RESULTS The median follow-up time was 6.4 years. Low Hb was associated with worse total hip and femoral neck bone mineral density (BMD), and lower tibia cortical and total volumetric BMD, and anemia was associated with increased risk of major osteoporotic fracture (MOF; hazard ratio 2.04; 95% CI 1.58-2.64). Similar results were obtained for hip fracture and any fracture, also when adjusting for CRFs. The ratio between 10-year fracture probabilities of MOF assessed in models with Hb levels included and not included ranged from 1.2 to 0.7 at the 10th and 90th percentile of Hb, respectively. CONCLUSION Anemia and decreasing levels of Hb are associated with lower cortical BMD and incident fracture in older women. Considering Hb levels may improve the clinical evaluation of patients with osteoporosis and the assessment of fracture risk.
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Affiliation(s)
- Raju Jaiswal
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, 413 45 Gothenburg, Sweden
| | - Helena Johansson
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, 413 45 Gothenburg, Sweden
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, 3000, Australia
| | - Kristian F Axelsson
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, 413 45 Gothenburg, Sweden
- Region Västra Götaland, Närhälsan Norrmalm, Health Centre, 549 40 Skövde, Sweden
| | - Per Magnusson
- Department of Clinical Chemistry, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Liesbeth Vandenput
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, 413 45 Gothenburg, Sweden
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, 3000, Australia
| | - Eugene McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
- MRC Versus Arthritis Centre for Integrated research in Musculoskeletal Ageing, Mellanby Centre for Musculoskeletal Research, University of Sheffield, Sheffield, UK
| | - John A Kanis
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, 3000, Australia
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
| | - Henrik Litsne
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, 413 45 Gothenburg, Sweden
| | - Lisa Johansson
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, 413 45 Gothenburg, Sweden
- Region Västra Götaland, Department of Orthopedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Mattias Lorentzon
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, 413 45 Gothenburg, Sweden
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, 3000, Australia
- Region Västra Götaland, Department of Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden
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Jaiswal R, Zoulakis M, Axelsson KF, Sundh D, Litsne H, Johansson L, Lorentzon M. Reply to the Submitted Comment Regarding our Publication "Increased Bone Material Strength Index Is Positively Associated With the Risk of Incident Osteoporotic Fractures in Older Swedish Women". J Bone Miner Res 2023; 38:1543-1544. [PMID: 37652404 DOI: 10.1002/jbmr.4903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/07/2023] [Accepted: 08/11/2023] [Indexed: 09/02/2023]
Affiliation(s)
- Raju Jaiswal
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Michail Zoulakis
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Kristian F Axelsson
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Närhälsan Norrmalm, Health Centre, Skövde, Sweden
| | - Daniel Sundh
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Henrik Litsne
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Lisa Johansson
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Orthopedic Surgery, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Mattias Lorentzon
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
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Jaiswal R, Zoulakis M, Axelsson KF, Darelid A, Rudäng R, Sundh D, Litsne H, Johansson L, Lorentzon M. Increased Bone Material Strength Index Is Positively Associated With the Risk of Incident Osteoporotic Fractures in Older Swedish Women. J Bone Miner Res 2023; 38:860-868. [PMID: 37088885 DOI: 10.1002/jbmr.4816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 04/04/2023] [Accepted: 04/16/2023] [Indexed: 04/25/2023]
Abstract
No previous studies have investigated the association between the bone material strength index (BMSi; an indicator of bone material properties obtained by microindentation) and the risk of incident fracture. The primary purpose of this prospective cohort study was to evaluate if BMSi is associated with incident osteoporotic fracture in older women and, secondarily, with prevalent fractures, anthropometric traits, or measurements of bone mineral density (BMD) by dual-energy X-ray absorptiometry (DXA). In a population-based cohort, 647 women aged 75 to 80 years underwent bone microindentation using the OsteoProbe device. Data on clinical risk factors (CRFs), prevalent fractures, and incident fractures were collected using questionnaires, medical records, and a regional X-ray archive. BMD and vertebral fracture assessment (VFA) were assessed by DXA (Hologic, Discovery A). Associations between BMSi, anthropometrics, BMD, and prevalent fractures were investigated using correlation and linear and logistic regression. Cox proportional hazards and competing risks analysis by Fine and Gray were used to study the association between BMSi and the risk of fracture and mortality. BMSi was weakly associated with age (r = -0.13, p < 0.001) and BMI (r = -0.21, p < 0.001) and with BMD of lumbar spine (β = 0.09, p = 0.02) and total hip (β = 0.08, p = 0.05), but only after adjustments. No significant associations were found between BMSi and prevalent fractures (self-reported and/or VFA identified, n = 332). During a median follow-up time of 6.0 years, 121 major osteoporotic fractures (MOF), 151 any fractures, and 50 deaths occurred. Increasing BMSi (per SD) was associated with increased risk of MOF (hazard ratio [HR] = 1.29, 95% confidence interval [CI] 1.07-1.56), any fracture (HR = 1.29, 95% CI 1.09-1.53), and mortality (HR = 1.44, 95% CI 1.07-1.93). The risk of fracture did not materially change with adjustment for confounders, CRFs, femoral neck BMD, or when considering the competing risk of death. In conclusion, unexpectedly increasing BMSi was associated with greater fracture risk. The clinical relevance and potential mechanisms of this finding require further study. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Raju Jaiswal
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Michail Zoulakis
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Kristian F Axelsson
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Närhälsan Norrmalm, Health Centre, Skövde, Sweden
| | - Anna Darelid
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Robert Rudäng
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Daniel Sundh
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Henrik Litsne
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Lisa Johansson
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Orthopedic Surgery, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Mattias Lorentzon
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
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Axelsson KF, Litsne H, Lorentzon M. The Importance of Recent Prevalent Fracture Site for Imminent Risk of Fracture - A Retrospective, Nationwide Cohort Study of Older Swedish Men and Women. J Bone Miner Res 2023. [PMID: 36970835 DOI: 10.1002/jbmr.4806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 03/08/2023] [Accepted: 03/21/2023] [Indexed: 04/26/2023]
Abstract
