[A good combination to achieve a reduced number of fractures: bone density measurements, drug therapy and hip protector].
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Aged↗
Biomedical subjects
O Johnell
Publications and source records attributed to O Johnell.
Ten year probabilities of osteoporotic fractures according to BMD and diagnostic thresholds.
The objectives of the present study were to estimate 10 year probabilities of osteoporotic fractures in men and women according to age and bone mineral density (BMD) at the femoral neck. Risks were computed from the incidence of a first hip, distal forearm, proximal humerus and symptomatic vertebral fracture from patient records in Malmö, Sweden and future mortality rates for each year of age from Poisson models using the Swedish patient register and statistical year book. Fracture probability was computed using the Swedish population and cut-off values for T-scores based on the NHANES III female population. We assumed that the risk of fracture increased with decreasing BMD as assessed by meta-analysis in independent studies. The 10-year probability of any fracture was determined from the proportion of individuals fracture-free from the age of 45 years. With the exception of forearm fractures in men, 10 year probabilities increased with age and T-score. In the case of hip and spine fractures, fracture probabilities for any age with low BMD were similar between men and women. The effect of age on risk independently of BMD suggests that intervention thresholds should not be at a fixed T-score but vary according to absolute probabilities. Intervention thresholds based on hip BMD T-scores are similar between sexes.
Age Factors↗
An assessment tool for predicting fracture risk in postmenopausal women.
Due to the magnitude of the morbidity and mortality associated with untreated osteoporosis, it is essential that high-risk individuals be identified so that they can receive appropriate evaluation and treatment. The objective of this investigation was to develop a simple clinical assessment tool based on a small number of risk factors that could be used by women or their clinicians to assess their risk of fractures. Using data from the Study of Osteoporotic Fractures (SOF), a total of 7782 women age 65 years and older with bone mineral density (BMD) measurements and baseline risk factors were included in the analysis. A model with and without BMD T-scores was developed by identifying variables that could be easily assessed in either clinical practice or by self-administration. The assessment tool, called the FRACTURE Index, is comprised of a set of seven variables that include age; BMD T-score, fracture after age 50 years, maternal hip fracture after age 50, weight less than or equal to 125 pounds (57 kg), smoking status, and use of arms to stand up from a chair. The FRACTURE Index was shown to be predictive of hip fracture, as well as vertebral and nonvertebral fractures. In addition, this index was validated using the EPIDOS fracture study. The FRACTURE Index can be used either with or without BMD testing by older postmenopausal women or their clinicians to assess the 5-year risk of hip and other osteoporotic fractures, and could be useful in helping to determine the need for further evaluation and treatment of these women.
Aged↗
Cost-effectiveness of preventing hip fracture in the general female population.
The aims of this study were to determine whether treatments that reduce the incidence of hip fracture might be used in the general female population rather than screening or case-finding strategies. Cost-effectiveness, measured as cost per quality-adjusted life-year (QALY) gained using threshold values for cost-effectiveness of $20,000 or $30,000/QALY gained, was assessed during and after treatment using a computer simulation model applied to the female population of Sweden. The base case assumed a 5-year intervention that reduced the risk of hip fracture by 35% during the treatment period, and an effect that reversed to the pretreatment risk during the next 5 years. Sensitivity analyses included the effects of age, different treatment costs and effectiveness. Cost-effectiveness was critically dependent upon the age and costs of intervention. Reasonable cost-effectiveness was shown even with relatively high intervention costs for women at average risk at the age of 84 years or more. For the cheapest interventions ($63/year) cost-effectiveness could be found from the age of 53 years. Variations in effectiveness (15-50% risk reduction) had marked effects on the age that treatment was worthwhile. We conclude that segments of the apparently healthy population could be advantaged by treatment if efficacy were supported by randomized controlled studies.
Age Factors↗
The burden of osteoporotic fractures: a method for setting intervention thresholds.
