The prevalence of low bone mineral density in Dutch perimenopausal women: the Eindhoven perimenopausal osteoporosis study

Cost-Effectiveness Analysis of CT-Based Finite Element Modeling for Osteoporosis Screening in Secondary Fracture Prevention: An Early Health Technology Assessment in the Netherlands

Objective. To conduct cost-utility analyses for Computed Tomography To Strength (CT2S), a novel osteoporosis screening service, compared with dual-energy X-ray absorptiometry (DXA), treat all without screening, and no screening methods for Dutch postmenopausal women referred to fracture liaison service (FLS). CT2S uses CT scans to generate femur models and simulate sideways fall scenarios for bone strength assessment. Methods. Early health technology assessment (HTA) was adopted to evaluate CT2S as a novel osteoporosis screening tool for secondary fracture prevention. We constructed a 2-dimensional simulation model considering 4 strategies (no screening, treat all without screening, DXA, CT2S) together with screening intervals (5 y, 2 y), treatments (oral alendronate, zoledronic acid), and discount rate scenarios among Dutch women in 3 age groups (60s, 70s, and 80s). Strategy comparisons were based on incremental cost-effectiveness ratios (ICERs), considering an ICER below €20,000 per QALY gained as cost-effective in the Netherlands. Results. Under the base-case scenario, CT2S versus DXA had estimated ICERs of €41,200 and €14,083 per QALY gained for the 60s and 70s age groups, respectively. For the 80s age group, CT2S was more effective and less costly than DXA. Changing treatment from weekly oral alendronate to annual zoledronic acid substantially decreased CT2S versus DXA ICERs across all age groups. Setting the screening interval to 2 y increased CT2S versus DXA ICERs to €100,333, €55,571, and €15,750 per QALY gained for the 60s, 70s, and 80s age groups, respectively. In all simulated populations and scenarios, CT2S was cost-effective (in some cases dominant) compared with the treat all strategy and cost-saving (more effective and less costly) compared with no screening. Conclusion. CT2S was estimated to be potentially cost-effective in the 70s and 80s age groups considering the willingness-to-pay threshold of the Netherlands. This early HTA suggests CT2S as a potential novel osteoporosis screening tool for secondary fracture prevention.

Highlights

For postmenopausal Dutch women who have been referred to the FLS, direct access to CT2S may be cost-effective compared with DXA for age groups 70s and 80s, when considering the ICER threshold of the Netherlands. This study positions CT2S as a potential novel osteoporosis-screening tool for secondary fracture prevention in the clinical setting.A shorter screening interval of 2 y increases the effectiveness of both screening strategies, but the ICER of CT2S compared with DXA also increased substantially, which made CT2S no longer cost-effective for the 70s age group; however, it remains cost-effective for individuals in their 80s.Annual zoledronic acid treatment with better adherence may contribute to a lower cost-effectiveness ratio when comparing CT2S to DXA screening and the treat all strategies for all age groups.

Risk of osteoporosis and fracture after hysterectomies without oophorectomies: a systematic review and pooled analysis

The present study provides evidence that women who underwent hysterectomy without oophorectomies are at a higher risk of osteoporosis and bone fractures than the general population. Early interventions for these susceptible women may help to delay or reduce the risk of osteoporosis and bone fractures.

INTRODUCTION

Mounting studies have shown that patients with hysterectomy are at high risk of developing osteoporosis or bone fractures, but the evidence from all the relevant studies has not been previously synthesized. The present study aims to investigate whether women with hysterectomy without oophorectomies have a prominently higher prevalence of osteoporosis or fractures than healthy subjects.

METHODS

Four electronic databases were systematically searched to identify the eligible studies. The combined effect was assessed by calculating the relative risk (RR) with a 95% confidence interval (CI). More methodologies for this study were available in the PROSPERO (ID: CRD42021227255).

RESULTS

Finally, three observational studies offering osteoporosis cases and two retrospective studies reporting fracture cases were included. One eligible study has provided independent data from three groups of fractures. Synthetic results revealed that hysterectomy without oophorectomies was significantly associated with an increased risk of osteoporosis as compared to the general population (combined RR from three studies = 1.47, 95%CI 1.253 to 1.725, P < 0.001; heterogeneity, I² = 76.2%, P = 0.015). Consistently, the prevalence of fractures was also significantly higher in patients with hysterectomy without oophorectomies than in healthy controls (pooled RR from four studies = 2.333, 95%CI: 1.314 to 4.144, P = 0.004; heterogeneity, I² = 92.3%, P < 0.001).

CONCLUSIONS

This is the first study to quantify the association between hysterectomy without oophorectomies and osteoporosis/fracture risk through a meta-analysis and has subsequently confirmed its positive relationship. Additional large-sample rigorously prospective cohorts are still warranted to validate the present evidence.

Bone Mineral Density in Adult Survivors of Pediatric Differentiated Thyroid Carcinoma: A Longitudinal Follow-Up Study

Background: Survivors of pediatric differentiated thyroid carcinoma (DTC) receive thyrotropin-suppressive therapy to minimize disease recurrence. However, knowledge about long-term effects of subclinical hyperthyroidism on bone mineral density (BMD) in pediatric DTC survivors is scarce, as is the information regarding long-term consequences of permanent hypoparathyroidism on BMD. We evaluated BMD in pediatric DTC survivors and investigated if BMD was affected by subclinical hyperthyroidism and/or permanent hypoparathyroidism during long-term follow-up. Methods: In this nationwide longitudinal study, we determined BMD in the lumbar spine and femur by dual energy X-ray absorptiometry in 65 pediatric DTC survivors. Measurements were repeated after minimal 5 years of follow-up in 46 pediatric DTC survivors. BMD results were evaluated according to the recommendations of the International Society for Clinical Densitometry (ISCD) and WHO. At both visits, we determined biochemical parameters and markers of bone resorption (C-terminal telopeptide of type I collagen [β-CTX]) and formation (N-propeptide of type I collagen [PINP] and osteocalcin). Results: First and second BMD measurements were done after a median follow-up of 17.0 (interquartile range [IQR] 8.0-25.0) and 23.5 (IQR 14.0-30.0) years after diagnosis, respectively. Median age at diagnosis was 15 years (IQR 13.0-17.0). Twenty-nine percent of the survivors had subclinical hyperthyroidism. In most survivors, BMD T- and Z-scores were within the reference range during both BMD evaluations. However, after 23.5 years of follow-up, a low BMD was found in 13.0%. In the 13 survivors with permanent hypoparathyroidism, BMD values did not differ after 5 years of follow-up compared with baseline values or in comparison with the 33 survivors without permanent hypoparathyroidism. During follow-up, turnover markers β-CTX and PINP remained stable. Conclusions: This longitudinal study of pediatric DTC survivors demonstrated normal and stable median lumbar spine and femur BMD values after a median time of 17 and 23.5 years after diagnosis. However, compared with controls, a lower BMD was still found in 13.0% after prolonged follow-up despite intensive follow-up. Based on the studied follow-up period, these data do not provide convincing evidence in support of standard monitoring of bone mass among DTC survivors, but may be restricted to individual cases at low frequency. Trial Registration: This follow-up study was registered in The Netherlands Trial Register under no. NL3280 (www.trialregister.nl/trial/3280).

Sesamin Promotes Osteoblastic Differentiation and Protects Rats from Osteoporosis

Background

Osteoporosis is a common osteopathy, resulting in fractures, especially in elder people. Sesamin has many pharmacological effects, including supplying calcium. However, how sesamin might prevent osteoporosis is still under study.

