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J M Pritchard, A Papaioannou,
C Tomowich,
L M Giangregorio,
S A Atkinson,
K A Beattie,
J D Adachi,
J Debeer,
M Winemaker,
V Avram,
H P Schwarcz
[show abstract]
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ABSTRACT: PURPOSE: The purpose of this study was to determine whether trabecular bone mineralization differed in adults with type 2 diabetes compared to adults without type 2 diabetes. METHODS: Proximal femur specimens were obtained following a total hip replacement procedure from men and women≥65years of age with and without type 2 diabetes. A scanning electron microscope was used for quantitative backscattered electron imaging (qBEI) analysis of trabecular bone samples from the femoral neck. Gray scale images (pixel size=5.6μm2) were uploaded to ImageJ software and gray level (GL) values were converted to calcium concentrations (weight [wt] % calcium [Ca]) using data obtained with energy dispersive x-ray spectrometry. The following bone mineralization density distribution (BMDD) outcomes were collected: the weighted mean bone calcium concentration (CaMEAN), the most frequently occurring bone calcium concentration (CaPEAK) and mineralization heterogeneity (CaWIDTH). Differences between groups were assessed using the Student's t-test for normally distributed data and Mann-Whitney U-test for non-normally distributed data. An alpha value of<0.05 was considered significant. RESULTS: Thirty-five Caucasian participants were recruited (mean±standard deviation [SD] age, 75.5±6.5years): 14 adults with type 2 diabetes (years since type 2 diabetes diagnosis, 13.5±7.4years) and 21 adults without type 2 diabetes. In the adults with type 2 diabetes, bone CaMEAN was 4.9% greater (20.36±0.98 wt % Ca versus 19.40±1.07 wt % Ca, p=0.015) and CaWIDTH was 9.4% lower (median [interquartile range] 3.55 [2.99-4.12] wt % Ca versus 3.95±0.71 wt % Ca, p<0.001) compared to controls. There was no between-group difference in CaPEAK (21.12±0.97 wt % Ca for type 2 diabetes versus 20.44±1.30 wt % Ca for controls, p=0.121). CONCLUSION: The combination of elevated mean calcium concentration in bone and lower mineralization heterogeneity in adults with type 2 diabetes may have deleterious effects on the biomechanical properties of bone. These microscopic alterations in bone mineralization, which may be mediated by suppressed bone remodeling, further elucidate higher fracture risk in adults with type 2 diabetes.
Bone 01/2013; · 4.02 Impact Factor
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ABSTRACT: A large Canadian cohort was studied over 10 years to see if proton pump inhibitor (PPI) use increased the risk of sustaining a fragility fracture. We found an increased risk of fracture in individuals who used PPIs. The risk remained after controlling for other known fracture risk factors. INTRODUCTION: Multiple retrospective studies have linked proton pump inhibitor use with increased risk of fragility fracture. We prospectively studied the association between PPI use and fracture in a large cohort over a 10-year period while controlling for known fracture risk factors. METHODS: We studied 9,423 participants in the Canadian Multicenter Osteoporosis Study. The cohort was formed in 1995-1997 and followed for 10 years with monitoring for incident nontraumatic fracture and PPI use. Cox regression analyses were used to assess the association between PPI use and incident fracture risk. RESULTS: PPI use, coded as a time-dependent variable, was associated with a shorter time to first nontraumatic fracture, hazard ratio (HR) = 1.75 (95 % confidence interval (CI) 1.41-2.17, p < 0.001). After controlling for multiple risk factors, including femoral neck bone density, the association remained significant, HR = 1.40 (95 % CI 1.11-1.77, p = 0.004). Similar results were obtained after controlling for bisphosphonate use, using PPI "ever" use, or when the outcome was restricted to hip fracture. CONCLUSIONS: In this large prospective population-based cohort study, we found an association between PPI use and increased risk of fragility fracture. Although the increased risk found was modest, this finding is important, given the high prevalence of PPI use and the excess morbidity and mortality associated with osteoporosis-related fractures.