There is limited evidence regarding which fracture types carry the highest risk for subsequent fracture. The aim of this study was to investigate how the risk of imminent fracture depends on index fracture site. This nationwide retrospective cohort study utilized national registers in Sweden to determine the risk of fracture according to recent (≤2 years) index fracture site and according to an old (>2 years) prevalent fracture compared with the risk observed in controls without a fracture. All Swedes 50 years or older between 2007 and 2010 were included in the study. Patients with a recent fracture were designated a specific fracture group depending on the type of previous fracture. Recent fractures were classified as major osteoporotic fracture (MOF), including fractured hip, vertebra, proximal humerus, and wrist, or non-MOF. Patients were followed until December 31, 2017, censored for death and emigration, and the risk of any fracture and hip fracture was assessed. A total of 3,423,320 persons were included in the study, 70,254 with a recent MOF, 75,526 with a recent non-MOF, 293,051 with an old fracture, and 2,984,489 persons with no previous fracture. The median time of follow-up for the four groups was 6.1 (interquartile range [IQR] 3.0-8.8), 7.2 (5.6-9.4), 7.1 (5.8-9.2), and 8.1 years (7.4-9.7), respectively. Patients with a recent MOF, recent non-MOF, and old fracture had a substantially increased risk of any fracture (hazard ratio [HR] adjusted for age and sex 2.11, 95% confidence interval [CI] 2.08-2.14; HR 2.24, 95% CI 2.21-2.27; and HR 1.77, 95% CI 1.76-1.78, respectively) compared with controls. All recent fractures, MOFs, and non-MOFs, as well as older fractures, increase the risk of subsequent fracture, suggesting that all recent fractures should be included in fracture liaison services and that case-finding strategies for those with older fractures may be warranted to prevent subsequent fractures. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Kristian F Axelsson
- Sahlgrenska Osteoporosis Centre, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Närhälsan Norrmalm Health Centre, Skövde, Sweden
| | - Henrik Litsne
- Sahlgrenska Osteoporosis Centre, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mattias Lorentzon
- Sahlgrenska Osteoporosis Centre, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
- Region Västra Götaland, Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden
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Axelsson KF, Litsne H, Lorentzon M. Comparison of Fractures Among Older Adults Who Are Ambulatory vs Those Who Use Wheelchairs in Sweden. JAMA Netw Open 2023; 6:e2255645. [PMID: 36780160 PMCID: PMC9926324 DOI: 10.1001/jamanetworkopen.2022.55645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/14/2023] Open
Abstract
IMPORTANCE Several diseases and conditions, such as cerebrovascular disease, arthritis, previous fractures, neurological diseases, or amputation, can result in severe immobility justifying wheelchair use for increased mobility. Immobility results in disuse osteoporosis and is considered a risk factor for fracture, although there are no large cohort studies that have investigated fracture risk in patients who use wheelchairs compared with an ambulatory control group. OBJECTIVE To investigate whether immobilized adults who used wheelchairs had a different risk of fracture and injurious falls compared with matched ambulatory controls. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study compared patients who used wheelchairs and controls (propensity score matched 1:1 using 22 variables relating to anthropometrics, general condition, comorbidity, and fall and fracture risk), identified through a national database of adults 65 years or older who underwent a health evaluation (baseline) at Swedish health care facilities. Patients were followed up from January 1, 2007, to December 31, 2017, and data analysis was performed between June 1 and 30, 2022. MAIN OUTCOMES AND MEASURES Incident fracture, injurious falls without fracture, and deaths. RESULTS A total of 55 442 adults using wheelchairs were included in the analysis (mean [SD] age, 83.2 [8.3] years; 60.5% women). Those who used wheelchairs and the 55 442 matched controls were followed up for a median of 2.0 (IQR, 0.5-3.2) and 2.3 (IQR, 0.8-3.6) years, respectively. Patients who used wheelchairs had a lower risk of any fracture (hazard ratio [HR], 0.43 [95% CI, 0.41-0.44]), major osteoporotic fracture (HR, 0.32 [95% CI, 0.31-0.33]), and hip fracture (HR, 0.30 [95% CI, 0.28-0.32]) compared with the ambulatory controls, associations that were only marginally affected by multivariable (same as the matching variables) adjustment. The risk of fall injury was lower among those who used wheelchairs than among ambulatory controls (unadjusted HR for Cox proportional hazards models, 0.48 [95% CI, 0.47-0.50]) and remained highly similar after adjustments. Patients who used wheelchairs had a significantly increased risk of death (HR, 1.35 [95% CI, 1.33-1.36]) compared with controls. Association between wheelchair use and fracture outcomes and injurious falls, calculated using a Fine and Gray model with death as a competing risk, was similar to associations obtained using Cox proportional hazards regression for all fracture outcomes. CONCLUSIONS AND RELEVANCE In this retrospective cohort study of older adults, wheelchair use was associated with a lower risk of fracture than observed in ambulatory controls. These findings suggest that immobility associated with wheelchair use should not be considered a risk factor for fracture.
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Affiliation(s)
- Kristian F. Axelsson
- Sahlgrenska Osteoporosis Centre, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Närhälsan Norrmalm Health Centre, Skövde, Sweden
| | - Henrik Litsne
- Sahlgrenska Osteoporosis Centre, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mattias Lorentzon
- Sahlgrenska Osteoporosis Centre, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne
- Region Västra Götaland, Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden
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Johansson L, Johansson H, Axelsson KF, Litsne H, Harvey NC, Liu E, Leslie WD, Vandenput L, McCloskey E, Kanis JA, Lorentzon M. Improved fracture risk prediction by adding VFA-identified vertebral fracture data to BMD by DXA and clinical risk factors used in FRAX. Osteoporos Int 2022; 33:1725-1738. [PMID: 35451623 PMCID: PMC9499899 DOI: 10.1007/s00198-022-06387-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/22/2022] [Indexed: 11/11/2022]
Abstract
Vertebral fracture (VF) is a strong predictor of subsequent fracture. In this study of older women, VF, identified by dual-energy X-ray absorptiometry (DXA) vertebral fracture assessment (VFA), were associated with an increased risk of incident fractures and had a substantial impact on fracture probability, supporting the utility of VFA in clinical practice. PURPOSE Clinical and occult VF can be identified using VFA with dual-energy X-ray absorptiometry (DXA). The aim of this study was to investigate to what extent VFA-identified VF improve fracture risk prediction, independently of bone mineral density (BMD) and clinical risk factors used in FRAX. METHODS A total of 2852 women, 75-80 years old, from the prospective population-based study SUPERB cohort, were included in this study. At baseline, BMD was measured by DXA, VF diagnosed by VFA, and questionnaires used to collect data on risk factors for fractures. Incident fractures were captured by X-ray records or by diagnosis codes. An extension of Poisson regression was used to estimate the association between VFA-identified VF and the risk of fracture and the 5- and 10-year probability of major osteoporotic fracture (MOF) was calculated from the hazard functions for fracture and death. RESULTS During a median follow-up of 5.15 years (IQR 4.3-5.9 years), the number of women who died or suffered a MOF, clinical VF, or hip fracture was 229, 422, 160, and 124, respectively. A VFA-identified VF was associated with an increased risk of incident MOF (hazard ratio [HR] = 1.78; 95% confidence interval [CI] 1.46-2.18), clinical VF (HR = 2.88; 95% [CI] 2.11-3.93), and hip fracture (HR = 1.67; 95% [CI] 1.15-2.42), adjusted for age, height, and weight. For women at age 75 years, a VFA-identified VF was associated with 1.2-1.4-fold greater 10-year MOF probability compared with not taking VFA into account, depending on BMD. CONCLUSION Identifying an occult VF using VFA has a substantial impact on fracture probability, indicating that VFA is an efficient method to improve fracture prediction in older women.