Material/Methods

Bone marrow stromal cells (BMSCs) extracted from rat femur were induced for osteoblastic differentiation. Cell proliferation, alkaline phosphatase (ALP), osterix (OSX), SRY-box 9 (SOX9), runt-related transcription factor 2 (RUNX2), osteocalcin (OCN), β-catenin, low density lipoprotein receptor-related protein 5 (LRP5), and glycogen synthase kinase-3β (GSK-3β) levels in BMSCs were detected in the presence or absence of sesamin (1 μM or 10 μM). In addition, FH535 (1 μM) was used to silence Wnt/β-catenin in vitro. Ovariectomized (OVX) rats were established and intragastrically administrated sesamin (80 mg/kg), and then the rat bones were analyzed by micro-computed tomography. Osteocalcin and collagen type I were measured in the rat femurs.

Results

Sesamin had no influence on BMSC proliferation. Higher sesamin concentration promoted Wnt/β-catenin activity and enhanced more expressions of ALP, OSX, SOX9, RUNX2, and OCN, gradually and significantly (P<0.05). Silencing Wnt/β-catenin weakened the enhancement on RUNX2 and OCN expression. Sesamin (80 mg/kg) promoted bone structure in ovariectomized rats, and significantly enhanced osteocalcin and collage type I expression (P<0.05).

Conclusions

Sesamin promoted osteoblastic differentiation of rat BMSCs by regulating the Wnt/β-catenin pathway, and improved rat bone structure. Sesamin could have therapeutic and preventive effects on osteoporosis.

Low bone mineral density is related to high physiological levels of free thyroxine in peri-menopausal women

OBJECTIVE

To determine whether thyroid hormone (free thyroxine (fT₄)) rather than TSH is directly related to bone mineral density (BMD).

DESIGN

Cross-sectional population cohort study of peri-menopausal women.

METHODS

Of a sample of 6846 peri-menopausal Dutch women who participated in an osteoporosis-screening programme, a cohort of 2584 was randomly selected for the assessment of thyroid function (TSH, fT₄ and thyroid peroxidase antibodies (TPO-Abs)). TPO-Ab-positive women, with a previous history of thyroid dysfunction, overt thyroid disease, subclinical hypothyroidism, osteoporosis or bilateral oophorectomy and those receiving thyroid hormone or hormone replacement therapy were excluded. Of 1477 eligible women, 1426 had TSH and fT₄ within the reference range and 51 had low or undetectable serum TSH. BMD was measured at the lumbar spine and low BMD was defined as <0.937 g/cm(2).

RESULTS

The mean BMD in the 51 women with low or undetectable serum TSH was 0.984 g/cm(2) compared with 1.001 g/cm(2) in the remaining 1426 (t=0.94, P=0.35); 33% of women with low or undetectable serum TSH had low BMD compared with 34% in 1426 euthyroid women. High fT₄ but not low TSH in euthyroid women was related to low BMD by multiple logistic regression corrected for age, BMI and smoking (OR, 1.30; 95% CI, 1.02-1.69).

CONCLUSIONS

Higher fT₄ levels within the normal reference range but not low or undetectable serum TSH were independently related to decreased BMD at lumbar spine in peri-menopausal women.

Relationship between Weight, Body Mass Index, and Bone Mineral Density in Men Referred for Dual-Energy X-Ray Absorptiometry Scan in Isfahan, Iran

Objective. Although several studies have investigated the association between body mass index (BMI) and bone mineral density (BMD), the results are inconsistent. The aim of this study was to further investigate the relation between BMI, weight and BMD in an Iranian men population. Methods. A total of 230 men 50-79 years old were examined. All men underwent a standard BMD scans of hip (total hip, femoral neck, trochanter, and femoral shaft) and lumbar vertebrae (L2-L4) using a Dual-Energy X-ray Absorptiometry (DXA) scan and examination of body size. Participants were categorised in two BMI group: normal weight <25.0 kg/m(2) and overweight and obese, BMI ≥ 25 kg/m(2). Results. Compared to men with BMI ≥ 25, the age-adjusted odds ratio of osteopenia was 2.2 (95% CI 0.85, 5.93) and for osteoporosis was 4.4 (1.51, 12.87) for men with BMI < 25. It was noted that BMI and weight was associated with a high BMD, compatible with a diagnosis of osteoporosis. Conclusions. These data indicate that both BMI and weight are associated with BMD of hip and vertebrae and overweight and obesity decreased the risk for osteoporosis. The results of this study highlight the need for osteoporosis prevention strategies in elderly men as well as postmenopausal women.

Bone mass, depressive, and anxiety symptoms in adolescent girls: variation by smoking and alcohol use

PURPOSE

The purpose of the study was to examine (a) the association between depressive and anxiety symptoms with bone health, (b) the association of smoking or alcohol use with bone health, and, in turn (c) whether the association between depressive and anxiety symptoms with bone health varied by smoking or alcohol use individually or by combined use. Bone health included total body bone mineral content (TB BMC) and bone mineral density (BMD) of the lumbar spine, total hip, and femoral neck. Previously published data have not examined these issues in adolescence, a period when more than 50% of bone mass is accrued.

METHODS

An observational study enrolled 262 healthy adolescent girls by age cohort (11, 13, 15, and 17 years). Participants completed questionnaires and interviews on substance use, depressive symptoms, and anxiety. BMC and BMD were measured by dual-energy X-ray absorptiometry.

RESULTS

Higher depressive symptoms were associated with lower TB BMC and BMD (total hip, femoral neck). Those with the lowest level of smoking had higher BMD of the hip and femoral neck, whereas no main effect differences were noted by alcohol use. Regular users of both cigarettes and alcohol demonstrated a stronger negative association between depressive symptoms and TB BMC as compared with nonusers/experimental users and regular alcohol users. Findings were parallel for anxiety symptoms.

CONCLUSION

Depressive and anxiety symptoms may negatively influence bone health in adolescent girls. Consideration of multiple substances, rather than cigarettes or alcohol separately, may be particularly informative with respect to the association of depression with bone health.

Hormone therapy and coronary heart disease risk by vasomotor menopausal symptoms

OBJECTIVES

We examined whether the association between hormone therapy (HT) use and coronary heart disease (CHD) risk differed between women with and without vasomotor symptoms (VMS).

STUDY DESIGN

We used data from a Dutch (EPOS) and Swedish (WHILA) population-based sample of 8865 women, aged 46-64 years, and free of CHD, stroke, venous thrombosis/pulmonary embolism or cancer at baseline. Data on HT use, VMS and potential confounders were collected by questionnaires.

MAIN OUTCOME MEASURES

CHD endpoints, obtained via registries.

RESULTS

252 CHD cases occurred during 10.3 years of follow-up. Neither for women with nor for women without flushing or (night) sweats ever HT use was associated with CHD risk, compared with never HT use. Among women with intense VMS, ever HT use borderline significantly decreased CHD risk compared with never HT use (HR 0.48 [95% CI 0.20-1.03]). Among women without intense VMS, ever HT use was associated with a borderline significant increased CHD risk (HR 1.28 [95% CI 0.96-1.70]; P for interaction=0.02). However, after multivariate adjustment, as compared to never HT use, ever HT use was not associated with risk of CHD among women with or without intense VMS.

CONCLUSIONS

In both groups of women with and without VMS, HT use does not seem to be associated with the risk of CHD. Hence, our findings do not support the view that HT use increases the CHD risk among women with an indication, i.e. VMS, but this needs to be confirmed in specifically designed studies.

Prevalence and related risk factors of osteoporosis in peri- and postmenopausal Indian women

AIM

We undertook this study involving 200 peri- and postmenopausal women to determine the prevalence of osteoporosis, and in turn increase the awareness, education, prevention, and treatment of osteoporosis.

SETTING AND DESIGN

Postgraduate Institute of Medical Education and Research, UT Chandigarh, India, and a clinical study.