Osteoporosis International 08/2012; · 4.58 Impact Factor
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R B Hopkins,
J E Tarride,
W D Leslie,
C Metge,
L M Lix,
S Morin,
G Finlayson,
M Azimaee,
E Pullenayegum,
R Goeree,
J D Adachi, A Papaioannou,
L Thabane
[show abstract]
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ABSTRACT: Based on a population age 50+, significant excess costs relative to matched controls exist for patients with incident fractures that are similar in relative magnitude to other chronic diseases such as stroke or heart disease. Prevalent fractures also have significant excess costs that are similar in relative magnitude to asthma/chronic obstructive pulmonary disease. INTRODUCTION: Cost of illness studies for osteoporosis that only include incident fractures may ignore the long-term cost of prevalent fractures and primary preventive care. We estimated the excess costs for patients with incident fractures, prevalent fractures, and nonfracture osteoporosis relative to matched controls. METHODS: Men and women age 50+ were selected from administrative records in the province of Manitoba, Canada for the fiscal year 2007-2008. Three types of cases were identified: (1) patients with incident fractures in the current year (2007-2008), (2) patients with prevalent fractures in previous years (1995-2007), and (3) nonfracture osteoporosis patients identified by specific pharmacotherapy or low bone mineral density. Excess resource utilization and costs were estimated by subtracting control means from case means. RESULTS: Seventy-three percent of provincial population age 50+ (52 % of all men and 91 % of all women) were included (121,937 cases, 162,171 controls). There were 3,776 cases with incident fracture (1,273 men and 2,503 women), 43,406 cases with prevalent fractures (15,784 men and 27,622 women) and 74,755 nonfracture osteoporosis cases (7,705 men and 67,050 women). All incident fractures had significant excess costs. Incident hip fractures had the highest excess cost: men $44,963 (95 % CI: $38,498-51,428) and women $45,715 (95 % CI: $36,998-54,433). Prevalent fractures (other than miscellaneous or wrist fractures) also had significant excess costs. No significant excess costs existed for nonfracture osteoporosis. CONCLUSION: Significant excess costs exist for patients with incident fractures and with prevalent hip, vertebral, humerus, multiple, and traumatic fractures. Ignoring prevalent fractures underestimate the true cost of osteoporosis.
Osteoporosis International 05/2012; · 4.58 Impact Factor
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L.-A. Fraser,
G. Ioannidis,
J. D. Adachi,
L. Pickard,
S. M. Kaiser,
J. Prior,
J. P. Brown,
D. A. Hanley,
W. P. Olszynski,
T. Anastassiades,
S. Jamal,
R. Josse,
D. Goltzman, A. Papaioannou,
the CaMos Research Group
[show abstract]
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ABSTRACT: SummaryCanadian women over 50years old were studied over a 10-year period to see if those who sustained a fracture (caused by minimal
trauma) were receiving the recommended osteoporosis therapy. We found that approximately half of these women were not being
treated, indicating a significant care gap in osteoporosis treatment.
IntroductionPrevalent fragility fracture strongly predicts future fracture. Previous studies have indicated that women with fragility
fractures are not receiving the indicated treatment. We aimed to describe post fracture care in Canadian women using a large,
population-based prospective cohort that began in 1995–1997.
MethodsWe followed 5,566 women over 50years of age from across Canada over a period of 10years in the Canadian Multicentre Osteoporosis
Study. Information on medication use and incident clinical fragility fractures was obtained during a yearly questionnaire
or interview and fractures were confirmed by radiographic/medical reports.
ResultsOver the 10-year study period, 42–56% of women with yearly incident clinical fragility fractures were not treated with an
osteoporosis medication. During year1 of the study, 22% of the women who had experienced a fragility fracture were on treatment
with a bisphosphonate and 26% were on hormone therapy (HT). We were not able to differentiate HT use for menopause symptoms
vs osteoporosis. Use of bisphosphonate therapy increased over time; odds ratio (OR) for use at year10 compared to use at
year1 was 3.65 (95% confidence interval (CI) 1.83–7.26). In contrast, HT use declined, with an OR of 0.07 (95%CI 0.02–0.24)
at year10 compared to year1 of the study.
ConclusionIn a large population-based cohort study, we found a therapeutic care gap in women with osteoporosis and fragility fractures.
Although bisphosphonate therapy usage improved over time, a substantial gap remains.
KeywordsBisphosphonates–Care gap–Fragility fracture–Osteoporosis–Postmenopausal women
Osteoporosis International 04/2012; 22(3):789-796. · 4.58 Impact Factor
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A. Papaioannou,
C. C. Kennedy,
A. Cranney,
G. Hawker,
J. P. Brown,
S. M. Kaiser,
W. D. Leslie,
C. J. M. O’Brien,
A. M. Sawka,
A. Khan,
K. Siminoski,
G. Tarulli,
D. Webster,
J. McGowan,
J. D. Adachi
[show abstract]
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ABSTRACT: SummaryIn this systematic review, we summarize risk factors for low bone mineral density and bone loss in healthy men age 50years
or older. Consistent risk factors were: age, smoking, low weight, physical/functional limitations, and previous fracture.
Data specific to men has clinical and policy implications.
IntroductionOsteoporosis is a significant health care problem in men as well as women, yet the majority of evidence on diagnosis and management
of osteoporosis is focused on postmenopausal women. The objective of this systematic review is to examine risk factors for
low bone mineral density (BMD) and bone loss in healthy men age 50years or older.