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Affiliation(s)
- L Johansson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Osteoporosis Centre, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedics, Region Västra Götaland, Sahlgrenska University Hospital, Mölndal, Sweden
| | - H Johansson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Osteoporosis Centre, University of Gothenburg, Gothenburg, Sweden
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - K F Axelsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Osteoporosis Centre, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Närhälsan Norrmalm Health Centre, Skövde, Sweden
| | - H Litsne
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Osteoporosis Centre, University of Gothenburg, Gothenburg, Sweden
| | - N C Harvey
- MRC Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK
| | - E Liu
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - W D Leslie
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - L Vandenput
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Osteoporosis Centre, University of Gothenburg, Gothenburg, Sweden
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - E McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
- MRC Versus Arthritis Centre for Integrated Research in Musculoskeletal Ageing, Mellanby Centre for Musculoskeletal Research, University of Sheffield, Sheffield, UK
| | - J A Kanis
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
| | - M Lorentzon
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Osteoporosis Centre, University of Gothenburg, Gothenburg, Sweden.
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia.
- Department of Geriatric Medicine, Institute of Medicine, Region Västra Götaland, University of Gothenburg, Sahlgrenska University Hospital Mölndal, 43180, Mölndal, Sweden.
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Flehr A, Källgård J, Alvén J, Lagerstrand K, Papalini E, Wheeler M, Vandenput L, Kahl F, Axelsson KF, Sundh D, Mysore RS, Lorentzon M. Development of a novel method to measure bone marrow fat fraction in older women using high-resolution peripheral quantitative computed tomography. Osteoporos Int 2022; 33:1545-1556. [PMID: 35113175 PMCID: PMC9187531 DOI: 10.1007/s00198-021-06224-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 10/26/2021] [Indexed: 11/24/2022]
Abstract
UNLABELLED Bone marrow adipose tissue (BMAT) has been implicated in a number of conditions associated with bone deterioration and osteoporosis. Several studies have found an inverse relationship between BMAT and bone mineral density (BMD), and higher levels of BMAT in those with prevalent fracture. Magnetic resonance imaging (MRI) is the gold standard for measuring BMAT, but its use is limited by high costs and low availability. We hypothesized that BMAT could also be accurately quantified using high-resolution peripheral quantitative computed tomography (HR-pQCT). METHODS In the present study, a novel method to quantify the tibia bone marrow fat fraction, defined by MRI, using HR-pQCT was developed. In total, 38 postmenopausal women (mean [standard deviation] age 75.9 [3.1] years) were included and measured at the same site at the distal (n = 38) and ultradistal (n = 18) tibia using both MRI and HR-pQCT. To adjust for partial volume effects, the HR-pQCT images underwent 0 to 10 layers of voxel peeling to remove voxels adjacent to the bone. Linear regression equations were then tested for different degrees of voxel peeling, using the MRI-derived fat fractions as the dependent variable and the HR-pQCT-derived radiodensity as the independent variables. RESULTS The most optimal HR-pQCT derived model, which applied a minimum of 4 layers of peeled voxel and with more than 1% remaining marrow volume, was able to explain 76% of the variation in the ultradistal tibia bone marrow fat fraction, measured with MRI (p < 0.001). CONCLUSION The novel HR-pQCT method, developed to estimate BMAT, was able to explain a substantial part of the variation in the bone marrow fat fraction and can be used in future studies investigating the role of BMAT in osteoporosis and fracture prediction.
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Affiliation(s)
- Alison Flehr
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - Julius Källgård
- Sahlgrenska Osteoporosis Centre, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jennifer Alvén
- Dept. of Molecular and Clinical Medicine, Inst. of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Computer Vision and Medical Image Analysis, Dept. of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden
| | - Kerstin Lagerstrand
- Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Radiation Physics, Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Evin Papalini
- Sahlgrenska Osteoporosis Centre, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Medical Physics and Biomedical Engineering, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Michael Wheeler
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - Liesbeth Vandenput
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
- Sahlgrenska Osteoporosis Centre, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Fredrik Kahl
- Department of Electrical Engineering, Chalmers University of Technology, Gothenburg, Sweden
| | - Kristian F Axelsson
- Sahlgrenska Osteoporosis Centre, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Primary Care, Skövde, Sweden
| | - Daniel Sundh
- Sahlgrenska Osteoporosis Centre, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Raghunath Shirish Mysore
- Sahlgrenska Osteoporosis Centre, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mattias Lorentzon
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia.
- Sahlgrenska Osteoporosis Centre, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Region Västra Götaland, Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden.
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9
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Axelsson KF, Woessner MN, Litsne H, Wheeler M, Flehr A, King AJ, Kalén M, Vandenput L, Lorentzon M. Eating disorders are associated with increased risk of fall injury and fracture in Swedish men and women. Osteoporos Int 2022; 33:1347-1355. [PMID: 35088102 PMCID: PMC9106600 DOI: 10.1007/s00198-022-06312-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/18/2022] [Indexed: 11/24/2022]
Abstract
UNLABELLED In this retrospective cohort study, men and women with eating disorders (n = 8867) had higher risk of injurious falls and hip fractures than age, sex, and county-matched controls (n = 88670). INTRODUCTION Eating disorders have been associated with decreased bone mineral density and increased fracture risk, but the association with fall injuries without fracture has not previously been investigated. Furthermore, fracture risk in men with eating disorders has been insufficiently studied. METHODS In the present study, 8867 patients (9.4% men) with a diagnosed eating disorders and 88670 age-, sex-, and county-matched controls were investigated. RESULTS The mean (standard deviation) age of the patients and controls was 41.6 (13.7) years and the follow-up time 9.6 (5.2, 14.4) years (median, interquartile range) for patients and 10.1 (5.5, 14.2) years for controls. The proportions of injurious falls without fracture (17.3% vs. 9.0%) and of hip fracture (1.6% vs. 0.7%) were substantially greater in patients with an eating disorder than in their corresponding population controls. In an unadjusted Cox proportional hazards model, individuals with an eating disorder had a higher risk of injurious falls without fracture (Hazard ratio (HR) 95% confidence interval (CI): 2.07 (1.96-2.18), and hip fracture (HR 2.30 (1.92-2.75)) than the risk observed in the controls. The HR for any investigated outcome associated with an eating disorder did not differ by sex or age (interaction term p > 0.10). The risk of injurious falls without fracture and hip fracture was increased in both women (HR 2.07 (1.95-2.19) and HR 2.41 (1.98-2.93), respectively) and men (HR 2.09 (1.76-2.49) and HR 1.84(1.12-3.02), respectively), with an eating disorder. CONCLUSION The risk of injurious falls without fracture and of hip fracture is increased in both women and men with eating disorders, indicating measures to prevent both falls and fractures are important in these patients, regardless of age and sex.
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Affiliation(s)
- K F Axelsson
- Sahlgrenska Osteoporosis Centre, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Närhälsan Norrmalm Health Centre, Skövde, Sweden
| | - M N Woessner
- Institute for Health and Sport (IHES), Victoria University, Melbourne, Australia
| | - H Litsne
- Sahlgrenska Osteoporosis Centre, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - M Wheeler
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - A Flehr
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - A J King
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - M Kalén
- Region Västra Götaland, Department of Psychiatry, Skaraborgs Hospital, Skövde, Sweden
| | - L Vandenput
- Sahlgrenska Osteoporosis Centre, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - M Lorentzon
- Sahlgrenska Osteoporosis Centre, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia.