MATERIALS AND METHODS

A detailed medical, obstetrical, menstrual, and drug history was recorded in a proforma designated for the study. Height and weight was measured, weight-bearing exercise was assessed, and sunlight exposure per day for each woman was recorded. Food intake was estimated by using the 24-hour dietary recall method, and calcium and vitamin D consumption pattern was assessed. Bone mineral density (BMD) at postero-anterior lumbar spine and dual femurs was assessed by densitometer. Women were classified according to the WHO criteria.

STATISTICAL ANALYSIS USED

Student's t-test, multiple logistic regression analysis.

RESULTS

The prevalence of low BMD was found in more than half of this population (53%). The mean age in group I (normal BMD) was found to be 50.56 ± 5.74 years as compared to 52.50 ± 5.94 in group II with low BMD (P=0.02). The two groups were similar with respect to parity, education, socioeconomic status, family history of osteoporosis, hormone replacement therapy, and thyroid disorders. 46.8% of the women in group I and 33% of the women in group II had low physical activity and there was no statistically significant difference in sunlight exposure between the groups. Parity or the number of children and type of menopause was not seen to have much association with low BMD in our study. Lack of exercise and low calcium diet were significantly associated with low BMD. Multiple logistic regression analysis showed that age, exercise, menopause, and low calcium diet acted as significant predictors of low bone density.

CONCLUSION

The findings from the study suggest the need for large community-based studies so that high-risk population can be picked up and early interventions and other life style changes can be instituted if there is delay in implementing national or international health strategies to tackle this increasing global health problem. Strategies to identify and manage low BMD in the primary care setting need to be established and implemented.

Vasomotor menopausal symptoms are associated with increased risk of coronary heart disease

OBJECTIVE

Emerging evidence suggests that women with vasomotor menopausal symptoms (VMS) may have an adverse cardiovascular disease (CVD) risk profile. We investigated whether VMS are related to an increased risk of future coronary heart disease (CHD) and whether possible associations can be explained by CVD risk factors.

METHODS

Data used were from a Dutch and Swedish population-based sample of 10,787 women enrolled between 1995 and 2000, aged 46 to 64 years, and free of CVD at baseline. Data on VMS were collected by questionnaires. Body mass index and blood pressure were measured in all women, and total cholesterol levels were measured in a subgroup of the population. Multivariable Cox regression models were used to analyze the data.

RESULTS

After a mean ± SD follow-up period of 10.3 ± 2.1 years, 303 women were diagnosed with CHD. Symptoms of flushing were not associated with risk of CHD. However, the presence of night sweats was associated with a significantly modest increased risk of CHD, with a multivariable-adjusted hazard ratio of 1.33 (95% CI, 1.05-1.69). This association was attenuated but not eliminated after correction for body mass index, blood pressure, and total cholesterol (hazard ratio, 1.25; 95% CI, 0.99-1.58).

CONCLUSIONS

Women with menopausal symptoms of night sweats have a significantly moderately increased risk of CHD, which cannot be totally explained by the levels of CVD risk factors.

Prediction of hip and hand fractures in older persons with or without a diagnosis of periodontitis

PURPOSE

In a prospective study, we assessed if a diagnosis of osteoporosis and periodontitis could predict hip and hand fractures in older persons.

MATERIALS AND METHODS

Bone density was assessed by a Densitometer. Periodontitis was defined by evidence of alveolar bone loss.

RESULTS

788 Caucasians (52.4% women, overall mean age: 76 years, S.D.± 9.0, range: 62 to 96) were enrolled and 7.4% had a hip/hand fracture in 3 years. Calcaneus PIXI T-values < -1.6 identified osteoporosis in 28.2% of the older persons predicting a hip/hand fracture with an odds ratio of 3.3:1 (95% CI: 1.9, 5.7, p < 0.001). Older persons with osteoporosis had more severe periodontitis (p < 0.01). Periodontitis defined by ≥ 30% of sites with ≥ 5 mm distance between the cemento-enamel junction (CEJ) and bone level (ABL) was found in 18.7% of the older persons predicting a hip/hand fracture with an odds ratio of 1.8:1 (95% CI: 1.0, 3.3, p < 0.05). Adjusted for age, the odds ratio of a hip/hand fracture in older persons with osteoporosis (PIXI T-value < -2.5) and periodontitis was 12.2:1 (95% CI: 3.5, 42.3, p < 0.001).

CONCLUSIONS

Older persons with osteoporosis and periodontitis have an increased risk for hip/hand fractures.

Low bone mass in urban Indian women above 40 years of age: prevalence and risk factors

OBJECTIVE

To assess the prevalence and the relative importance of risk factors for low bone mass in Indian pre- and post-menopausal women.

METHODS

Data were collected on anthropometry and lifestyle factors in apparently healthy 80 pre- and 92 post-menopausal (40-75 years) women. Bone mineral density (BMD) was measured by dual energy X-ray absorptiometry. Fasting blood samples were analysed for Parathyroid hormone, vitamin D, calcium and zinc.

RESULTS

BMD at all three sites was significantly lower in post-menopausal than the pre-menopausal women (p < 0.001). Prevalence of osteoporosis was highest at the lumbar spine (25.8%) in post-menopausal women, while prevalence of osteopenia was high in pre-menopausal women (44.3%). Vitamin D deficiency was seen in 54.5% pre and 41.8% post-menopausal women and significant correlation of serum 25(OH)D levels (r = 0.16) was obtained only for total hip Z-score (p < 0.05). Correlation between sun index and lumbar spine BMD was marginally significant (r = 0.14, p = 0.07). Generalised linear models revealed that after adjusting for age, weight and height, percent decrease of 2.1-4.5% in BMD may be attributed to menopause.

CONCLUSION

Age, weight, height, menopause, low intakes of calcium and low 25(OH)D along with poor sunlight exposure are the major factors contributing to bone loss in Indian women above 40 years of age.

Effect of a comprehensive lifestyle modification program on the bone density of male heavy drinkers

BACKGROUND

Heavy alcohol drinking is implicated in osteoporosis. Although abstinence is rapidly followed by a restoration of osteoblastic activity, little is known about the contributions of alcohol-related factors or the effectiveness of a lifestyle modification program (LMP) on bone density.

METHODS

We conducted a study of 138 male alcoholic patients to investigate whether drinking history and concurrent factors were associated with the bone density of the calcaneus. A 2.5-months LMP in an institutionalized setting was completed by 20 of them, and its effect on bone density, serum parathyroid hormone (PTH), and 1.25-(OH)(2) vitamin D levels were assessed.

RESULTS

The patients had a high prevalence of daytime drinking (93.5%), continuous drinking (84.1%), and current smoking (82.0%) with mean duration of alcohol abuse of 30.0 +/- 12.8 years. The patients had lower bone density than a reference control group (Z-scores: -0.45 +/- 1.02). Multiple stepwise regression analysis identified age, poor activities of daily living (ADL), continuous drinking, absence of liver cirrhosis, depression, and dementia as determinants of low bone density. The bone density of the 20 participants in the LMP improved 2.3% (p = 0.0003) with a more ameliorating effect on bone density than a conventional abstinence therapy (p = 0.014 for interventional effect). The upper normal range of PTH levels at baseline were significantly decreased, and 1.25-(OH)(2) vitamin D levels also had a trend toward decrease during the abstinence.

CONCLUSIONS

Alcoholic patients may have many complications such as poor ADL and dementia, which are independently associated with decreased bone density. The results of this study support the idea that comprehensive approach to lifestyle factors to minimize risk of osteoporosis is the best way to improve bone density.

Relationship of Bone Densitometry and Bone Resorption Markers With Menopausal Type and Duration

Objective: Menopause age and bone mineral density are positively related and there is a rapid bone loss in the early post-menopausal period. A ratio of 30% of post-menopausal women are affected from osteoporosis developing due to bone loss and this causes 40% risk of fracture in a 50- year old woman.