Materials and methodsA systematic search for observational studies was conducted in MEDLINE, Cochrane Database of Systematic Reviews, DARE, CENTRAL,
CINAHL and Embase, Health STAR. The three main search concepts were bone density, densitometry, and risk factors. Trained
reviewers assessed articles using a priori criteria.
ResultsOf 642 screened abstracts, 299 articles required a full review, and 25 remained in the final assessment. Consistent risk factors
for low BMD/bone loss were: advancing age, smoking, and low weight/weight loss. Although less evidence was available, physical/functional
limitations and prevalent fracture (after age 50) were also associated with low BMD/bone loss. The evidence was inconsistent
or weak for physical activity, alcohol consumption, calcium intake, muscle strength, family history of fracture/osteoporosis,
and height/height loss.
ConclusionIn this systematic review, we identified several risk factors for low BMD/bone loss in men that are measurable in primary
practice.
Osteoporosis International 04/2012; 20(4):507-518. · 4.58 Impact Factor
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ABSTRACT: To update the 1993 burden of illness of osteoporosis in Canada, administrative and community data were used to calculate the 2010 costs of osteoporosis at $2.3 billion in Canada or 1.3% of Canada's healthcare expenditures. Prevention of fractures in high-risk individuals is key to decrease the financial burden of osteoporosis. INTRODUCTION: Since the 1996 publication of the burden of osteoporosis in 1993 in Canada, the population has aged and the management of osteoporosis has changed. The study purpose was to estimate the current burden of illness due to osteoporosis in Canadians aged 50 and over. METHODS: Analyses were conducted using five national administrative databases from the Canadian Institute for Health Information for the fiscal-year ending March 31 2008 (FY 2007/2008). Gaps in national data were supplemented by provincial and community data extrapolated to national levels. Osteoporosis-related fractures were identified using a combination of most responsible diagnosis at discharge and intervention codes. Fractures associated with severe trauma codes were excluded. Costs, expressed in 2010 dollars, were calculated for osteoporosis-related hospitalizations, emergency care, same day surgeries, rehabilitation, continuing care, homecare, long-term care, prescription drugs, physician visits, and productivity losses. Sensitivity analyses were conducted to measure the impact on the results of key assumptions. RESULTS: Osteoporosis-related fractures were responsible for 57,413 acute care admissions and 832,594 hospitalized days in FY 2007/2008. Acute care costs were estimated at $1.2 billion. When outpatient care, prescription drugs, and indirect costs were added, the overall yearly cost of osteoporosis was over $2.3 billion for the base case analysis and as much as $3.9 billion if a proportion of Canadians were assumed to be living in long-term care facilities due to osteoporosis. CONCLUSIONS: Osteoporosis is a chronic disease that affects a large segment of the adult population and results in a substantial economic burden to the Canadian society.
Osteoporosis International 03/2012; · 4.58 Impact Factor
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S B Jaglal,
O S Donescu,
V Bansod,
J Laprade,
K Thorpe,
G Hawker,
S R Majumdar,
L Meadows,
S M Cadarette, A Papaioannou,
M Kloseck,
D Beaton,
E Bogoch,
M Zwarenstein
[show abstract]
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ABSTRACT: We conducted a cluster randomized trial evaluating the effect of a centralized coordinator who identifies and follows up with fracture patients and their primary care physicians about osteoporosis. Compared with controls, intervention patients were five times more likely to receive BMD testing and two times more likely to receive appropriate management.
To determine if a centralized coordinator who follows up with fracture patients and their primary care physicians by telephone and mail (intervention) will increase the proportion of patients who receive appropriate post-fracture osteoporosis management, compared to simple fall prevention advice (attention control).
A cluster randomized controlled trial was conducted in small community hospitals in the province of Ontario, Canada. Hospitals that treated between 60 and 340 fracture patients per year were eligible. Patients 40 years and older presenting with a low trauma fracture were identified from Emergency Department records and enrolled in the trial. The primary outcome was 'appropriate' management, defined as a normal bone mineral density (BMD) test or taking osteoporosis medications.
Thirty-six hospitals were randomized to either intervention or control and 130 intervention and 137 control subjects completed the study. The mean age of participants was 65 ± 12 years and 69% were female. The intervention increased the proportion of patients who received appropriate management within 6 months of fracture; 45% in the intervention group compared with 26% in the control group (absolute difference of 19%; adjusted OR, 2.3; 95% CI, 1.3-4.1). The proportion who had a BMD test scheduled or performed was much higher with 57% of intervention patients compared with 21% of controls (absolute difference of 36%; adjusted OR, 4.8; 95% CI, 3.0-7.0).