The aim of this study was to assess the relationship between morbidity from hip fracture and that from other osteoporotic fractures by age and sex based on the population of Sweden. Osteoporotic fractures were designated as those associated with low bone mineral density (BMD) and those that increased in incidence with age after the age of 50 years. Severity of fractures was weighted according to their morbidity using utility values based on those derived by the National Osteoporosis Foundation. Morbidity from fractures other than hip fracture was converted to hip fracture equivalents according to their disutility weights. Excess morbidity was 3.34 and 4.75 in men and women at the age of 50 years, i.e. the morbidity associated with osteoporotic fractures was 3-5 times that accounted for by hip fracture. Excess morbidity decreased with age to approximately 1.25 between the ages of 85 and 89 years. On the assumption that the age- and sex-specific pattern of fractures due to osteoporosis is similar in different communities, the computation of excess morbidity can be utilized to determine the total morbidity from osteoporotic fractures from knowledge of hip fracture rates alone. Such data can be used to weight probabilities of hip fracture in different countries in order to take into account the morbidity from fractures other than hip fracture, and to modify intervention thresholds based on hip fracture risk alone. If, for example, a 10-year probability of hip fracture of 10% was considered an intervention threshold, this would be exceeded in women with osteoporosis aged 65 years and more, but when weighted for other osteoporotic fractures would be exceeded in all women (and men) with osteoporosis.
Age Distribution↗
Acute and long-term increase in fracture risk after hospitalization for vertebral fracture.
The aims of this study were to determine the magnitude of the increase in risk of further fracture following hospitalization for vertebral fracture, and in particular to determine the time course of this risk. The records of the Swedish Patient Register were examined from 1987 to 1994 to identify all patients who were admitted to hospital for thoracic or lumbar vertebral fractures. Vertebral fractures were characterized as due to high- or low-energy trauma. Patients were followed for subsequent hospitalizations for hip fracture, and for all fractures combined. A Poisson model was used to determine the absolute risk of subsequent nonvertebral fracture and compared with that of the general population. We analyzed 13.4 million hospital admissions from which 28,869 individuals with vertebral fracture were identified, of which 60% were associated with low-energy trauma. There was a marked increase in subsequent incidence of hip and all fractures within the first year following hospitalization for vertebral fracture in both men and women. Thereafter, fracture incidence declined toward, but did not attain, baseline risk. Increased risks were particularly marked in the young. The increase in fracture risk was more marked following low-energy vertebral fracture than in the case of high-energy trauma. We conclude that the high incidence of new fractures within a year of hospitalization for vertebral fractures, irrespective of the degree of trauma involved, indicates that such patients should be preferentially targeted for treatment. It is speculated that short courses of treatment at the time of first vertebral fracture could provide important therapeutic dividends.
Acute Disease↗
Peripubertal moderate exercise increases bone mass in boys but not in girls: a population-based intervention study.
On the basis of cross-sectional studies in elite athletes and longitudinal studies, physical activity in growing children has been suggested to enhance bone mineral acquisition and prevent osteoporosis later in life. The level of exercise in most of these studies is not applicable in a population on a day-to-day basis. The aim of this study was to determine whether moderate increased exercise within the school curriculum from age 12 to 16 years would have anabolic bone effects. In a population-based setting of 40 boys and 40 girls the school curriculum was enhanced to physical education 4 times per week for 3-4 years. Controls were 82 boys and 66 girls who had had physical education twice a week over a corresponding period. Both cases and controls were measured at age 16 years. Bone mineral content (BMC), areal bone mineral density (aBMD), bone size (femoral neck width) and volumetric BMD (vBMD) were measured in total body, spine and femoral neck (FN) by dual-energy X-ray absorptiometry. Data are presented as mean +/- SD. BMC (8 +/- 15%, p = 0.04), aBMD (9 +/- 13%, p = 0.002) and vBMD (9 +/- 15%, p = 0.001) were all higher in FN in the male intervention group compared with controls. FN bone size was no higher in the intervention group than in the controls. In girls, no differences were found when comparing the intervention group with controls. The results remained after adjusting for confounding factors such as weight, height, milk intake and activity after school. In summary, we report that increased bone mass can be achieved in a population-based cohort of boys (but not in girls) by moderate increased physical activity within the school curriculum from age 12 to 16 years. We speculate that the same results can be seen in girls if intervention starts at an earlier age. We conclude that increasing the physical education content of the Swedish school curriculum may improve bone mass in at least peripubertal boys.
Absorptiometry, Photon↗
Prevalent vertebral deformity predicts incident hip though not distal forearm fracture: results from the European Prospective Osteoporosis Study.