Materials and Methods: In this sudy, serum osteocalcin and urine deoxypridinoline levels were analyzed in 102 postmenapausal and 48 healthy premenopausal controls who presented to gynecology outpatient clinic. Bone densitometry was obtained from all postmenopausal women. Postmenopausal patients were further divided into four groups according to time since menopause:<5 years, 5-9 years, 10-19 years and >20 years.

Results: Mean (SD) age in 48 premenopausal women was 47.7 (3.7) while it was 56.5 (6.8) in 102 post-menopausal women. 34 out of 102 post-menopausal women had surgical menopause due to bilateral oopheroctomy+hysterectomy while the remaining had natural menopause. No significant difference was found in bone-turnover markers between women with surgical and natural menopause.

Conclusion: Although there was not a statistically significant difference between bone-turnover markers, bone mineral density stays lower in surgical menopausal patients and this difference disappear only after about 20 years. Also bone turnover markers are usually high up to five years after surgical menopause and return to normal levels after then. Thus, our study suggested that oopheroctomy does not cause additional risk to hysterectomy. We also suggest that there is not a long-term relationship between serum bone turnover markers or bone density and the etiology of menopause. (Turk J Rheumatol 2010; 25: 29-33)

Vasomotor symptoms are associated with a lower bone mineral density

OBJECTIVE

The severity of vasomotor symptoms has been hypothesized to be linked to a lower bone mineral density (BMD). We examined whether women with vasomotor symptoms are different from women without symptoms with regard to BMD.

METHODS

We used data from a population-based sample of 5,600 women, aged 46 to 57 years and free from bone diseases, who participated in the first cross-sectional part of the Eindhoven Perimenopausal Osteoporosis Study between 1994 and 1995. Questionnaires at baseline were used to collect data on vasomotor symptoms and potential confounders. At baseline, BMD of the lumbar spine was measured using dual energy x-ray absorptiometry. Linear regression analysis was used to analyze the data.

RESULTS

Flushing was reported by 39% of all women, and night sweats, by 38% of all women. The average BMD was 1.01 +/- 0.14 g/cm and decreased with increasing frequency of flushing (P for trend < 0.0001) and night sweats (P for trend = 0.03). After multivariate adjustments for age, body mass index, menopause status, smoking, education, exercise, and hormone use, women with the highest frequency of symptoms had a 0.022 g/cm (95% CI, -0.03 to -0.01) lower BMD compared with asymptomatic women. Women who reported having the highest frequency of night sweats had a 0.011 g/cm (95% CI, -0.02 to -0.001) lower BMD compared with women with no symptoms of night sweats.

CONCLUSIONS

Our findings show that vasomotor symptoms are associated with reduced bone density. It could be hypothesized that women with vasomotor symptoms might be more susceptible to the beneficial effects of estrogens, possibly by neutralizing the effect of estrogen fluctuations. Further research is needed to extend these findings to other estrogen-sensitive end organs.

A genome-wide association study of northwestern Europeans involves the C-type natriuretic peptide signaling pathway in the etiology of human height variation

Northwestern Europeans are among the tallest of human populations. The increase in body height in these people appears to have reached a plateau, suggesting the ubiquitous presence of an optimal environment in which genetic factors may have exerted a particularly strong influence on human growth. Therefore, we performed a genome-wide association study (GWAS) of body height using 2.2 million markers in 10 074 individuals from three Dutch and one German population-based cohorts. Upon genotyping, the 12 most significantly height-associated single nucleotide polymorphisms (SNPs) from this GWAS in 6912 additional individuals of Dutch and Swedish origin, a genetic variant (rs6717918) on chromosome 2q37.1 was found to be associated with height at a genome-wide significance level (P_combined = 3.4 × 10⁻⁹). Notably, a second SNP (rs6718438) located ∼450 bp away and in strong LD (r² = 0.77) with rs6717918 was previously found to be suggestive of a height association in 29 820 individuals of mainly northwestern European ancestry, and the over-expression of a nearby natriuretic peptide precursor type C (NPPC) gene, has been associated with overgrowth and skeletal anomalies. We also found a SNP (rs10472828) located on 5p14 near the natriuretic peptide receptor 3 (NPR3) gene, encoding a receptor of the NPPC ligand, to be associated with body height (P_combined = 2.1 × 10⁻⁷). Taken together, these results suggest that variation in the C-type natriuretic peptide signaling pathway, involving the NPPC and NPR3 genes, plays an important role in determining human body height.

Systematic review: The evidence base for long-term management of coeliac disease

BACKGROUND

While gluten-free diet is an effective treatment for coeliac disease, the need for and goals of long-term management of patients are poorly defined.

AIM

To review systematically the complications and associations of coeliac disease, to identify potential risk factors, to define ways of assessing risk factors and to provide a strategy for management.

METHODS

Review of medical literature from 1975.

RESULTS

There is an increasing list of potential complications and/or conditions associated with coeliac disease, in particular, autoimmune disease, malignancy and bone disease. Risk factors that may predict or influence long-term outcomes include genetic susceptibility, environmental factors predominantly gluten ingestion, persistent small intestinal inflammation/injury and nutritional deficiencies. Genotyping of patients is yet to have an established clinical role in long-term management. Assessment of adherence to the gluten-free diet largely relies upon skilled dietary history, but the ultimate test is duodenal histopathology, which is the only currently established means of assessing healing. Symptoms, serology or other non-invasive means are poor predictors of healing and the likelihood of complications.

CONCLUSION

Evidence (albeit limited) that adherence to a gluten-free diet and mucosal healing prevent and/or ameliorate complications indicates that a planned long-term strategy for follow-up is essential.

Identification of the risk factors for osteoporosis among postmenopausal women

OBJECTIVES

The aim of this study was to determine the effect of different durations of menopause at the time of bone mineral density (BMD) measurement and of different age at menopause intervals on the prevalence of osteopenia and osteoporosis among untreated postmenopausal women. We also assessed related factors leading to low BMD.

METHODS

A total of 2769 postmenopausal women who had not taken any anti-osteoporosis treatment and/or hormone replacement therapy were divided into three groups according to duration of menopause at the time of BMD measurement. The women were also evaluated in four different age groups according to their age at menopause onset. Multinomial logistic regression analysis was used to determine related factors leading to low BMD. Investigated parameters include demographic characteristics, plasma glucose, lipids, and lipoproteins.

RESULTS

According to World Health Organization (WHO) criteria, among 2769 patients, 449 (16.2%) were identified as having osteoporosis, 1085 (39.2%) as having osteopenia, and 1235 (44.6%) as having normal BMD. Osteoporosis was determined in 10.6% and 16.2% of women with menopause duration of 0-3 years and 4-7 years, respectively, whereas this rate was 31.9% in women with menopause duration of over 7 years (p = 0.001). The percentages for osteopenia remained constant among the three different menopause durations (0-3 years: 37.2%, 4-7 years: 42.1%, and >7 years: 40.9%). Thirty percent of women with age at onset of <40 years were osteoporotic. However, the percentages of women with osteoporosis among the other age groups were similar (40-46 years: 18.3%, 47-52 years: 14.1%, and >52 years: 15.4%). The percentages for osteopenia remained relatively constant among the four age groups (36.7, 40, 39.1 and 39%). According to the multinomial logistic regression analysis, duration of menopause at the time of BMD test and parity were positively correlated with both osteoporosis and osteopenia, while glucose level was negatively correlated with both osteoporosis and osteopenia. Age at menopause was negatively correlated only for osteoporosis. Low-density lipoprotein cholesterol (LDL-c) level may be accepted as a clinically significant factor for osteopenia (OR: 1.01; CI(95%): 1.00-1.02). No differences were determined in the prevalence of osteopenia and osteoporosis in women with menopause duration of >7 years when evaluated according to the four menopause age groups as described before (p = 0.74). Contribution to the regression model was 0.8% by age at menopause, 5.6% by menopause duration at time of BMD measurement, 5.8% by both factors.