- Region Västra Götaland, Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Building K, 6th Floor, 431 80, Mölndal, Sweden.
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10
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Axelsson KF, Wallander M, Johansson H, Harvey NC, Vandenput L, McCloskey E, Liu E, Kanis JA, Litsne H, Lorentzon M. Analysis of Comorbidities, Clinical Outcomes, and Parathyroidectomy in Adults With Primary Hyperparathyroidism. JAMA Netw Open 2022; 5:e2215396. [PMID: 35657624 PMCID: PMC9166253 DOI: 10.1001/jamanetworkopen.2022.15396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/17/2022] [Indexed: 11/22/2022] Open
Abstract
Importance Patients with primary hyperparathyroidism (pHPT) appear to have an increased risk of fractures and other comorbidities, such as cardiovascular disease, although results from previous studies have been inconsistent. Evidence of the association of parathyroidectomy (PTX) with these outcomes is also limited because of the lack of large well-controlled trials. Objective To investigate whether untreated pHPT was associated with an increased risk of incident fractures and cardiovascular events (CVEs) and whether PTX was associated with a reduced risk of these outcomes. Design, Setting, and Participants This cohort study included all patients who were diagnosed with pHPT at hospitals in Sweden between July 1, 2006, and December 31, 2017. Each patient was matched with 10 control individuals from the general population by sex, birth year, and county of residence. The patients were followed up until December 31, 2017. Data analyses were performed from October 2021 to April 2022. Main Outcomes and Measures The primary outcomes were fractures, CVEs, and death. Cumulative incidence of events was estimated using the 1-minus Kaplan-Meier estimator of corresponding survival function. Cox proportional hazards regression models were used to calculate hazard ratios (HRs). Results A total of 16 374 patients with pHPT were identified (mean [SD] age, 67.5 [12.9] years; 12 806 women [78.2%]), with 163 740 control individuals. The follow-up time was 42 310 person-years for the pHPT group and 803 522 person-years for the control group. Compared with the control group, the pHPT group had a higher risk of any fracture (unadjusted HR, 1.39; 95% CI, 1.31-1.48), hip fracture (unadjusted HR, 1.51; 95% CI, 1.35-1.70), CVEs (unadjusted HR, 1.45; 95% CI, 1.34-1.57), and death (unadjusted HR, 1.72; 95% CI, 1.65-1.80). In a time-dependent Poisson regression model, PTX was associated with a reduced risk of any fracture (HR, 0.83; 95% CI, 0.75-0.93), hip fracture (HR, 0.78; 95% CI, 0.61-0.98), CVEs (HR, 0.84; 95% CI, 0.73-0.97), and death (HR, 0.59; 95% CI, 0.53-0.65). Conclusions and Relevance Results of this study suggest that pHPT is associated with increased risk of fractures, CVEs, and death, highlighting the importance of identifying patients with this condition to prevent serious unfavorable outcomes. The reduced risk of these outcomes associated with PTX suggests a clinical benefit of surgery.
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Affiliation(s)
- Kristian F. Axelsson
- Region Västra Götaland, Närhälsan Norrmalm, Health Centre, Skövde, Sweden
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Märit Wallander
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Helena Johansson
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - Nicholas C. Harvey
- Medical Research Council (MRC) Lifecourse Epidemiology Centre, University of Southampton, Southampton, United Kingdom
- National Institute for Health Research Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton National Health Service Foundation Trust, Southampton, United Kingdom
| | - Liesbeth Vandenput
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - Eugene McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, United Kingdom
- MRC Versus Arthritis Centre for Integrated Research in Musculoskeletal Ageing, Mellanby Centre for Musculoskeletal Research, University of Sheffield, Sheffield, United Kingdom
| | - Enwu Liu
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - John A. Kanis
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
- MRC Versus Arthritis Centre for Integrated Research in Musculoskeletal Ageing, Mellanby Centre for Musculoskeletal Research, University of Sheffield, Sheffield, United Kingdom
| | - Henrik Litsne
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Mattias Lorentzon
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
- Region Västra Götaland, Department of Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden
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11
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Larsson BAM, Johansson L, Mellström D, Johansson H, Axelsson KF, Harvey N, Vandenput L, McCloskey E, Liu E, Sundh D, Kanis JA, Lorentzon M. One leg standing time predicts fracture risk in older women independent of clinical risk factors and BMD. Osteoporos Int 2022; 33:185-194. [PMID: 34498096 PMCID: PMC8758616 DOI: 10.1007/s00198-021-06039-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/15/2021] [Indexed: 11/28/2022]
Abstract
In women of ages 75-80 years, a low one leg standing time (OLST) was associated with an increased risk of incident fractures, independently of bone mineral density and clinical risk factors. OLST contributed substantially to fracture probability, indicating that the test should be considered when evaluating fracture risk in older women. INTRODUCTION Physical function and risk of falls are important risk factors for fracture. A few previous studies have suggested that a one leg standing time (OLST) less than 10 s predicts fracture risk, but the impact of OLST, in addition to known clinical risk factors, for fracture probability is unknown. The aim of this study was to determine the independent contribution of OLST to fracture probability in older women. METHODS The Sahlgrenska University Hospital Prospective Evaluation of Risk of Bone Fractures (SUPERB) is a prospective population-based study of 3028 women 75-80 years old, recruited from the greater Gothenburg area in Sweden. At baseline, information on risk factors was collected using questionnaires, bone mineral density was measured with dual-energy X-ray absorptiometry (DXA), and OLST was performed. RESULTS During a median follow-up of 3.6 years (IQR 1.5 years), X-ray-verified incident fractures were identified using health records. OLST was available in 2405 women. OLST less than 10 s was associated with an increased risk for incident hip fracture (Hazard Ratio (HR) 3.02, 95% Confidence Interval (CI) [1.49-6.10]), major osteoporotic fracture (HR 95% CI 1.76 [1.34-1.46]), and nonvertebral fracture (HR 95% CI 1.61 [1.26-2.05]) in Cox regression analyses adjusted for age, height, and weight. Depending on BMD, the 4-year fracture probability increased by a factor of 1.3 to 1.5 in a 75-year-old woman with a low OLST (<10 s). CONCLUSION A low OLST has a substantial impact on fracture probability and should be considered when evaluating fracture risk in older women.
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Affiliation(s)
- B A M Larsson
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - L Johansson
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - D Mellström
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - H Johansson
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - K F Axelsson
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Närhälsan Norrmalm Health Centre, Skövde, Sweden
| | - N Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK
| | - L Vandenput
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - E McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
- MRC and Arthritis Research UK Centre for Integrated Research in Musculoskeletal Ageing, Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK
| | - E Liu
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - D Sundh
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - J A Kanis
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
| | - M Lorentzon
- Sahlgrenska Osteoporosis Centre, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia.
- Region Västra Götaland, Department of Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden.
