Summary
Meta-analysis of prospective studies shows that quantitative ultrasound of the heel using validated devices predicts risk of different types of fracture with similar performance across ...different devices and in elderly men and women. These predictions are independent of the risk estimates from hip DXA measures.
Introduction
Clinical utilisation of heel quantitative ultrasound (QUS) depends on its power to predict clinical fractures. This is particularly important in settings that have no access to DXA-derived bone density measurements. We aimed to assess the predictive power of heel QUS for fractures using a meta-analysis approach.
Methods
We conducted an inverse variance random effects meta-analysis of prospective studies with heel QUS measures at baseline and fracture outcomes in their follow-up. Relative risks (RR) per standard deviation (SD) of different QUS parameters (broadband ultrasound attenuation BUA, speed of sound SOS, stiffness index SI, and quantitative ultrasound index QUI) for various fracture outcomes (hip, vertebral, any clinical, any osteoporotic and major osteoporotic fractures) were reported based on study questions.
Results
Twenty-one studies including 55,164 women and 13,742 men were included in the meta-analysis with a total follow-up of 279,124 person-years. All four QUS parameters were associated with risk of different fracture. For instance, RR of hip fracture for 1 SD decrease of BUA was 1.69 (95% CI 1.43–2.00), SOS was 1.96 (95% CI 1.64–2.34), SI was 2.26 (95%CI 1.71–2.99) and QUI was 1.99 (95% CI 1.49–2.67). There was marked heterogeneity among studies on hip and any clinical fractures but no evidence of publication bias amongst them. Validated devices from different manufacturers predicted fracture risks with similar performance (meta-regression
p
values > 0.05 for difference of devices). QUS measures predicted fracture with a similar performance in men and women. Meta-analysis of studies with QUS measures adjusted for hip BMD showed a significant and independent association with fracture risk (RR/SD for BUA = 1.34 95%CI 1.22–1.49).
Conclusions
This study confirms that heel QUS, using validated devices, predicts risk of different fracture outcomes in elderly men and women. Further research is needed for more widespread utilisation of the heel QUS in clinical settings across the world.
Summary
Gaining full benefits from osteoporosis medications requires long-term treatment. Investigating the real-world persistence of women receiving osteoporosis medications in the UK, we found that ...most patients stop treatment within a year. To prevent osteoporotic fragility fractures, long-term treatment persistence must be improved.
Introduction
Persistence with osteoporosis therapies has historically been poor. To treat this chronic and progressive disease, it is essential that patients receive the full benefit of these medications. We estimated persistence and compliance with osteoporosis therapies in a large sample of postmenopausal women in the UK.
Methods
Data were obtained from the Clinical Practice Research Datalink for all women aged 50 years and over or women with early menopause, who received at least one prescription in primary care for any licensed osteoporosis therapy between January 1, 2010 and December 31, 2015. Persistence and compliance at 24 months (primary objective) and at 5 years (exploratory objective) were estimated in three patient cohorts: “All Patients,” “Naïve Patients,” and “Drug-Specific.”
Results
The All Patients cohort included 72,256 women. Persistence with any therapy was 56.1%, 43.6%, 36.4%, and 31.0% at 6, 12, 18, and 24 months, respectively, and 23.2% and 13.1% at 3 years and 5 years, respectively. Patients were generally more persistent and compliant if evaluated from their first exposure to osteoporosis therapy (Naïve Patients cohort). In the drug-specific analysis, 64% of patients receiving denosumab (administered subcutaneously every 6 months) were persistent at 24 months compared with 28% and 23% of those taking oral bisphosphonates and intravenous bisphosphonates, respectively.
Conclusions
Only about one in three patients who received osteoporosis therapy continued to be on treatment after 2 years. There is a need to improve persistence with osteoporosis therapy, especially for high-risk patients
Summary
The relationship between bone quantitative ultrasound (QUS) and fracture risk was estimated in an individual level data meta-analysis of 9 prospective studies of 46,124 individuals and 3018 ...incident fractures. Low QUS is associated with an increase in fracture risk, including hip fracture. The association with osteoporotic fracture decreases with time.
Introduction
The aim of this meta-analysis was to investigate the association between parameters of QUS and risk of fracture.