The presence of a vertebral deformity increases the risk of subsequent spinal deformities. The aim of this analysis was to determine whether the presence of vertebral deformity predicts incident hip and other limb fractures. Six thousand three hundred and forty-four men and 6788 women aged 50 years and over were recruited from population registers in 31 European centers and followed prospectively for a median of 3 years. All subjects had radiographs performed at baseline and the presence of vertebral deformity was assessed using established morphometric methods. Incident limb fractures which occurred during the follow- up period were ascertained by annual postal questionnaire and confirmed by radiographs, review of medical records and personal interview. During a total of 40348 person-years of follow-up, 138 men and 391 women sustained a limb fracture. Amongst the women, after adjustment for age, prevalent vertebral deformity was a strong predictor of incident hip fracture, (rate ratio (RR) = 4.5; 95% CI 2.1-9.4) and a weak predictor of 'other' limb fractures (RR = 1.6; 95% CI 1.1-2.4), though not distal forearm fracture (RR = 1.0; 95% CI 0.6-1.6). The predictive risk increased with increasing number of prevalent deformities, particularly for subsequent hip fracture: for two or more deformities, RR = 7.2 (95% CI 3.0-17.3). Amongst men, vertebral deformity was not associated with an increased risk of incident limb fracture though there was a nonsignificant trend toward an increased risk of hip fracture with increasing number of deformities. In summary, prevalent radiographic vertebral deformities in women are a strong predictor of hip fracture, and to a lesser extent humerus and 'other' limb fractures; however, they do not predict distal forearm fractures.
Aged↗
Mortality, morbidity, and assessment of fracture risk in male osteoporosis.
Several studies show that for most clinical fractures the mortality is higher in men than in women, also compared with the general population. However, there are still uncertainties whether this is true for the vertebral deformities. There are few studies comparing men and women but there does not seem to be any difference in morbidity between men and women even though data here are scarce. Several of the risk factors that have been identified in women are also important in men. However, there are problems comparing men and women, such as recreational activity, where men have more strenuous activities. The same for alcohol intake and for BMD. Larger studies in men are needed. At present there are no diagnosis or intervention thresholds for men. Indication thresholds should be determined for those who have a high risk of fractures and should be based on a combination of risk factors in which bone mineral density (BMD) is the most important. This review of papers has dealt with women and men within the same study to compare differences or similarities.
Aged↗
Diagnosis of osteoporosis and fracture threshold in men.
This review examines the hypothesis that there are gender differences in the relationship between bone mineral density (BMD) and fracture risk. Prospective studies of spine and hip fracture risk drawn from population samples suggest that the fracture risk increases as BMD decreases in men in the same way as that described in women. Moreover, for any given BMD at the spine, heel, or proximal femur the risk in men is similar to that in women. Although data are limited, prior fragility fractures increase subsequent fracture risks in both men and women. These studies suggest that the same BMD criteria used to diagnose osteoporosis in women can be applied to men.
Absorptiometry, Photon↗
Bone mass changes in weight-loaded and unloaded skeletal regions following a fracture of the hip.
Higher bone mineral density (BMD) has been reported in weight-loaded skeletal regions and lower BMD in unloaded regions in active athletes compared with controls. These discrepancies remain the first decades after cessation of active careers in former athletes with no remaining discrepancies found after age 65 years compared with age- and gender-matched controls. Physical activity is reduced after a hip fracture and BMD decreases in weight-loaded skeletal regions following the injury. If BMD increases in unloaded regions following a fracture of the hip it is not known. A BMD increase in an unloaded region would support the hypothesis of discrepancies in BMD response to physical activity in loaded and unloaded skeletal regions. BMD (g/cm2) was measured longitudinally using dual X-ray absorptiometry (DXA) in 32 women, mean age 77 years (range 57-90) and 12 men, mean age 74 years (range 53-89) with a hip fracture, the upper part of the skull representing an unloaded skeletal region, the arms a partly loaded region, and the femoral neck a weight-loaded region. Measurements (mean) were done in 11 days, 5 months, and 13 months after the hip fracture. Data are presented as mean +/- SEM. BMD increased in the upper part of the skull by 1.9%+/-0.8% the first 5 months and 3.7%+/-0.9% the first 13 months after the fracture (P < 0.05 and P < 0.001, respectively). BMD did not change in the arms but decreased in the nonfractured femoral neck by 4.7%+/-1.8% the first 5 months and 4.5%+/-1.7% the first 13 months after the fracture (both P < 0.01, respectively). In summary, in this longitudinal study, BMD increased in an unloaded skeletal region and decreased in a weight-loaded region following a hip fracture with reduced activity level, suggesting that loaded and unloaded skeletal regions confer different BMD response after changed activity level.