A centralized osteoporosis coordinator is effective in improving the quality of osteoporosis care in smaller communities that do not have on-site coordinators or direct access to osteoporosis specialists.
Osteoporosis International 07/2011; 23(1):87-95. · 4.58 Impact Factor
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ABSTRACT: It is not clear whether ankle fractures predict future osteoporotic fractures in women, and whether diabetes influences this relationship. We found that a prior ankle fracture does not predict subsequent osteoporotic fractures in women with or without diabetes.
We aimed to determine: (1) whether a prior ankle fracture was a risk factor for a subsequent major osteoporotic fracture in older women; (2) whether this risk was modified by the presence of diabetes; (3) the risk factors for ankle fracture in older women.
We identified 3,054 women age 50 years and older with diabetes and 9,151 matched controls using the Manitoba Bone Density Program database. Multivariable regression models were used to examine factors associated with prior ankle fracture, and the importance of prior ankle fracture as a predictor of subsequent major osteoporotic fracture during a mean 4.8 years of observation.
A prior ankle fracture was not a significant predictor of subsequent major osteoporotic fracture for women with diabetes (hazard ratio [HR] 1.13; 95% confidence interval [CI], 0.68-1.83; p = 0.623) or women without diabetes (HR 1.16; 95% CI, 0.79-1.71; p = 0.460), and there was no interaction between diabetes and ankle fracture after pooling all women in the cohort (p = 0.971). The presence of diabetes was not independently associated with prior ankle fracture (adjusted odds ratio [OR] 1.14 [95% CI, 0.93-1.38], p = 0.200), whereas higher body mass index (adjusted OR 1.04 per standard deviation increase [95% CI, 1.03-1.06], p < 0.001), previous major osteoporotic fracture (adjusted OR 1.40 [95% CI, 1.13-1.75], p = 0.002), and multiple comorbidities (>6 ambulatory diagnostic groups) (adjusted OR 1.81 [95% CI, 1.40-2.36], p < 0.001) were related to prior ankle fracture.
Ankle fracture was not a significant predictor of major osteoporotic fracture in women, and a diagnosis of diabetes did not influence the relationship.
Osteoporosis International 05/2011; 23(3):957-62. · 4.58 Impact Factor
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[show abstract]
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ABSTRACT: In Canada in 2008, based on current rates of fracture and mortality, a woman or man at age 50 years will have a projected lifetime risk of fracture of 12.1% and 4.6%, respectively, and 8.9% and 6.7% after incorporating declining rates of hip fracture and increases in longevity.
In 1989, the lifetime risk of hip fractures in Canada was 14.0% (women) and 5.2% (men). Since then, there have been changes in rates of hip fracture and increased longevity. We update these estimates to 2008 adjusted for these trends, and in addition, we estimated the lifetime risk of first hip fracture.
We used national administrative data from fiscal year April 1, 2007 to March 31, 2008 to identify all hip fractures in Canada. We estimated the crude lifetime risk of hip fracture for age 50 years to end of life using life tables. We projected lifetime risk incorporating national trends in hip fracture and increased longevity from Poisson regressions. Finally, we removed the percentage of second hip fractures to estimate the lifetime risk of first hip fracture.
From April 1, 2007 to March 31, 2008, there were 21,687 hip fractures, 15,742 (72.6%) in women and 5,945 (27.4%) in men. For women and men, the crude lifetime risk was 12.1% (95%CI, 12.1, 12.2%) and 4.6% (95%CI, 4.5, 4.7%), respectively. When trends in mortality and hip fractures were both incorporated, the lifetime risk of hip fracture were 8.9% (95%CI, 2.3, 15.4%) and 6.7% (95%CI, 1.2, 12.2%). The lifetime risks for first hip fracture were 7.3% (95%CI, 0.8, 13.9%) and 6.2% (95%CI, 0.7, 11.7%).
The lifetime risk of hip fracture has fallen from 1989 to 2008 for women and men. Adjustments for trends in mortality and rates of hip fracture with removing second fractures produced non-significant differences in estimates.
Osteoporosis International 05/2011; 23(3):921-7. · 4.58 Impact Factor
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L-A Fraser,
G Ioannidis,
J D Adachi,
L Pickard,
S M Kaiser,
J Prior,
J P Brown,
D A Hanley,
W P Olszynski,
T Anastassiades,
S Jamal,
R Josse,
D Goltzman, A Papaioannou
[show abstract]
[hide abstract]
ABSTRACT: Canadian women over 50 years old were studied over a 10-year period to see if those who sustained a fracture (caused by minimal trauma) were receiving the recommended osteoporosis therapy. We found that approximately half of these women were not being treated, indicating a significant care gap in osteoporosis treatment.