Methods
In an individual-level analysis, we studied participants in nine prospective cohorts from Asia, Europe and North America. Heel broadband ultrasonic attenuation (BUA dB/MHz) and speed of sound (SOS m/s) were measured at baseline. Fractures during follow-up were collected by self-report and in some cohorts confirmed by radiography. An extension of Poisson regression was used to examine the gradient of risk (GR, hazard ratio per 1 SD decrease) between QUS and fracture risk adjusted for age and time since baseline in each cohort. Interactions between QUS and age and time since baseline were explored.
Results
Baseline measurements were available in 46,124 men and women, mean age 70 years (range 20–100). Three thousand and eighteen osteoporotic fractures (787 hip fractures) occurred during follow-up of 214,000 person-years. The summary GR for osteoporotic fracture was similar for both BUA (1.45, 95 % confidence intervals (CI) 1.40–1.51) and SOS (1.42, 95 % CI 1.36–1.47). For hip fracture, the respective GRs were 1.69 (95 % CI, 1.56–1.82) and 1.60 (95 % CI, 1.48–1.72). However, the GR was significantly higher for both fracture outcomes at lower baseline BUA and SOS (
p
< 0.001). The predictive value of QUS was the same for men and women and for all ages (
p
> 0.20), but the predictive value of both BUA and SOS for osteoporotic fracture decreased with time (
p
= 0.018 and
p
= 0.010, respectively). For example, the GR of BUA for osteoporotic fracture, adjusted for age, was 1.51 (95 % CI 1.42–1.61) at 1 year after baseline, but at 5 years, it was 1.36 (95 % CI 1.27–1.46).
Conclusions
Our results confirm that quantitative ultrasound is an independent predictor of fracture for men and women particularly at low QUS values.
Summary
Fracture-related costs vary by country. A standardized methodology and presentations were proposed to fairly assess the economic burden of osteoporotic fracture. Results indicated substantial ...costs of osteoporotic fractures for pharmacy, hospitalization, emergency care, and outpatient visits in women aged ≥ 50 years in Australia, Germany, South Korea, Spain, and the USA.
Purpose
The objective of this multinational, retrospective matched cohort study was to use a standardized methodology across different healthcare systems to estimate the burden of osteoporotic fracture (OF) in women aged ≥ 50 years in Australia, Germany, South Korea, Spain, and the USA.
Methods
Within each country, healthcare resource utilization and direct costs of care were compared between patients with newly identified OF and a propensity score–matched cohort without OF during follow-up periods of up to 5 years.
Results
Across all five countries, the OF cohort had significantly higher rates and length of inpatient admissions compared with the non-OF cohort. In each country, the adjusted total costs of care ratio between OF and non-OF cohorts were significant. The adjusted cost ratios for pharmacy, inpatient care, emergency care, and outpatient visits were similarly higher in the OF cohort across countries.
Conclusion
The current study demonstrates the substantial economic burden of OF across different countries when compared with matched non-OF patients. The findings would assist stakeholders and policymakers in developing appropriate health policies.
Summary
Conservation of muscle mass is important for fall and fracture prevention but further understanding of the causes of age-related muscle loss is required. This study found a more alkaline diet ...was positively associated with muscle mass in women suggesting a role for dietary acid–base load in muscle loss.
Introduction
Conservation of skeletal muscle is important for preventing falls and fractures but age-related loss of muscle mass occurs even in healthy individuals. However, the mild metabolic acidosis associated with an acidogenic dietary acid–base load could influence loss of muscle mass.
Methods
We investigated the association between fat-free mass (FFM), percentage FFM (FFM%) and fat-free mass index (FFMI, weight/height
2
), measured using dual-energy X-ray absorptiometry in 2,689 women aged 18–79 years from the TwinsUK Study, and dietary acid–base load. Body composition was calculated according to quartile of potential renal acid load and adjusted for age, physical activity, misreporting and smoking habit (FFM, FFMI also for fat mass) and additionally with percentage protein.
Results
Fat-free mass was positively associated with a more alkalinogenic dietary load (comparing quartile 1 vs 4: FFM 0.79 kg
P
< 0.001, FFM% 1.06 % <0.001, FFMI 0.24 kg/m
2
P
= 0.002), and with the ratio of fruits and vegetables to potential acidogenic foods.
Conclusions
We observed a small but significant positive association between a more alkaline diet and muscle mass indexes in healthy women that was independent of age, physical activity and protein intake equating to a scale of effect between a fifth and one half of the observed relationship with 10 years of age. Although protein is important for maintenance of muscle mass, eating fruits and vegetables that supply adequate amounts of potassium and magnesium are also relevant. The results suggest a potential role for diet in the prevention of muscle loss.