CONCLUSION

According to our results, osteoporosis is related more to the duration of menopause at the time of BMD measurement rather than the age at menopause among untreated postmenopausal women. High parity was determined as another risk factor for low BMD.

Menopausal Complaints Are Associated With Cardiovascular Risk Factors

It has been hypothesized that women with vasomotor symptoms differ from those without with respect to cardiovascular risk factors or responses to exogenous hormone therapy. We studied whether the presence and extent of menopausal complaints are associated with cardiovascular risk profile. Data were used from a population-based sample of 5523 women, aged 46 to 57 years, enrolled between 1994 and 1995. Data on menopausal complaints and potential confounders were collected by questionnaires. Total cholesterol, systolic and diastolic blood pressures, and body mass index were measured. Linear and logistic regression analyses were used to analyze the data. Night sweats were reported by 38% and flushing by 39% of women. After multivariate adjustment, women with complaints of flushing had a 0.27-mmol/L (95% CI: 0.15 to 0.39) higher cholesterol level, a 0.60-kg/m 2 (95% CI: 0.35 to 0.84) higher BMI, a 1.59-mm Hg (95% CI: 0.52 to 2.67) higher systolic blood pressure, and a 1.09-mm Hg (95% CI: 0.48 to 1.69) higher diastolic blood pressure compared with asymptomatic women. Flushing was also associated with hypercholesterolemia (odds ratio: 1.52; 95% CI: 1.25 to 1.84) and hypertension (OR: 1.20; 95% CI: 1.07 to 1.34). Results were similar for complaints of night sweating. The findings support the view that menopausal complaints are associated with a less favorable cardiovascular risk profile. These findings substantiate the view that differences in the presence of menopausal symptoms as a reason for using hormone therapy could explain discrepant findings between observational research and trials.

[Factors associated with low bone mineral density among white women]

OBJECTIVE

To analyze whether the factors causing low bone mineral density among elderly women are the same as those observed in other age groups.

METHODS

A cross-sectional study was carried out on the medical records of a random sample of 413 white women seen at an imaging diagnostics service in a city of Southern Brazil, in 2003. Femoral bone mineral densities with adjustment using T-scores were used. The following variables were investigated: age, body mass index, tobacco smoking, alcohol consumption, milk consumption, physical activity and hormone replacement therapy. Univariate and multivariate unconditional logistic regression were used.

RESULTS

In the sample, 52.5% were up to 59 years old and 47.5% were 60 or over. The mean bone mineral density was 0.867 g/cm2 (SD=0.151) for the femoral neck. Significant age-adjusted values were obtained for physical activity (adjusted OR=0.47; 95% CI: 0.23;0.97), body mass index greater than or equal to 30.0 kg/m2 (adjusted OR=0.10; 95% CI: 0.05;0.21), alcohol consumption (adjusted OR=7.90; 95% CI: 2.17;28.75), low milk consumption (adjusted OR=3.29; 95% CI: 1.91;5.68) and hormone replacement (adjusted OR = 0.44; 95% CI: 0.21;0.90). Among the elderly women, body mass, milk consumption and physical activity were independent protection factors.

CONCLUSIONS

Advanced age, body mass, physical activity, milk and alcohol consumption were important factors in bone mass regulation. The influence of behavioral factors was maintained among the women of advanced aged, thus reinforcing the role of preventive measures in medical practice and public health promotion policies aimed at healthy aging.

GnRH and LHR gene variants predict adverse outcome in premenopausal breast cancer patients

BACKGROUND

Breast cancer development and progression are dependent on estrogen activity. In premenopausal women, estrogen production is mainly regulated through the hypothalamic-pituitary-gonadal (HPG) axis.

METHODS

We have investigated the prognostic significance of two variants of genes involved in the HPG-axis, the GnRH (encoding gonadotropin-releasing hormone) 16Trp/Ser genotype and the LHR (encoding the luteinizing hormone receptor) insLQ variant, in retrospectively collected premenopausal breast cancer patients with a long follow-up (median follow-up of 11 years for living patients).

RESULTS

Carriership was not related with breast cancer risk (the case control study encompassed 278 premenopausal cases and 1,758 premenopausal controls). A significant adverse relationship of the LHR insLQ and GnRH 16Ser genotype with disease free survival (DFS) was observed in premenopausal (hormone receptor positive) breast cancer patients. In particular, those patients carrying both the GnRH 16Ser and LHR insLQ allele (approximately 25%) showed a significant increased risk of relapse, which was independent of traditional prognostic factors (hazard ratio 2.14; 95% confidence interval 1.32 to 3.45; P = 0.002).

CONCLUSION

We conclude that the LHR insLQ and GnRH 16Ser alleles are independently associated with shorter DFS in premenopausal patients. When validated, these findings may provide a lead in the development of tailored treatment for breast cancer patients carrying both polymorphisms.

A reference standard for the description of osteoporosis

In 1994, the World Health Organization published diagnostic criteria for osteoporosis. Since then, many new technologies have been developed for the measurement of bone mineral at multiple skeletal sites. The information provided by each assessment will describe the clinical characteristics, fracture risk and epidemiology of osteoporosis differently. Against this background, there is a need for a reference standard for describing osteoporosis. In the absence of a true gold standard, this paper proposes that the reference standard should be based on bone mineral density (BMD) measurement made at the femoral neck with dual-energy X-ray absorptiometry (DXA). This site has been the most extensively validated, and provides a gradient of fracture risk as high as or higher than that of many other techniques. The recommended reference range is the NHANES III reference database for femoral neck measurements in women aged 20-29 years. A similar cut-off value for femoral neck BMD that is used to define osteoporosis in women can be used for the diagnosis of osteoporosis in men - namely, a value for BMD 2.5 SD or more below the average for young adult women. The adoption of DXA as a reference standard provides a platform on which the performance characteristics of less well established and new methodologies can be compared.

Polymorphic variations in exon 10 of the luteinizing hormone receptor: functional consequences and associations with breast cancer

Polymorphic variation of the LHR gene may affect receptor function and accordingly may influence ovarian steroid hormone action, including steroid hormone-dependent clinical outcome. The functional effects of two single nucleotide polymorphisms (SNPs), i.e. LHR 291Asn/Ser (rs12470652) and 312Ser/Asn (rs2293275) in the biologically interesting exon 10 of the LHR gene are described. Furthermore, ethnic diversity in allele frequencies and genotype distributions of both SNPs was determined. In addition associations with breast cancer were studied in 751 breast cancer patients. In vitro transfection studies revealed altered glycosylation status and increased receptor sensitivity for the 291Ser LHR variant. No functional consequences were observed for the 312SerAsn LHR SNP. The LHR 312Asn allele was slightly more often present in two independent breast cancer patient cohorts as compared to controls (OR=1.15; p=0.03 and 1.26; p=0.001, respectively). In conclusion, although functional changes of the LHR 291Ser candidate allele were observed, no associations with breast cancer were found, while the LHR 312Asn allele can be regarded as a weak breast cancer risk allele.

Alcohol consumption, bone density, and hip fracture among older adults: the cardiovascular health study

INTRODUCTION

Previous studies have found inconsistent relationships of alcohol consumption with risk of hip fracture, and the importance of bone mineral density and risk of falls in mediating such a relationship has not been determined.

METHODS

As part of the Cardiovascular Health Study, a population-based cohort study of adults aged 65 years and older from four U.S. communities, 5,865 participants reported their use of beer, wine, and liquor yearly. We identified cases of hip fracture unrelated to malignancy or motor vehicle accidents using hospitalization discharge diagnoses. A subgroup of 1,567 participants in two communities underwent dual-energy x-ray absorptiometry scans to assess bone mineral density.