Prevalent fragility fracture strongly predicts future fracture. Previous studies have indicated that women with fragility fractures are not receiving the indicated treatment. We aimed to describe post fracture care in Canadian women using a large, population-based prospective cohort that began in 1995-1997.
We followed 5,566 women over 50 years of age from across Canada over a period of 10 years in the Canadian Multicentre Osteoporosis Study. Information on medication use and incident clinical fragility fractures was obtained during a yearly questionnaire or interview and fractures were confirmed by radiographic/medical reports.
Over the 10-year study period, 42-56% of women with yearly incident clinical fragility fractures were not treated with an osteoporosis medication. During year 1 of the study, 22% of the women who had experienced a fragility fracture were on treatment with a bisphosphonate and 26% were on hormone therapy (HT). We were not able to differentiate HT use for menopause symptoms vs osteoporosis. Use of bisphosphonate therapy increased over time; odds ratio (OR) for use at year 10 compared to use at year 1 was 3.65 (95% confidence interval (CI) 1.83-7.26). In contrast, HT use declined, with an OR of 0.07 (95%CI 0.02-0.24) at year 10 compared to year 1 of the study.
In a large population-based cohort study, we found a therapeutic care gap in women with osteoporosis and fragility fractures. Although bisphosphonate therapy usage improved over time, a substantial gap remains.
Osteoporosis International 03/2011; 22(3):789-96. · 4.58 Impact Factor
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L-A Fraser,
L Langsetmo,
C Berger,
G Ioannidis,
D Goltzman,
J D Adachi, A Papaioannou,
R Josse,
C S Kovacs,
W P Olszynski, [......],
S M Kaiser,
J Prior,
S Jamal,
N Kreiger,
J P Brown,
H Johansson,
A Oden,
E McCloskey,
J A Kanis,
W D Leslie
[show abstract]
[hide abstract]
ABSTRACT: A new Canadian WHO fracture risk assessment (FRAX®) tool to predict 10-year fracture probability was compared with observed 10-year fracture outcomes in a large Canadian population-based study (CaMos). The Canadian FRAX tool showed good calibration and discrimination for both hip and major osteoporotic fractures.
The purpose of this study was to validate a new Canadian WHO fracture risk assessment (FRAX®) tool in a prospective, population-based cohort, the Canadian Multicentre Osteoporosis Study (CaMos).
A FRAX tool calibrated to the Canadian population was developed by the WHO Collaborating Centre for Metabolic Bone Diseases using national hip fracture and mortality data. Ten-year FRAX probabilities with and without bone mineral density (BMD) were derived for CaMos women (N = 4,778) and men (N = 1,919) and compared with observed fracture outcomes to 10 years (Kaplan-Meier method). Cox proportional hazard models were used to investigate the contribution of individual FRAX variables.
Mean overall 10-year FRAX probability with BMD for major osteoporotic fractures was not significantly different from the observed value in men [predicted 5.4% vs. observed 6.4% (95%CI 5.2-7.5%)] and only slightly lower in women [predicted 10.8% vs. observed 12.0% (95%CI 11.0-12.9%)]. FRAX was well calibrated for hip fracture assessment in women [predicted 2.7% vs. observed 2.7% (95%CI 2.2-3.2%)] but underestimated risk in men [predicted 1.3% vs. observed 2.4% (95%CI 1.7-3.1%)]. FRAX with BMD showed better fracture discrimination than FRAX without BMD or BMD alone. Age, body mass index, prior fragility fracture and femoral neck BMD were significant independent predictors of major osteoporotic fractures; sex, age, prior fragility fracture and femoral neck BMD were significant independent predictors of hip fractures.
The Canadian FRAX tool provides predictions consistent with observed fracture rates in Canadian women and men, thereby providing a valuable tool for Canadian clinicians assessing patients at risk of fracture.