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12
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Axelsson KF, Litsne H, Lorentzon M. Fractures and fall injuries after hospitalization for seasonal influenza-a national retrospective cohort study. Osteoporos Int 2022; 33:47-56. [PMID: 34436639 PMCID: PMC8390060 DOI: 10.1007/s00198-021-06068-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 07/12/2021] [Indexed: 01/27/2023]
Abstract
In this retrospective cohort study of 6604 adults, 65 years or older, admitted with seasonal influenza at Swedish hospitals, and 330,200 age- and sex-matched controls from the general population admitted for other reasons, were included. Patients with influenza had increased risk of fall injuries and fractures compared to controls. INTRODUCTION Fractures and fall injuries often lead to disability, increased morbidity, and mortality. Older adults are at higher risk of influenza-related complications such as pneumonia, cardiovascular events, and deaths, but the risk of fractures and fall injuries is unclear. The primary objective of this study was to investigate the risk of fractures and fall injuries in older patients after admission with seasonal influenza. METHODS In this retrospective cohort study of 6604 adults, 65 years or older, admitted with seasonal influenza at Swedish hospitals (from December 1, 2015, to December 31, 2017) and 330,200 age- and sex-matched controls from the general population and admitted for other reasons, the risk of fracture or fall injury was investigated. RESULTS The mean (SD) age of the 6604 influenza patients was 80.9 (8.1) years and 50.1% were women. During the first year after hospital discharge, there were 680 (10.3%) patients suffering from a fracture or fall injury among the patients with influenza, and 25,807 (7.8%) among the controls, corresponding to incident rates of 141 (95% CI, 131-152) and 111 (95% CI, 110-112) fractures or fall injuries per 1000 person-years respectively, translating to a significantly increased risk of fracture or fall injury in a Cox regression model (hazard ratio (HR) 1.28 (95% CI, 1.19-1.38)), a risk that was maintained after multivariable adjustment (HR 1.22 (95% CI 1.13-1.31)). CONCLUSIONS Older adults admitted with influenza diagnosis have an increased risk of fracture or fall injury during the first year after discharge.
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Affiliation(s)
- K F Axelsson
- Närhälsan Norrmalm Health Centre, Skövde, Sweden
- Sahlgrenska Osteoporosis Centre, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Mölndal, Building K, 6th Floor, 431 80, Mölndal, Sweden
| | - H Litsne
- Sahlgrenska Osteoporosis Centre, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Mölndal, Building K, 6th Floor, 431 80, Mölndal, Sweden
| | - M Lorentzon
- Sahlgrenska Osteoporosis Centre, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Mölndal, Building K, 6th Floor, 431 80, Mölndal, Sweden.
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia.
- Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden.
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13
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Larsson BAM, Johansson L, Johansson H, Axelsson KF, Harvey N, Vandenput L, Magnusson P, McCloskey E, Liu E, Kanis JA, Sundh D, Lorentzon M. The timed up and go test predicts fracture risk in older women independently of clinical risk factors and bone mineral density. Osteoporos Int 2021; 32:75-84. [PMID: 33089354 PMCID: PMC7755867 DOI: 10.1007/s00198-020-05681-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 10/09/2020] [Indexed: 12/12/2022]
Abstract
The timed up and go (TUG) test measures physical performance and predicts falls in the elderly. In older women, TUG time predicts the risk of major osteoporotic fracture and hip fracture independently of clinical risk factors and bone mineral density, and has a substantial impact on fracture probabilities. INTRODUCTION The timed up and go (TUG) test measures physical performance and predicts falls in the elderly. A slow TUG has been associated with an increased fracture risk, but it is unclear whether the association is independent of clinical risk factors and bone mineral density (BMD). The aim of this study was to investigate if TUG time was associated with fracture risk independently of clinical risk factors and BMD and to determine its impact on fracture probabilities in older women. METHODS A standardized questionnaire was used to assess information regarding clinical risk factors in the large population-based SUPERB study of 3028 older women (75-80 years). At baseline, the TUG test was performed and BMD measured with DXA. The association between TUG time and the risk of hip fracture and major osteoporotic fracture (MOF) was examined using an extension of Poisson regression. RESULTS Fracture incidence increased steeply with increasing TUG time up to 12 s and subsequently started to level off. A slow TUG time was therefore defined as TUG > 12 s, a cutoff level then used in Cox models to study the association between slow TUG and fracture risk. A slow TUG time was associated with an increased risk of fracture (MOF 2.39 [1.80-3.18] and hip fracture 2.96 [1.62-5.40]). These associations were slightly attenuated but remained significant after adjustment for clinical risk factors and femoral neck BMD. Depending on BMD, the 4-year fracture probability of MOF increased by a factor of 1.5-1.9 in a 75-year-old woman with slow TUG (> 12 s). CONCLUSION The TUG time predicts the risk of MOF and hip fracture independently of clinical risk factors and BMD and has a substantial impact on fracture probabilities, indicating that inclusion of the TUG test in patient evaluation should be considered in order to improve fracture prediction in older women.
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Affiliation(s)
- B A M Larsson
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - L Johansson
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - H Johansson
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - K F Axelsson
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Orthopaedic Surgery, Skaraborg Hospital, Skövde, Sweden
| | - N Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, UK
| | - L Vandenput
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
- Centre for Bone and Arthritis Research, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - P Magnusson
- Department of Clinical Chemistry, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - E McCloskey
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
- MRC and Arthritis Research UK Centre for Integrated Research in Musculoskeletal Ageing, Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK
| | - E Liu
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - J A Kanis
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
- Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
| | - D Sundh
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - M Lorentzon
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia.
- Region Västra Götaland, Department of Geriatric Medicine, Sahlgrenska University Hospital, 43180, Mölndal, Sweden.
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Axelsson KF, Johansson H, Lundh D, Möller M, Lorentzon M. Association Between Recurrent Fracture Risk and Implementation of Fracture Liaison Services in Four Swedish Hospitals: A Cohort Study. J Bone Miner Res 2020; 35:1216-1223. [PMID: 32097504 DOI: 10.1002/jbmr.3990] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 01/16/2020] [Accepted: 01/29/2020] [Indexed: 11/07/2022]
Abstract
Structured secondary preventions programs, called fracture liaison services (FLSs), increase the rate of evaluation with bone densitometry and use of osteoporosis medication after fracture. However, the evidence regarding the effect on the risk of recurrent fracture is insufficient. The aim of this study was to investigate if implementation of FLS was associated with reduced risk of recurrent fractures. In this retrospective cohort study, electronic health records during 2012 to 2017 were used to identify a total of 21,083 patients from four hospitals in Western Sweden, two with FLS (n = 15,449) and two without (n = 5634). All patients aged 50 years or older (mean age 73.9 [SD 12.4] years, 76% women) with a major osteoporotic index fracture (hip, clinical spine, humerus, radius, and pelvis) were included. The primary outcome was recurrent major osteoporotic fracture. All patients with an index fracture during the FLS period (n = 13,946) were compared with all patients in the period before FLS implementation (n = 7137) in an intention-to-treat analysis. Time periods corresponding to the FLS hospitals were used for the non-FLS hospitals. In the hospitals with FLSs, there were 1247 recurrent fractures during a median follow-up time of 2.2 years (range 0-6 years). In an unadjusted Cox model, the risk of recurrent fracture was 18% lower in the FLS period compared with the control period (hazard ratio = 0.82, 95% confidence interval [CI] 0.73-0.92, p = .001), corresponding to a 3-year number needed to screen of 61, and did not change after adjustment for clinical risk factors. In the hospitals without FLSs, no change in recurrent fracture rate was observed. Treatment decisions were made according to the Swedish treatment guidelines. In conclusion, implementation of FLS was associated with a reduced risk of recurrent fracture, indicating that FLSs should be included routinely at hospitals treating fracture patients. © 2020 The Authors. Journal of Bone and Mineral Research published by American Society for Bone and Mineral Research.