RESULTS

A total of 412 cases of hip fracture occurred during an average of 12 years of follow-up. There was a significant U-shaped relationship between alcohol intake and risk of hip fracture (p quadratic 0.02). Compared with long-term abstainers, the adjusted hazard ratios for hip fracture were 0.78 (95% confidence interval [CI], 0.61-1.00) among consumers of up to 14 drinks per week and 1.18 (95% CI, 0.77-1.81) among consumers of 14 or more drinks per week. Alcohol intake was associated with bone mineral density of the total hip and femoral neck in a stepwise manner, with approximately 5% (95% CI, 1%-9%) higher bone density among consumers of 14 or more drinks per week than among abstainers. These relationships were all similar among men and women.

CONCLUSIONS

Among older adults, moderate alcohol consumption has a U-shaped relationship with risk of hip fracture, but a graded positive relationship with bone mineral density at the hip.

Bone mineral density in patients with recently diagnosed, active rheumatoid arthritis

OBJECTIVES

Osteoporosis is a well-known extra-articular phenomenon in patients with uncontrolled, long-standing rheumatoid arthritis (RA). In the present study, the extent of osteoporosis and reduced bone mineral density (BMD) and the disease-related and demographic factors that are associated with osteoporosis and reduced BMD were examined in patients with recently diagnosed, active RA.

METHODS

BMD of the total hip and the lumbar spine was measured using dual-energy x ray absorptiometry in 381 patients with recently diagnosed active RA, who had never been treated with DMARDs or corticosteroids. Osteoporosis was defined as a T score <or=-2.5 SD and reduced BMD as Z score <or=-1 SD. Multivariate logistic regression analyses were performed to detect associations of osteoporosis and reduced BMD with disease activity, functional disability, joint damage (Sharp-van der Heijde score) and demographic factors.

RESULTS

Osteoporosis and reduced BMD were found in the spine and/or the hip in 11% and 25%, respectively, of the patients. Longer symptom duration and presence of rheumatoid factor (RF) were the only RA-specific markers for osteoporosis and reduced BMD. Further, postmenopausal status in women, a low body mass index, familial osteoporosis, and, remarkably, male gender, were independently associated with osteoporosis and reduced BMD.

CONCLUSION

In patients with recently diagnosed active RA who had never been treated with DMARDs or corticosteroids, BMD seems to be well-preserved and predominantly related to demographic factors. Longer symptom duration and a positive RF, but not higher disease activity or more joint damage, were related to osteoporosis and reduced BMD.

Moderate alcohol consumption and increased bone mineral density: potential ethanol and non-ethanol mechanisms

Mounting epidemiological evidence indicates an association between the moderate ingestion of alcoholic beverages and higher bone mineral density (v. abstainers). More limited findings provide some evidence for translation of this association into reduced fracture risk, but further studies are required. Here, these data are reviewed and caveats in their assimilation, comparison and interpretation as well as in the use and application of bone health indices are discussed. Whilst it is concluded that evidence is now strong for the moderate alcohol-bone health association, at least in relation to bone mineral density, mechanisms are less clear. Both ethanol and non-ethanol components have been implicated as factors that positively affect bone health in the light of moderate consumption of alcoholic beverages, and four particular areas are discussed. First, recent findings suggest that moderate ethanol consumption acutely inhibits bone resorption, in a non-parathyroid hormone- and non-calcitonin-dependent fashion, which can only partly be attributed to an energy effect. Second, critical review of the literature does not support a role for moderate ethanol consumption affecting oestrogen status and leading to a knock-on effect on bone. Third, Si is present at high levels in certain alcoholic beverages, especially beer, and may have a measurable role in promoting bone formation. Fourth, a large body of work indicates that phytochemicals (e.g. polyphenols) from alcoholic beverages could influence bone health, but human data are lacking. With further work it is hoped to be able to model epidemiological observations and provide a clear pathway between the magnitude of association and the relative contribution of these mechanisms for the major classes of alcoholic beverage.

Randomized controlled trial of the effect of hysterectomy or LNG-IUS use on bone mineral density: a five-year follow-up

A 72-year-old female with scirrhous-type advanced gastric cancer was treated with TS-1/CDDP as neoadjuvant chemotherapy. TS-1 (80 mg/m(2)/day) was orally administered for 3 weeks and CDDP (60 mg/m(2)) was administered by intravenous drip on day 8. Partial response (PR) was obtained after the first course, and total gastrectomy was performed. The histological diagnosis revealed complete disappearance of cancer cells in the stomach and a few regional lymph node metastases (3/67). The patient has now been in good health without a recurrence for 1 year and 9 months after surgery.

Prevalência de osteoporose: uma revisão crítica

A queda da mortalidade, seguida da redução da fecundidade e aumento da expectativa de vida, resulta no envelhecimento da população e no aumento das taxas de doenças crônico-degenerativas, entre as quais a osteoporose. Pesquisas epidemiológicas vêm sendo desenvolvidas com a finalidade de estimar sua prevalência na população empregando diferentes técnicas. O propósito dessa investigação foi revisar os estudos de prevalência de osteoporose e discutir suas implicações do ponto de vista da Saúde Coletiva. Foi realizada revisão da literatura mediante a qual foram incluídas publicações contendo estimativas de prevalência da osteoporose calculadas a partir da densidade mineral óssea aferida pela absorção de raios X de dupla energia. Os dados foram classificados segundo o ano, a região ou o país, autor, características da população investigada, e sítio esquelético. Os resultados mostraram ampla dispersão entre as taxas, com os valores variando entre 0,4% e 40,0% de acordo com o sítio pesquisado, o grupo etário, o sexo e o tipo de estudo. Nos estudos de base populacional, os valores das estimativas por ponto variaram de 7,9% a 16,0% considerando DMO no sítio femoral de mulheres com 50 e mais anos de idade. Nas áreas brasileiras mais desenvolvidas é necessário implementar projetos para conhecer sua prevalência incluindo-a na agenda dos formuladores de políticas públicas.

Bone mineral density and its determinants in diabetes: the Fremantle Diabetes Study

AIMS/HYPOTHESIS

We assessed the effects of type 1 and type 2 diabetes on bone density and metabolism.

MATERIALS AND METHODS

We analysed bone mineral density (BMD) measured at the hip, spine and forearm using dual energy X-ray absorptiometry in 34 patients with type 1 and 194 patients with type 2 diabetes. Patients were from the community-based Fremantle Diabetes Study, and findings for them were compared with those from normal age- and sex-matched control subjects from the local community. Biochemical and hormonal markers of bone metabolism were measured in a subset of 70 patients.

RESULTS

After adjusting for age and BMI, there was a lower BMD at total hip (p<0.001) and femoral neck (p=0.012) in type 1 men vs control subjects, but type 1 women and matched controls had similar BMD at each site. There was a higher BMD at total hip (p=0.006), femoral neck (p=0.026) and forearm (p<0.001) in type 2 women vs control subjects, but diabetes status was not associated with BMD in type 2 men after adjustment for age and BMI. Serum oestradiol, BMI, C-terminal telopeptide of collagen type 1 and male sex were consistently and independently associated with BMD at forearm, hip and femoral neck and explained 61, 55 and 50% of the total variance in BMD, respectively, at these sites. Spine BMD was independently associated with BMI and ln(oestradiol).

CONCLUSIONS/INTERPRETATION

Men with type 1 diabetes may be at increased risk of osteoporosis, while type 2 women appear to be protected even after adjusting for BMI. Low serum oestradiol concentrations may predispose to diabetes-associated osteoporosis regardless of sex.