Absorptiometry, Photon↗
Age, gender, and fragility fractures are associated with differences in quantitative ultrasound independent of bone mineral density.
Bone strength is determined by bone mineral density (BMD) and bone structure. Dual-energy X-ray absorptiometry (DXA) measures BMD. Whether quantitative ultrasound (qUS) measures a property of bone distinct from BMD is uncertain. To evaluate this, DXA and qUS were measured in 58 fracture patients and 428 controls. To study the independent effects of age and gender on qUS measurements and control for BMD by study design rather than statistical methods, subgroups from the normative database were created and intentionally matched by the same femoral neck (FN) BMD. Speed of sound (SOS; m/sec), broadband ultrasound attenuation (BUA; dB/MHz), and stiffness index (SI) were then compared in individuals matched by FN BMD but differing in age, gender, and presence or absence of fractures. The results are presented as percentage difference (mean +/- SD). Elderly women with the same FN BMD as young women had 1 +/- 2% lower SOS (p < 0.05), 8 +/- 15% lower SI (p < 0.05), and 4 +/- 9% lower BUA (p = 0.07). Elderly women with the same FN BMD as elderly men had 5 +/- 9% lower BUA (p < 0.05). Elderly men with the same FN BMD as young men had 1 +/- 2% lower SOS (p = 0.1), 5 +/- 14% lower SI (p = 0.2), and 1 +/- 9% lower BUA (n.s.). Young women with the same FN BMD as young men had 2 +/- 7% lower BUA (n.s.). Women with fragility fractures had 8 +/- 11% lower BUA (p < 0.001) and 13 +/- 22% lower SI (p < 0.01) than controls with no fractures matched by FN BMD, age, and gender. Men with fragility fractures had 13 +/- 12% lower BUA (p < 0.01) and 16 +/- 19% lower SI (p < 0.05) than controls with no fractures matched by FN BMD, age, and gender. Despite comparable femoral neck BMD, qUS measurements differed according to age, gender, and fracture status, suggesting that qUS may provide additional information independent of femoral neck BMD, such as differences in connectivity or other properties yet to be identified.
Absorptiometry, Photon↗
Bone loss in relation to menopause: a prospective study during 16 years.
This prospective study evaluated bone loss in the peri- and postmenopausal period in 156 women followed from age 48 to 64 years. All women were premenopausal at the start of the study. Areal bone mineral density (g/cm(2)) was measured by single-photon absorptiometry (SPA) of the forearm at the 1 cm level (BMD 1 cm) and the 6 cm level (BMD 6 cm) every second year. Onset of menopause (MP) was determined according to the criteria of the World Health Organization (12 months of amenorrhea and elevated follicle-stimulating hormone). At the end of the study, 125 of 156 women (80%) remained. Bone mineral density (BMD) at age 48 years correlated with BMD at age 64 years within the respective region (r = 0.4-0.5, p < 0.001, respectively). There was no BMD loss in the premenopausal period. BMD loss was accelerated at menopause (MP) independent of chronological age. BMD loss was greater during the first 5 years following MP than during the following 6 years (BMD 1 cm 2.4% per year [1.0%-3.9%] vs. 0.4% per year [-0.3%-1.0%], p < 0.01). The quartile of women with late MP (>53.7 years) had greater bone loss during the first 5 years after MP than the quartile of women with early MP (<50.3 years) (p < 0.001). At age 64 years, BMD was no different when comparing the quartile of women with late MP vs. the quartile of women with early MP. Furthermore, there was no correlation between age at menopause and BMD at the age of 64. In summary, among women still menstruating at age 48 years, there was no measurable BMD loss in the premenopausal period. Independent of chronological age, BMD loss accelerated during MP. Rates of loss were highest in the early postmenopausal period. Independent of age at MP, premenopausal women with low age-specific BMD at age 48 years had an increased risk of sustaining low BMD at age 64 years also.
Female↗
Targeting of hormone replacement therapy immediately after menopause.