Objective To estimate the potential magnitude in unselected patients of the benefits and harms of prolonged dual antiplatelet therapy after acute myocardial infarction seen in selected patients with ...high risk characteristics in trials.Design Observational population based cohort study.Setting PEGASUS-TIMI-54 trial population and CALIBER (ClinicAl research using LInked Bespoke studies and Electronic health Records).Participants 7238 patients who survived a year or more after acute myocardial infarction.Interventions Prolonged dual antiplatelet therapy after acute myocardial infarction.Main outcome measures Recurrent acute myocardial infarction, stroke, or fatal cardiovascular disease. Fatal, severe, or intracranial bleeding.Results 1676/7238 (23.1%) patients met trial inclusion and exclusion criteria (“target” population). Compared with the placebo arm in the trial population, in the target population the median age was 12 years higher, there were more women (48.6% v 24.3%), and there was a substantially higher cumulative three year risk of both the primary (benefit) trial endpoint of recurrent acute myocardial infarction, stroke, or fatal cardiovascular disease (18.8% (95% confidence interval 16.3% to 21.8%) v 9.04%) and the primary (harm) endpoint of fatal, severe, or intracranial bleeding (3.0% (2.0% to 4.4%) v 1.26% (TIMI major bleeding)). Application of intention to treat relative risks from the trial (ticagrelor 60 mg daily arm) to CALIBER’s target population showed an estimated 101 (95% confidence interval 87 to 117) ischaemic events prevented per 10 000 treated per year and an estimated 75 (50 to 110) excess fatal, severe, or intracranial bleeds caused per 10 000 patients treated per year. Generalisation from CALIBER’s target subgroup to all 7238 real world patients who were stable at least one year after acute myocardial infarction showed similar three year risks of ischaemic events (17.2%, 16.0% to 18.5%), with an estimated 92 (86 to 99) events prevented per 10 000 patients treated per year, and similar three year risks of bleeding events (2.3%, 1.8% to 2.9%), with an estimated 58 (45 to 73) events caused per 10 000 patients treated per year.Conclusions This novel use of primary-secondary care linked electronic health records allows characterisation of “healthy trial participant” effects and confirms the potential absolute benefits and harms of dual antiplatelet therapy in representative patients a year or more after acute myocardial infarction.
. Moayyeri A, Luben RN, Wareham NJ, Khaw K‐T (University of Cambridge, Cambridge; Institute of Metabolic Science; Cambridge, UK). Body fat mass is a predictor of risk of osteoporotic fractures in ...women but not in men: a prospective population study. J Intern Med 2012; 271: 472–480.
Objectives. Obesity has generally been associated with higher bone density and lower fracture risk. However, weight‐related indices of obesity may be related differently to health end‐points, compared with fat‐related indices (such as body fat distribution and fat mass), as they may capture different dimensions of obesity and the associated biological effects. The aim of this study was to examine the association between percentage body fat (%BF) and prospective risk of fracture.
Methods. The European Prospective Investigation into Cancer (EPIC) in Norfolk was a population‐based prospective study. A total of 14 789 participants (6470 men, aged 42–82 years at baseline) were included. The main outcome measures were quantitative ultrasound of the heel and incident hip and any osteoporotic fractures.
Results. A total of 556 participants suffered a fracture (184 hip fractures) during 8.7 ± 0.8 years of follow‐up. Risk of hip fracture decreased linearly with increasing %BF amongst women but not men. After adjustment for age, history of fracture, height, smoking, alcohol intake and heel broadband ultrasound attenuation (BUA), the hazard ratio (95% CI) for a 10% higher %BF on risk of hip fracture was 0.56 (0.39–0.79) in women and 0.92 (0.39–2.21) in men. The effect size in women was approximately equivalent to a difference of 5 years in age or 1 standard deviation (17 dB MHz−1) increased BUA. A nonlinear negative association was also observed between %BF and risk of ‘any type of fracture’ amongst women but not men.
Conclusions. The %BF appears to predict hip fracture risk in women with an effect size comparable to that of bone density as measured by heel ultrasound. This effect was not observed in men. Understanding the differences in relationships between different indices of obesity as well as sex differences may help to elucidate the metabolic and other underlying mechanisms involved in bone health and fracture risk.
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