Osteoporosis International 03/2011; 22(3):829-37. · 4.58 Impact Factor
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ABSTRACT: Bone morbidity associated with antineoplastic treatment is a significant health concern for postmenopausal breast cancer patients. Trials have demonstrated that adjuvant therapy with an Aromatase Inhibitor is associated with an increase in musculoskeletal disorders and bone fractures. The objective of this study was to utilize Peripheral Quantitative Computed Tomography (pQCT) to assess in vivo trabecular and cortical volumetric bone at peripheral skeletal sites in healthy postmenopausal women and breast cancer patients prescribed Anastrozole. Fifty-eight women were recruited for this study: 27 breast cancer patients and 31 healthy control participants. pQCT measurements were taken at distal and diaphyseal sites of the radius and tibia using a Stratec XCT-2000 pQCT scanner. Bone measurement values for total density and total content at the 4% radius; total and cortical content as well as cortical density at the 20% radius; total density at the 4% tibia; and cortical density at the 38% tibia were found to be significantly lower in breast cancer patients. Moreover, the duration of time on Anastrozole showed a significant negative correlation with the following measurements: total content at the 4% radius (r=-0.36, p<0.01); total content (r=-0.33, p<0.05), cortical content (r=-0.34, p<0.05) and cortical density (r=-0.44, p<0.01) at the 20% radius; as well as cortical density (r=-0.39, p<0.01) and cortical content (r=-0.27, p<0.05) at the 38% tibia. Overall, the breast cancer patients demonstrated significantly lower values for volumetric bone density and content at the radius and tibia compared with healthy postmenopausal women. Furthermore, this novel study found adverse effects from Anastrozole treatment primarily in cortical bone.
Bone 02/2011; 48(2):218-24. · 4.02 Impact Factor
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ABSTRACT: In the last decade, there have been a number of action plans published to highlight the importance of preventing osteoporosis and related fractures. In the province of Ontario Canada, the Ministry of Health provided funding for the Ontario Osteoporosis Strategy. The goal is to reduce morbidity, mortality, and costs from osteoporosis and related fractures through an integrated and comprehensive approach aimed at health promotion and disease management. This paper describes the components of the Ontario Osteoporosis Strategy and progress on implementation efforts as of March 2009. There are five main components: health promotion; bone mineral density testing, access, and quality; postfracture care; professional education; and research and evaluation. Responsibility for implementation of the initiatives within the components is shared across a number of professional and patient organizations and academic teaching hospitals with osteoporosis researchers. The lessons learned from each phase of the development, implementation, and evaluation of the Ontario Osteoporosis Strategy provides a tremendous opportunity to inform other jurisdictions embarking on implementing similar large-scale bone health initiatives.
Osteoporosis International 03/2010; 21(6):903-8. · 4.58 Impact Factor
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A K O Wong,
K A Beattie,
P D Emond,
D Inglis,
J Duryea,
A Doan,
G Ioannidis,
C E Webber,
J O'Neill,
J de Beer,
J D Adachi, A Papaioannou
[show abstract]
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ABSTRACT: To determine the ability of radiographic bone texture (BTX) parameters to quantify subchondral tibia sclerosis and to examine clinical relevance for assessing osteoarthritis (OA) progression. We examined the relationship between BTX parameters and each of (1) location-specific joint space width (JSW) [JSW(x)] and minimum JSW (mJSW) of the affected compartment, and (2) knee alignment (KA) angle in knee radiographs of participants undergoing total knee arthroplasty (TKA).
Digitized fixed-flexion knee radiographs were analyzed for run-length and topological BTX parameters in a subchondral region using an algorithm. Medial JSW(x) was computed at x=0.200, 0.225, 0.250 and 0.275 according to a coordinate system defined by anatomic landmarks. mJSW was determined for medial and lateral compartment lesions. KA angles were determined from radiographs using an anatomic landmark-guided algorithm. JSW measures and the magnitude of knee malalignment were each correlated with BTX parameters. Reproducibility of BTX parameters was measured by root-mean square coefficients of variation (RMSCV%).
Run-length BTX parameters were highly reproducible (RMSCV%<1%) while topological parameters showed poorer reproducibility (>5%). In TKA participants (17 women, 13 men; age: 66+/-9 years; body mass index (BMI): 31+/-6 kg m(-2); WOMAC: 41.5+/-16.1; Kellgren-Lawrence score mode: 4), reduced trabecular spacing (Tb.Sp) and increased free ends (FE) were correlated with decreased JSW after accounting for BMI, gender and knee malalignment. These relationships were dependent on site of JSW measurement.
High reproducibility in quantifying bone sclerosis using Tb.Sp and its significant relationship with JSW demonstrated potential for assessing OA progression. Increased trabecular FE and reduced porosity observed with smaller JSW suggest collapsing subchondral bone or trabecular plate perforation in advanced knee OA.
Osteoarthritis and Cartilage 05/2009; 17(11):1453-60. · 3.90 Impact Factor
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ABSTRACT: SAUMMARY: Using a Markov state-transition model, we estimated fractures averted with risedronate using two different types of clinical efficacy data. Summary data, as opposed to individual patient data (IPD), underestimated the number of fractures averted when applied in a specified high risk population. The choice of clinical efficacy data is an important consideration in health economic models evaluating osteoporosis therapies.