The aim of this study was to model the effect of short (3-year) treatments with hormone replacement therapy (HRT) at the time of menopause on the risk of osteoporotic fracture, and to assess the impact of strategies to target high-risk individuals. From the relationship between bone mineral density (BMD) and fracture risk, treatment that increased bone mineral density at the hip by 6% over untreated women would save 35 vertebral, 62 hip, 13 proximal humeral, and 16 forearm fractures per 1000 women. The number needed to treat (NNT) to prevent one of these fractures was 8. The NNT fell modestly by targeting HRT to women with low bone mass or osteoporosis (NNT 6 and 5, respectively). The gains in fractures saved from targeting women with low bone mass or osteoporosis were offset by the requirement for assessment by BMD. Changes in the assumptions about the efficacy of HRT had a modest impact on fractures saved compared with the effect of changing assumptions concerning the offset of effect when treatment was stopped. We conclude that comparatively short courses of HRT might be effectively offered to all suitable women at menopause provided that the effects on bone persist when treatment is stopped.
Bone Density↗
Vertebral deformation in urban Swedish men and women: prevalence based on 797 subjects.
Vertebral fracture-deformation, a common feature of osteoporosis, shows considerable age, sex and geographical variation. We present the prevalence in an urban population of south-west Sweden. Lateral spine radiographs of 797 men and women, age 50-86 years, were evaluated by morphomety. The age-standardized prevalence of subjects with vertebral deformation using the deformation criterion -3 SD was 39 (95%CI 34-43)% in women and 33 (95%CI 28-38)% in men. The prevalence increased with age in both sexes. After adjustment for age, women had a higher prevalence than men, odds ratio 1.4. The proportion of vertebrae with deformation ranged from 2%-11%, increasing with age. The vertebrae most commonly deformed were Th 11, Th 12 and L1.
Age Factors↗
Bo Nilsson--1933-2001.
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History, 20th Century↗
Management of the patient after an osteoporotic fracture: Guidelines for orthopedic surgeons--consensus conference on Treatment of Osteoporosis for Orthopedic Surgeons, Nordic Orthopedic Federation, Tampere, Finland 2000.
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Accidental Falls↗
Bone mineral density in subjects with mild asthma randomised to treatment with inhaled corticosteroids or non-corticosteroid treatment for two years.
BACKGROUND: Inhaled corticosteroids are clearly beneficial for patients with asthma of moderate severity, but the risks and benefits of using them in patients with milder asthma are less clear. We have compared the change in bone mineral density over 2 years in adults with mild asthma randomised to receive an inhaled corticosteroid or non-corticosteroid treatment. METHODS: Subjects with mild asthma (mean forced expiratory volume in one second (FEV(1)) 86% predicted, mean age 35 years, taking beta agonists only) were randomised to receive inhaled budesonide, inhaled beclomethasone dipropionate, or non-corticosteroid treatment for 2 years in a prospective randomised open study in 19 centres in France, New Zealand, Spain, and the UK. The corticosteroid dose was adjusted according to a written self-management plan. The main outcome measure-change in bone mineral density after 6, 12, and 24 months-was measured "blind". Secondary outcomes included lung function, the relation between change in bone density and inhaled steroid dose and change in biochemical markers of bone metabolism. RESULTS: Of 374 subjects randomised, 239 (64%) completed the study and were included in the analysis. The median daily doses of inhaled budesonide (n=87) and beclomethasone (n=74) were 389 microg and 499 microg, respectively. Subjects treated with an inhaled corticosteroid had better asthma control than those in the reference group (n=78). Change in bone mineral density did not differ between the three groups over the 2 years, nor did it correlate with changes in markers of bone metabolism. The mean change in bone mineral density over 2 years in the budesonide, beclomethasone dipropionate, and reference groups was 0.1%, -0.4%, and 0.4% for the lumbar spine and -0.9%, -0.9%, and -0.4% for neck of the femur. Mean daily dose of inhaled steroid was related to reduction in bone mineral density at the lumbar spine but not at the femoral neck. CONCLUSION: In subjects with mild asthma an inhaled corticosteroid provided better asthma control than alternative non-corticosteroid treatment with no difference in change in bone mineral density over 2 years. The relation between dose of inhaled corticosteroid and change in bone density at the lumbar spine may be due to a direct effect of inhaled corticosteroids on bone. Since inhaled steroid dose is also related inversely to lung function, an effect of asthma severity on bone density was also possible.
Administration, Inhalation↗