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Affiliation(s)
- Kristian F Axelsson
- Department of Orthopaedic Surgery, Region Västra Götaland, Skaraborg Hospital, Skövde, Sweden.,Geriatric Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Helena Johansson
- Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
| | - Dan Lundh
- Department of Natural Science and Biomedicine, School of Health and Welfare, Jönköping University, Jönköping, Sweden
| | - Michael Möller
- Region Västra Götaland, Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden.,Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mattias Lorentzon
- Geriatric Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia.,Region Västra Götaland, Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden
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Larsson BAM, Sundh D, Mellström D, Axelsson KF, Nilsson AG, Lorentzon M. Response to Letter to the Editor: "Association Between Cortical Bone Microstructure and Statin Use in Older Women". J Clin Endocrinol Metab 2019; 104:3368-3369. [PMID: 30848828 DOI: 10.1210/jc.2019-00486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 03/04/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Berit A M Larsson
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Daniel Sundh
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Dan Mellström
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Geriatric Medicine Clinic, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Kristian F Axelsson
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedic Surgery, Skaraborg Hospital, Skövde, Sweden
| | - Anna G Nilsson
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mattias Lorentzon
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Geriatric Medicine Clinic, Sahlgrenska University Hospital, Mölndal, Sweden
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Larsson BAM, Sundh D, Mellström D, Axelsson KF, Nilsson AG, Lorentzon M. Association Between Cortical Bone Microstructure and Statin Use in Older Women. J Clin Endocrinol Metab 2019; 104:250-257. [PMID: 30423123 DOI: 10.1210/jc.2018-02054] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 11/08/2018] [Indexed: 12/19/2022]
Abstract
CONTEXT Treatment with statins has been associated with increased bone mineral density, but whether this association depends on differences in cortical or trabecular volumetric bone microstructure is unknown. OBJECTIVE The aim of this study was to investigate if treatment with statins is associated with bone microstructure and geometry in older women. DESIGN SETTING AND PARTICIPANTS Older women were included in a population-based study of 3028 women (mean age ± SD, 77.8 ± 1.6 years) from the greater Gothenburg area in Sweden. Information regarding medical history, medication, and lifestyle factors was obtained from validated questionnaires. MAIN OUTCOME Bone geometry and microstructure were measured at the ultradistal and distal (14%) site of radius and tibia using high-resolution peripheral quantitative computed tomography. RESULTS The 803 women in the cohort who used statins had higher body weight, worse physical function, and more frequent cardiovascular disease and diabetes than nonusers (P < 0.05). Statin users had lower cortical porosity (radius, 2.2 ± 1.9 vs 2.5 ± 2.0%; tibia, 5.2 ± 2.4 vs 5.4 ± 2.5; P = 0.01), higher cortical bone density (radius, 1008 ± 39.1 vs 1001 ± 38.4 mg/cm3; tibia, 919 ± 42.6 vs 914 ± 41.5; P < 0.01), and greater cortical area (radius, 60.5 ± 9.6 vs 58.6 ± 9.7 mm2; tibia, 150.0 ± 23.6 vs 146.7 ± 23.8; P < 0.01) than nonusers after adjustment for a large number of confounders, including age, weight, smoking, other medications, and prevalent diseases. CONCLUSIONS Use of statins was associated with better cortical bone characteristics in older women.
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Affiliation(s)
- Berit A M Larsson
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Göteborg Gothenburg, Sweden
| | - Daniel Sundh
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Göteborg Gothenburg, Sweden
| | - Dan Mellström
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Göteborg Gothenburg, Sweden
- Geriatric Medicine, Sahlgrenska University Hospital, Mölndal Mölndal, Sweden
| | - Kristian F Axelsson
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Göteborg Gothenburg, Sweden
- Department of Orthopaedic Surgery, Skaraborg Hospital, Göteborg Skövde, Sweden
| | - Anna G Nilsson
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Göteborg Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Göteborg Gothenburg, Sweden
| | - Mattias Lorentzon
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Göteborg Gothenburg, Sweden
- Geriatric Medicine, Sahlgrenska University Hospital, Mölndal Mölndal, Sweden
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Wallander M, Axelsson KF, Lundh D, Lorentzon M. Patients with prostate cancer and androgen deprivation therapy have increased risk of fractures-a study from the fractures and fall injuries in the elderly cohort (FRAILCO). Osteoporos Int 2019; 30:115-125. [PMID: 30324413 PMCID: PMC6331736 DOI: 10.1007/s00198-018-4722-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 09/26/2018] [Indexed: 12/31/2022]
Abstract
UNLABELLED Osteoporosis is a common complication of androgen deprivation therapy (ADT). In this large Swedish cohort study consisting of a total of nearly 180,000 older men, we found that those with prostate cancer and ADT have a significantly increased risk of future osteoporotic fractures. INTRODUCTION Androgen deprivation therapy (ADT) in patients with prostate cancer is associated to increased risk of fractures. In this study, we investigated the relationship between ADT in patients with prostate cancer and the risk of incident fractures and non-skeletal fall injuries both compared to those without ADT and compared to patients without prostate cancer. METHODS We included 179,744 men (79.1 ± 7.9 years (mean ± SD)) from the Swedish registry to which national directories were linked in order to study associations regarding fractures, fall injuries, morbidity, mortality and medications. We identified 159,662 men without prostate cancer, 6954 with prostate cancer and current ADT and 13,128 men with prostate cancer without ADT. During a follow-up of approximately 270,300 patient-years, we identified 10,916 incident fractures including 4860 hip fractures. RESULTS In multivariable Cox regression analyses and compared to men without prostate cancer, those with prostate cancer and ADT had increased risk of any fracture (HR 95% CI 1.40 (1.28-1.53)), hip fracture (1.38 (1.20-1.58)) and MOF (1.44 (1.28-1.61)) but not of non-skeletal fall injury (1.01 (0.90-1.13)). Patients with prostate cancer without ADT did not have increased risk of any fracture (0.97 (0.90-1.05)), hip fracture (0.95 (0.84-1.07)), MOF (1.01 (0.92-1.12)) and had decreased risk of non-skeletal fall injury (0.84 (0.77-0.92)). CONCLUSIONS Patients with prostate cancer and ADT is a fragile patient group with substantially increased risk of osteoporotic fractures both compared to patients without prostate cancer and compared to those with prostate cancer without ADT. We believe that this must be taken in consideration in all patients with prostate cancer already at the initiation of ADT.