This paper contrasts fracture reduction estimates for risedronate utilizing efficacy data from two approaches to meta-analysis: summary data versus individual patient data. We also examined differences in fracture reduction explained by varied cohort selection, especially the inclusion of low- versus high-risk populations.
Using a Markov state-transition model, we compared fractures averted over 3 years in a hypothetical cohort by inputting fracture risk reduction estimates (risedronate versus placebo) from two data sources (summary data versus IPD). The cohort consisted of 100,000 Canadian women, age > or =65 years with osteoporosis (WHO criteria T-score < or = -2.5) and prevalent morphometric vertebral fracture.
Non-vertebral fractures averted with risedronate were: 3,571 and 6,584 per 100,000 women for summary data and IPD, respectively. For vertebral fractures, the numbers were 8,552 and 10,127. When IPD versus summary data was used, an additional 3,013 more non-vertebral fractures and 1,575 vertebral fractures were averted.
Relative risk estimates from IPD analyses were the best choice for modelling fracture outcomes when applied in a specified high-risk population. In addition to superior statistical methodology, they utilized RCT cohorts that are more representative of higher risk patients requiring treatment (osteoporotic women > or =65 years with a prevalent vertebral fracture).
Osteoporosis International 03/2009; 20(10):1785-93. · 4.58 Impact Factor
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ABSTRACT: Fractures in long-term care (LTC) residents have substantial economic and human costs. Osteoporosis management in residents with fractures or osteoporosis is low, and certain subgroups are less likely to receive therapy, e.g., those with >5 comorbidities, dementia, and wheelchair use. Many LTC residents who are at risk of fracture are not receiving optimal osteoporosis management.
The objective of this study was to describe the prevalence and predictors of osteoporosis management among LTC residents with osteoporosis or fractures.
In a retrospective study, LTC residents of 17 facilities in Ontario and Manitoba, Canada were investigated. The participants were 65+ years old with osteoporosis, history of hip fracture, or recent fracture. Comprehensive assessments were conducted by trained nurse assessors between June 2005 and June 2006 using a standardized instrument, known as the Resident Assessment Instrument 2.0.
Among residents (n = 525) with osteoporosis or fractures, 177 (34%) had had a recent fall. Bisphosphonate use was reported in 199 (38%) residents, calcitonin use in six (1%), and raloxifene use in six (1%). Calcium and vitamin D supplementation were reported in 140 (27%) residents. Fifty-four (10.3%) residents were on a bisphosphonate but were not taking vitamin D or multivitamin. Variables negatively associated with osteoporosis therapy [OR (95% CI)]: six or more comorbidities [0.46 (0.28-0.77), p = 0.028], wheelchair use [0.62 (0.40-0.95), p = 0.003], cognitive impairment [0.71 (0.55-0.92), p = 0.009], depression [0.54 (0.34-0.87), p = 0.01], swallowing difficulties [0.99 (0.988-0.999), p = 0.034] or Manitoba residence [0.47 (0.28-0.78), p = 0.004]. Prescription of 10+ medications was positively associated with therapy [3.34 (2.32-4.84), p < 0.001].
Osteoporosis management is not optimal among residents at risk of future fracture. Identifying at-risk subgroups of residents that are not receiving therapy may facilitate closing the osteoporosis care gap.
Osteoporosis International 02/2009; 20(9):1471-8. · 4.58 Impact Factor
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ABSTRACT: Based on a systematic review of the literature, only low body weight and menopausal status can be considered with confidence, as important risk factors for low BMD in healthy 40-60 year old women. The use of body weight to identify high risk women may reduce unnecessary BMD testing in this age group.
BMD testing of perimenopausal women is increasing but may be unnecessary as fracture risk is low. Appropriate assessment among younger women requires identification of risk factors for low BMD specific to this population.
We conducted a systematic literature review of risk factors for low BMD in healthy women aged 40-60 years. Articles were retrieved from six databases and reviewed for eligibility and methodological quality. A grade for overall strength of evidence for each risk factor was assigned.
There was good evidence that low body weight and post-menopausal status are risk factors for low BMD. There was good or fair evidence that alcohol and caffeine intake, and reproductive history are not risk factors. There was inconsistent or insufficient evidence for the effect of calcium intake, physical activity, smoking, age at menarche, history of amenorrhea, family history of OP, race and current age on BMD.
Based on current evidence in Caucasians, we suggest that, in healthy women aged 40-60 years, only those with a low body weight (< 70 kg) be selected for BMD testing. Further research is necessary to determine optimal race-specific discriminatory weight cut-offs and to evaluate the risk factors for which there was inconclusive evidence.
Osteoporosis International 01/2009; 20(1):1-21. · 4.58 Impact Factor
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ABSTRACT: To explore the perceptions of patients who have sustained a fragility fracture regarding their future fracture risk and the beliefs underlying their perceptions.