Osteoporosis in otherwise healthy perimenopausal and early postmenopausal women: physical and biochemical characteristics

Population studies have shown that about 3-5% of perimenopausal women already have osteoporosis according to the WHO definition of osteoporosis for postmenopausal women ( t -score<or=-2.5). In general, this bone loss arises from well-characterized diseases or conditions that affect acquisition of peak bone mass and/or the rate of bone loss after peak bone mass has been attained. However, there often remains a subset of these women, with no identifiable cause of bone loss. This group has so far been little studied. We prospectively evaluated a group of 60 perimenopausal and early postmenopausal women (mean age 52.2+/-2.5 years) who were found to have apparently unexplained low bone mass, and we compared them to 120 controls matched for age and menopausal status. These women were extensively investigated, including by detailed questionnaire and laboratory testing. Of the 60 women with osteoporosis, only three were found to have previously undiagnosed disorders (two with subclinical hyperthyroidism and one with elevated serum PTH levels) that might have contributed to their low bone mass. On the other hand, osteoporotic patients were characterized by a significantly lower body weight, higher prevalence of personal and parental histories of fractures and a higher level of bone turnover as assessed by increased serum osteocalcin and bone alkaline phosphatase levels and urinary type I collagen C-telopeptide (CTX) excretion, as compared to controls. These findings support theories of a genetic contribution to osteoporosis and underline the predictive value of a previous history of personal and familial fracture in the identification of osteoporosis in early postmenopausal women.

Quantitative ultrasound measurements at the calcaneus in natural and surgically induced menopause

OBJECTIVE

The aim of the study was to assess skeletal status in natural and surgically induced menopausal women regarding the presence of previous osteoporotic fracture.

METHODS

Ninety-three females after bilateral oophorectomy in mean age of 56.8+/-8.3y. (48 without and 45 with fracture, groups 1 and 2, respectively) and 285 females with natural menopause in mean age of 56.4+/-7.0y (176 without and 109 with fracture, groups 3 and 4, respectively) were studied. Mean age, age of menopause, years since menopause (YSM), duration of fertile period (durFER) and body size did not differ between women after surgical and natural menopause and between non-fractured and fractured groups. No additional factors known to influence bone metabolism (either diseases or medications) or osteoporosis treatment were noted in the subjects studied. Skeletal status was evaluated by quantitative ultrasound (QUS) of the calcaneum using the Achilles system (Lunar, USA).

RESULTS

Calcaneal QUS results were significantly higher: in women after natural than surgical menopause (p<0.05), in non-fractured females after natural menopause than in non-fractured females after surgical menopause (p<0.001) and in women after natural menopause without fracture compared with those with fracture (p<0.000001). The same comparisons between fractured groups and between women after surgical menopause with and without fracture revealed no significant differences. QUS parameters were regressed in a stepwise, multiple regression analysis on age, YSM, durFER, weight and height for all groups. In group 1, YSM had a negative influence and durFER was a protective factor; in group 2, age and durFER were a negative factors and YSM had no influence; in group 3, age and YSM were a negative factors (no role of durFER) and in group 4, only YSM had a negative influence, and durFER was a protective factor.

CONCLUSION

Surgical menopause seems to be a risk factor for osteoporotic fracture because of low ultrasound values.

Hypothyroidism might be related to breast cancer in post-menopausal women

An association between breast cancer and thyroid (autoimmune) diseases or the presence of thyroid peroxidase antibodies (TPOAb; a marker of thyroid autoimmune disease) has been suggested. However, little is known about whether women with thyroid (autoimmune) diseases are at increased risk for developing breast cancer. This cross-sectional and prospective cohort study investigated whether the presence of TPOAb or thyroid dysfunction is related to the presence or development of breast cancer. An unselected cohort of 2,775 women around menopause was screened for the thyroid parameters thyrotropin (TSH), free thyroxine (FT(4)), and TPOAb during 1994. Detailed information on previous or actual thyroid disorders and breast cancer, and on putative factors related to breast cancer and thyroid disorders, was obtained. Clinical thyroid dysfunction was defined by both abnormal FT4 and TSH, and subclinical thyroid dysfunction by abnormal TSH (with normal FT4). A TPOAb concentration >or= 100 U/ml was defined as positive (TPOAb(+)). The study group was linked with the Eindhoven Cancer Registry to detect all women with (in situ) breast cancer (ICD-O code 174) diagnosed between 1958 and 1994. Subsequently, in the prospective study, all women who did not have breast cancer in 1994 (n = 2,738) were followed up to July, 2003, and all new cases of (in situ) breast cancer and all cancer-related deaths were registered. Of the 2,775 women, 278 (10.0%) were TPOAb(+). At the 1994 screening, 37 women (1.3%) had breast cancer. TPOAbs were (independently) related to a current diagnosis of breast cancer (OR = 3.3; 95% CI 1.3-8.5). Of the remaining women, 61 (2.2%) developed breast cancer. New breast cancer was related to: (1) an earlier diagnosis of hypothyroidism (OR = 3.8; 95% CI 1.3-10.9); (2) the use of thyroid medication (OR = 3.2; 95% CI 1.0-10.7); and (3) low FT4 (lowest tenth percentile: OR = 2.3; 95% CI 1.2-4.6). In the first 3 years follow up, the relationship between FT4 and log-TSH was disturbed in women with a new breast cancer diagnosis. The presence of TPOAb was not related to breast cancer during follow-up. A direct relationship between thyroid autoimmunity and breast cancer is unlikely. Hypothyroidism and low-normal FT4 are related with an increased risk of breast cancer in post-menopausal women. Studies are needed to clarify the origins of this possible association.

Comparison between the Klemetti index and heel DXA BMD measurements in the diagnosis of reduced skeletal bone mineral density in the elderly

Osteopenia/osteoporosis affect many elderly people and might not be detected until symptoms of fractures occur. Early detection of osteopenia/osteoporosis is important and would allow preventive measures and treatment. Access to screening for osteopenia/osteoporosis is often limited, whereas panoramic radiography is commonly used in dentistry. The aim of this study was to determine the validity of the Klemetti index (KI), measured on panoramic radiographs, in the diagnosis of osteopenia/osteoporosis as defined by a bone mineral density (BMD) measurement below -1.5 standard deviations (SDs) of a community based sample. In total, 211 consecutive participants (102 men and 109 women) 60-96 years in the SNAC-Blekinge study (Swedish National Study on Ageing and Care) underwent bone densitometry [by dual-energy X-ray absorptiometry (DXA)] of both heels. A panoramic radiograph was taken of each participant, and mandibular cortex on a panoramic radiograph was classified as '0' or normal (even and sharp endosteal margin), '1', moderately eroded (evidence of lacunar resorption or endosteal cortical residues), or '2', severely eroded (unequivocal porosity). From logistic regression, the odds ratio of having a BMD measurement below -1.5 SD was 8.04 (95% CI 2.39 to 27.12, P<0.001) in the 'osteopenic' (KI category 2), compared with the 'normal' group (KI categories 0 and 1). Receiver operating characteristic (ROC) curve analysis was used to measure the validity of the KI indicating osteopenia (KI category 2) in predicting reduced BMD. This point provided a sensitivity of 50% and a specificity of 89%. Positive and negative predictive values were 21% and 97%, respectively. There were 87% correctly classified subjects. The area under the ROC curve was 0.64. The present study demonstrated that a negative finding (KI category <2) is highly predictive of the absence of osteopenia/osteoporosis as defined by the DXA measurements.

The elderly at risk for periodontitis and systemic diseases

The increasing population of older subjects with dental care needs will become a major challenge to our society and its care providers. To manage the health care needs of the elderly, a coordination between medical and dental care providers will become necessary. From the dental perspective, it is important to develop skills in the risk assessment of older patients. Such risk assessment of older subjects should take an approach that is holistic and focused on the reduction of the infectious burden and the improvement of self-efficacy.