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Affiliation(s)
- M Wallander
- Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Center for Bone Research at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - K F Axelsson
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Center for Bone Research at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedic Surgery, Skaraborg Hospital, Skövde, Sweden
| | - D Lundh
- School of Health and Education, University of Skövde, Skövde, Sweden
| | - M Lorentzon
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Center for Bone Research at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Geriatric Medicine, Institute of Medicine, The Sahlgrenska Academy, Sahlgrenska University Hospital, Building K, 6th Floor, 431 80, Mölndal, Sweden.
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Axelsson KF, Lorentzon M. Reply to: Bariatric Surgery, Physical Activity, and Fracture Risk. J Bone Miner Res 2018; 33:2237. [PMID: 30399201 DOI: 10.1002/jbmr.3592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Kristian F Axelsson
- Department of Orthopaedic Surgery, Skaraborg Hospital, Skövde, Sweden.,Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Mattias Lorentzon
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.,Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden
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Axelsson KF, Werling M, Eliasson B, Szabo E, Näslund I, Wedel H, Lundh D, Lorentzon M. Fracture Risk After Gastric Bypass Surgery: A Retrospective Cohort Study. J Bone Miner Res 2018; 33:2122-2131. [PMID: 30011091 DOI: 10.1002/jbmr.3553] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 06/13/2018] [Accepted: 07/07/2018] [Indexed: 12/20/2022]
Abstract
Gastric bypass surgery constitutes the most common and effective bariatric surgery to treat obesity. Gastric bypass leads to bone loss, but fracture risk following surgery has been insufficiently studied. Furthermore, the association between gastric bypass and fracture risk has not been studied in patients with diabetes, which is a risk factor for fracture and affected by surgery. In this retrospective cohort study using Swedish national databases, 38,971 obese patients undergoing gastric bypass were identified, 7758 with diabetes and 31,213 without. An equal amount of well-balanced controls were identified through multivariable 1:1 propensity score matching. The risk of fracture and fall injury was investigated using Cox proportional hazards and flexible parameter models. Fracture risk according to weight loss and degree of calcium and vitamin D supplementation 1-year postsurgery was investigated. During a median follow-up time of 3.1 (interquartile range [IQR], 1.7 to 4.6) years, gastric bypass was associated with increased risk of any fracture, in patients with and without diabetes using a multivariable Cox model (hazard ratio [HR] 1.26; 95% CI, 1.05 to 1.53; and HR 1.32; 95% CI, 1.18 to 1.47; respectively). Using flexible parameter models, the fracture risk appeared to increase with time. The risk of fall injury without fracture was also increased after gastric bypass. Larger weight loss or poor calcium and vitamin D supplementation after surgery were not associated with increased fracture risk. In conclusion, gastric bypass surgery is associated with an increased fracture risk, which appears to be increasing with time and not associated with degree of weight loss or calcium and vitamin D supplementation following surgery. An increased risk of fall injury was seen after surgery, which could contribute to the increased fracture risk. © 2018 American Society for Bone and Mineral Research.
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Affiliation(s)
- Kristian F Axelsson
- Department of Orthopaedic Surgery, Skaraborg Hospital, Skövde, Sweden.,Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Malin Werling
- Department of Gastrosurgical Research & Education, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Björn Eliasson
- Department of Molecular and Clinical Medicine, the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eva Szabo
- Department of Surgery. Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Ingmar Näslund
- Department of Surgery. Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Hans Wedel
- Health Metrics, Sahlgrenska Academin, University of Gothenburg, Gothenburg, Sweden
| | - Dan Lundh
- School of Bioscience, University of Skövde, Skövde, Sweden
| | - Mattias Lorentzon
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.,Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden
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Abstract
BACKGROUND There is high evidence for secondary prevention of fractures, including hip fracture, with alendronate treatment, but alendronate's efficacy to prevent hip fractures in the oldest-old (≥80 years old), the population with the highest fracture risk, has not been studied. OBJECTIVE To investigate whether alendronate treatment amongst the oldest-old with prior fracture was related to decreased hip fracture rate and sustained safety. METHODS Using a national database of men and women undergoing a fall risk assessment at a Swedish healthcare facility, we identified 90 795 patients who were 80 years or older and had a prior fracture. Propensity score matching (four to one) was then used to identify 7844 controls to 1961 alendronate-treated patients. The risk of incident hip fracture was investigated with Cox models and the interaction between age and treatment was investigated using an interaction term. RESULTS The case and control groups were well balanced in regard to age, sex, anthropometrics and comorbidity. Alendronate treatment was associated with a decreased risk of hip fracture in crude (hazard ratio (HR) 0.62 (0.49-0.79), P < 0.001) and multivariable models (HR 0.66 (0.51-0.86), P < 0.01). Alendronate was related to reduced mortality risk (HR 0.88 (0.82-0.95) but increased risk of mild upper gastrointestinal symptoms (UGI) (HR 1.58 (1.12-2.24). The alendronate association did not change with age for hip fractures or mild UGI. CONCLUSION In old patients with prior fracture, alendronate treatment reduces the risk of hip fracture with sustained safety, indicating that this treatment should be considered in these high-risk patients.
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Affiliation(s)
- K F Axelsson
- Department of Orthopaedic Surgery, Skaraborg Hospital, Skövde, Sweden.,Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - M Wallander
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.,Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
| | - H Johansson
- Institute for Health and Ageing, Catholic University of Australia, Melbourne, Vic., Australia
| | - D Lundh
- School of Bioscience, University of Skövde, Skövde, Sweden
| | - M Lorentzon
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.,Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden
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21
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Affiliation(s)
| | - Anna G Nilsson
- Geriatric Medicine, University of Gothenburg, Gothenburg, Sweden
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22
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Abstract
IMPORTANCE Oral glucocorticoid treatment increases fracture risk, and evidence is lacking regarding the efficacy of alendronate to protect against hip fracture in older patients using glucocorticoids. OBJECTIVE To investigate whether alendronate treatment in older patients using oral prednisolone is associated with decreased hip fracture risk and adverse effects. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study using a national database (N = 433 195) of patients aged 65 years or older undergoing a health evaluation (baseline) at Swedish health care facilities; 1802 patients who were prescribed alendronate after at least 3 months of oral prednisolone treatment (≥5 mg/d) were identified. Propensity score matching was used to select 1802 patients without alendronate use from 6076 patients taking prednisolone with the same dose and treatment time criteria. Follow-up occurred between January 2008 and December 2014. EXPOSURES Alendronate vs no alendronate use; no patients had previously taken alendronate at the time of prednisolone initiation. MAIN OUTCOMES AND MEASURES The primary outcome was incident hip fracture. RESULTS Of the 3604 included patients, the mean age was 79.9 (SD, 7.5) years, and 2524 (70%) were women. After a median follow-up of 1.32 years (interquartile range, 0.57-2.34 years), there were 27 hip fractures in the alendronate group and 73 in the no-alendronate group, corresponding to incidence rates of 9.5 (95% CI, 6.5-13.9) and 27.2 (95% CI, 21.6-34.2) fractures per 1000 person-years, with an absolute rate difference of -17.6 (95% CI, -24.8 to -10.4). The use of alendronate was associated with a lower risk of hip fracture in a multivariable-adjusted Cox model (hazard ratio, 0.35; 95% CI, 0.22-0.54). Alendronate treatment was not associated with increased risk of mild upper gastrointestinal tract symptoms (alendronate vs no alendronate, 15.6 [95% CI, 11.6-21.0] vs 12.9 [95% CI, 9.3-18.0] per 1000 person-years; P = .40) or peptic ulcers (10.9 [95% CI, 7.7-15.5] vs 11.4 [95% CI, 8.0-16.2] per 1000 person-years; P = .86). There were no cases of incident drug-induced osteonecrosis and only 1 case of femoral shaft fracture in each group. CONCLUSIONS AND RELEVANCE Among older patients using medium to high doses of prednisolone, alendronate treatment was associated with a significantly lower risk of hip fracture over a median of 1.32 years. Although the findings are limited by the observational study design and the small number of events, these results support the use of alendronate in this patient group.