Patients with fragility fracture participated in a telephone interview. Quantitative and qualitative methods were used to characterize patient characteristics and perspectives of future fracture risk. Content analysis of qualitative statements was independently performed by three investigators to identify common themes and contrasting statements, and the findings were discussed to ensure consensus.
Consistent themes were identified among participant responses irrespective of whether they responded "yes", "no" or "unsure" when asked whether they were at increased fracture risk: (1) patients' perception of risk was influenced by whether or not they believed they had osteoporosis, which may be altered by interaction with health care providers; (2) patients' had their own perceptions of their bone health; (3) patients' attributed their risk to their own actions or "carefulness"; and (4) patients' had specific beliefs about their fracture and determinants of fracture risk.
Patients who experience fragility fractures develop perceptions about future fracture risk that are influenced by interactions with health care providers, as well as beliefs about their fracture and beliefs that they can modify their risk.
Health care providers should discuss strategies for fracture prevention with all patients after fragility fracture to ensure that patients understand that participation in preventative behaviours can modify their risk.
Patient Education and Counseling 11/2008; 74(2):213-20. · 2.31 Impact Factor
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ABSTRACT: (1) To investigate the reproducibility of computer-assisted measurements of knee alignment angle (KA) from digitized radiographs of osteoarthritis (OA) participants requiring total knee arthroplasty (TKA) and (2) to determine whether landmark choice affects the precision of KA measurements on radiographs.
Using a custom algorithm, femoral, central, and tibial measurement-guiding rules were interactively placed on digitized posteroanterior fixed-flexion knee radiographs by mouse control and positioned according to different anatomic landmarks. The angle subtended by lines connecting these guiding rules was measured by three readers to assess interobserver, intraobserver and experience-inexperience reproducibility. Test-retest reproducibility was evaluated with duplicate radiographs from a healthy cohort. Reproducibility was assessed using root-mean square coefficients of variation (RMSCV%). The Bland-Altman method was performed on data obtained from varying anatomic landmarks (confidence interval, CI= 95%).
From 16 healthy and 30 TKA participants, reproducibility analyses revealed a high degree of intraobserver (n=38, RMSCV=0.56%), interobserver (n=38, RMSCV=0.72%), test-retest (n=16, RMSCV=0.87%) and experience-inexperience (n=38, RMSCV=0.73%) reproducibility with variances below 1%. Varying the orientation of tibial and femoral rules according to anatomic landmarks produced a difference that exceeded an a priori limit of agreement of -1.11 degrees to +1.67 degrees.
Our custom-designed software provides a robust method for measuring KAs within digitized knee radiographs. Although test-retest analyses were only performed in a healthy cohort, we anticipate a similar degree of reproducibility in an OA sample. A standardized set of anatomic landmarks employed for KA measurement is recommended since arbitrary selection of landmarks resulted in imprecise KA measurement even with a computer-assisted technique.
Osteoarthritis and Cartilage 11/2008; 17(5):579-85. · 3.90 Impact Factor
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ABSTRACT: Nitrates may have beneficial effects on bone. To determine if nitrates were associated with increased bone mineral density (BMD), we conducted a secondary analysis using data from subjects in a prospective study. Subjects reporting nitrate use had increased BMD compared with non-users, confirming that nitrates have positive BMD effects in women and men.
Prior studies suggest positive associations between nitrates and bone.
We used linear regression models, stratified by gender and adjusted for age, weight, and baseline differences, to determine the association between daily nitrate use and BMD among subjects participating in the Canadian Multicentre Osteoporosis Study. All results are reported as annualised percent change in BMD at the hip and spine among nitrate users compared to non-users.
We included 1,419 men (71 reported daily nitrate use) and 2,587 women (97 reported daily nitrate use). Male non-users had decreased hip BMD (-1.3%; 95% confidence interval [95%CI] = -1.6 to -1.1) and increased spine BMD (2.8%; 95%CI = 2.5 to 3.1). Male nitrate users had increased hip BMD (1.4%; 95%CI = 0.1 to 2.8) and spine BMD (4.5%; 95%CI = 3.2 to 5.7). Among women, non-users had decreased hip BMD (-1.9; 95%CI = -2.1 to -1.7) and increased spine BMD (2.1%; 95%CI = 1.9 to 2.4) whilst users had an increase in hip BMD (2.0%; 95%CI = 1.2 to 2.8) and spine BMD (4.1%; 95%CI = 3.4 to 4.9).
Nitrate use is associated with increased BMD at the hip and spine in men and women.
Osteoporosis International 10/2008; 20(5):737-44. · 4.58 Impact Factor