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Affiliation(s)
- Kristian F. Axelsson
- Department of Orthopaedic Surgery, Skaraborg Hospital, Skövde, Sweden
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Anna G. Nilsson
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Internal Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Hans Wedel
- Health Metrics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Dan Lundh
- School of Bioscience, University of Skövde, Skövde, Sweden
| | - Mattias Lorentzon
- Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Geriatric Medicine, Sahlgrenska University Hospital, Mölndal, Sweden
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Wallander M, Axelsson KF, Nilsson AG, Lundh D, Lorentzon M. Type 2 Diabetes and Risk of Hip Fractures and Non-Skeletal Fall Injuries in the Elderly: A Study From the Fractures and Fall Injuries in the Elderly Cohort (FRAILCO). J Bone Miner Res 2017; 32:449-460. [PMID: 27664946 DOI: 10.1002/jbmr.3002] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 09/21/2016] [Accepted: 09/22/2016] [Indexed: 01/26/2023]
Abstract
Questions remain about whether the increased risk of fractures in patients with type 2 diabetes (T2DM) is related mainly to increased risk of falling or to bone-specific properties. The primary aim of this study was to investigate the risk of hip fractures and non-skeletal fall injuries in older men and women with and without T2DM. We included 429,313 individuals (aged 80.8 ± 8.2 years [mean ± SD], 58% women) from the Swedish registry "Senior Alert" and linked the data to several nationwide registers. We identified 79,159 individuals with T2DM (45% with insulin [T2DM-I], 41% with oral antidiabetics [T2DM-O], and 14% with no antidiabetic treatment [T2DM-none]) and 343,603 individuals without diabetes. During a follow-up of approximately 670,000 person-years, we identified in total 36,132 fractures (15,572 hip fractures) and 20,019 non-skeletal fall injuries. In multivariable Cox regression models where the reference group was patients without diabetes and the outcome was hip fracture, T2DM-I was associated with increased risk (adjusted hazard ratio (HR) [95% CI] 1.24 [1.16-1.32]), T2DM-O with unaffected risk (1.03 [0.97-1.11]), and T2DM-none with reduced risk (0.88 [0.79-0.98]). Both the diagnosis of T2DM-I (1.22 [1.16-1.29]) and T2DM-O (1.12 [1.06-1.18]) but not T2DM-none (1.07 [0.98-1.16]) predicted non-skeletal fall injury. The same pattern was found regarding other fractures (any, upper arm, ankle, and major osteoporotic fracture) but not for wrist fracture. Subset analyses revealed that in men, the risk of hip fracture was only increased in those with T2DM-I, but in women, both the diagnosis of T2DM-O and T2DM-I were related to increased hip fracture risk. In conclusion, the risk of fractures differs substantially among patients with T2DM and an increased risk of hip fracture was primarily found in insulin-treated patients, whereas the risk of non-skeletal fall injury was consistently increased in T2DM with any diabetes medication. © 2016 American Society for Bone and Mineral Research.
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Affiliation(s)
- Märit Wallander
- Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden.,Geriatric Medicine, Center for Bone Research at the Sahlgrenska Academy, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Kristian F Axelsson
- Geriatric Medicine, Center for Bone Research at the Sahlgrenska Academy, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.,Department of Orthopaedic Surgery, Skaraborg Hospital, Skövde, Sweden
| | - Anna G Nilsson
- Geriatric Medicine, Center for Bone Research at the Sahlgrenska Academy, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Dan Lundh
- School of Bioscience, University of Skövde, Skövde, Sweden
| | - Mattias Lorentzon
- Geriatric Medicine, Center for Bone Research at the Sahlgrenska Academy, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
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Abstract
PURPOSE The purpose of this study was to investigate if a 2-year intervention with a minimal resource fracture liaison service (FLS) was associated with increased investigation and medical treatment and if treatment was related to reduced re-fracture risk. METHODS The FLS started in 2013 using existing secretaries (without an FLS coordinator) at the emergency department and orthopaedic wards to identify risk patients. All patients older than 50 years of age with a fractured hip, vertebra, shoulder, wrist or pelvis were followed during 2013-2014 (n = 2713) and compared with their historic counterparts in 2011-2012 (n = 2616) at the same hospital. Re-fractures were X-ray verified. A time-dependent adjusted (for age, sex, previous fracture, index fracture type, prevalent treatment, comorbidity and secondary osteoporosis) Cox model was used. RESULTS The minimal resource FLS increased the proportion of DXA-investigated patients after fracture from 7.6 to 39.6 % (p < 0.001) and the treatment rate after fracture from 12.6 to 31.8 %, which is well in line with FLS types using the conventional coordinator model. Treated patients had a 51 % lower risk of any re-fracture than untreated patients (HR 0.49, 95 % CI 0.37-0.65 p < 0.001). CONCLUSIONS We found that our minimal resource FLS was effective in increasing investigation and treatment, in line with conventional coordinator-based services, and that treated patients had a 51 % reduced risk of new fractures, indicating that also non-coordinator based fracture liaison services can improve secondary prevention of fractures.
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Affiliation(s)
- K F Axelsson
- Department of Orthopaedic Surgery, Skaraborg Hospital, Skövde, Sweden
- Geriatric Medicine, Institute of Medicine, University of Gothenburg, Sahlgrenska University Hospital, Building K, 6th Floor, Mölndal, 431 80, Sweden
- Center for Bone Research at the Sahlgrenska Academy, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - R Jacobsson
- Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - D Lund
- School of Bioscience, University of Skövde, Skövde, Sweden
| | - M Lorentzon
- Geriatric Medicine, Institute of Medicine, University of Gothenburg, Sahlgrenska University Hospital, Building K, 6th Floor, Mölndal, 431 80, Sweden.
- Center for Bone Research at the Sahlgrenska Academy, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.
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