Bone mineral density of the spine and femur in healthy Saudis

The reference values of bone mineral density (BMD) were determined in healthy Saudis of both sexes and compared with US / northern European and other reference data. BMD was determined by dual-energy X-ray absorptiometry (DXA) at the lumbar spine and femur including subregions: trochanter, Ward's triangle, and neck, in 1,980 randomly selected Saudis (age range 20-79 years; 915 males and 1,065 females) living in the Jeddah area. Age-related changes in BMD were similar to those described in US / northern European and Lebanese reference data. Decreases in BMD of males were evident (% per year): 0.3-0.8 (lumbar spine), 0.2-0.4 (femoral trochanter), 0.2-1.4 (Ward's triangle), and 0.2-0.7 (femoral neck). Also, decreases in BMD of females were observed (% per year): 0.8-0.9 (lumbar spine), 0.7-0.9 (Ward's triangle), and 0.3-0.7 (femoral neck). Using stepwise multiple regressions that included both body weight and height, the former had 2-4 times greater effect on BMD than the latter. Using the mean BMD of the <35-year-old group the T-score values were calculated for Saudis. The prevalence of osteoporosis in Saudis (50-79 years) at the lumbar spine using the manufacturer's vs Saudi reference data was 38.3-47.7% vs 30.5-49.6 (P<0.000), respectively. Similarly, based on BMD of total femur, the prevalence of osteoporosis using the manufacturer's vs Saudi reference data was 6.3-7.8% vs 1.2-4.7% (P<0.000), respectively. Saudis (> or =50 years) in the lowest quartile of body weight exhibited higher prevalence of osteoporosis (25.6% in females and 15.5% in males) as compared to that of the highest quartiles (0.0% in females and 0.8% in males). The present study underscores the importance of using population-specific reference values for BMD measurements to avoid overdiagnosis and/or underdiagnosis of osteoporosis.

The increase in cholesterol with menopause is associated with the apolipoprotein E genotype. A population-based longitudinal study

During menopause, a sharp increase in cholesterol concentration occurs with an unexplained wide variation in change. Possibly, this is attributable to genetic variation. The authors prospectively studied the effect of the apolipoprotein E (APOE) genotype on the change in cholesterol level with menopause among 1116 Dutch women. Women with the APOE3E3 genotype were regarded as the reference category and changes were adjusted for age at baseline, years of follow-up, years since menopause, and body mass index. At baseline, the women were on average 50.4 years. After 5.9 years of follow-up, the women were on average 4.3 years (S.D. 1.5 years) postmenopausal. The mean increase in cholesterol with menopause in women with the APOE3E3 genotype was 0.67 mmol/L (95% CI, 0.61-0.72 mmol/L). In women with the APOE2E3 genotype the increase in cholesterol was 0.44 mmol/L (CI, 0.32-0.56 mmol/L). The increase in cholesterol in women with the APOE3E4 genotype did not differ from the increase in women with the APOE3E3 genotype. These results show that the increase in cholesterol level with menopause is 30% lower in women with the APOE2E3 genotype when compared with women with the APOE3E3 genotype, indicating that the APOE genotype contributes to the variation in cholesterol increase with menopause.

Multiple assessments of depressive symptoms as an index of depression in population-based samples

The incremental validity of repeated measurements of a short depression questionnaire was examined regarding the clinical diagnosis of depression. Participants were 951 randomly selected women of around menopausal age. They completed the Edinburgh Depression Scale (EDS) at two time points, with approximately 18 months in between. At the second time point, they participated in a structured clinical interview for depression diagnosis based on the Research Diagnostic Criteria (RDC). With repeated assessments, specificity and negative predictive value (NPV) did not change much relative to a single assessment, with a specificity of 95.0% and a NPV of 91.7% at a cut-off score of 12 on the EDS. As expected, sensitivity dropped, from 87.9% to 58.8%. However, positive predictive value (PPV) increased from 42.0% to 49.1% at a cut-off of 12. When using a cut-off score of 15 on the EDS, the PPV based on both EDS measurements reached 61.8%, yielding a 25-fold probability of being a case for women scoring above 15 at both time points (OR=24.54, 95% CI=14.24-42.28). In conclusion, the 10-item EDS is a reliable, valid and valuable screening instrument. When employed repeatedly, a more stable depression may be tapped, which can be of substantial value for both epidemiological research and clinical practice.

Osteoporosis prevalence in men varies by the normative reference

Controversy surrounds which normative data should be used to estimate osteoporosis prevalence in men. Prevalence estimates may vary significantly when different normative standards are applied. Five normative datasets (NHANES female norms, local female norms, Hologic densitometer manufacturer female norms, NHANES male norms, Hologic male norms) were used to estimate the prevalence of osteoporosis by World Health Organization diagnostic criteria in a study population of 311 consecutive men between the age of 30 and 91 (mean 60.3 yr) referred to an outpatient osteoporosis center between January 1996 and December 1998. Statistically significant variations were seen in osteoporosis prevalence measured at three anatomical sites. The greatest relative variation was seen for the total femur, where osteoporosis prevalence ranged from 7.0% (NHANES and Hologic female norms) to 15.6% (NHANES male norms). The least relative variation was seen at the lumbar spine, where prevalence ranged from 18.1% (Hologic female norms) to 29.6% (local female norms). When considering osteoporosis at any site, prevalence was lowest (23.5%) based on Hologic female norms and highest (35.8%) based on local female norms. Interpretation of prevalence data should include an assessment of how normative standards influence reporting of the population at high risk of fracture.

Menopausal transition and increased depressive symptomatology: a community based prospective study

OBJECTIVE

Prevalence of depression is suggested to be substantially higher in women around menopause. Declining estrogen levels might be an explanation. This study attempts to determine whether depressive symptomatology in healthy women is independently related to menopausal transition.

METHOD

All caucasian women born between 1941 and 1947, living in the city of Eindhoven the Netherlands were invited to take part in a screening program (n=8098) of whom 78% participated (n=6648). About 92% returned the questionnaires of which 81% (n=4975) was fully completed. Women using estrogens and/or having undergone hysterectomy and/or ovariectomy were excluded (43.6%). Of the remaining 2820 women, after 3.5 years, 2748 returned another postal questionnaire, of which 76% was fully completed (n=2103). Depressive symptomatology was assessed using the Edinburgh Depression Scale (EDS). Independent relationship between an intra-individual change in EDS score during the follow-up period and menopausal transition was analysed by multiple logistic regression (enter as well as stepwise method).

RESULTS

Beside the classical determinants of depression (unemployment OR 3.1, CI 1.6-5.8, inability to work OR 1.7, CI 1.0-2.8, financial problems OR 2.9, CI 1.1-7.3 death of a partner OR 2.6, CI 1.1-6.1, death of a child OR 5.9, CI 1.1-32.1 and a previous episode of depression OR 2.0, CI 1.5-2.7) transition from pre to perimenopause and peri to postmenopause was significantly related to a high increase (>5.4) of the EDS score (OR 1.8, CI 1.1-3.3 and OR 1.8, CI 1.5-2.7, respectively).

CONCLUSION

The transition from pre to perimenopause as well as from peri to postmenopause seems to be independently related to a high increase of depressive symptomatology. This suggests that the decrease of ovarian estrogen production is a risk factor for depressive symptomatology.

Decreased bone mineral density is common after autologous blood or marrow transplantation

Survivors of autologous blood or marrow transplantation (ABMT) are predisposed to decreased bone mineral density (BMD), but data are lacking on the incidence and risk factors for this condition. Therefore, we measured BMD in 64 of 68 consecutive ABMT survivors (35 men and 29 women) attending the University of Toronto ABMT long-term follow-up clinic. Patients were evaluated a median of 4.2 years (range: 4.9 months-11.4 years) after ABMT. Median age at evaluation was 49.6 years (range: 23.5-68.2 years). At the L1-L4 vertebrae, 17 (26%) patients (eight men and nine women) had osteopenia and one male (2%) had osteoporosis. Mean BMD at L1-L4 did not differ from healthy young adults or age and sex matched controls. At the femoral neck, 30 patients (46%) (18 men and 12 women) had osteopenia and five (8%) (two men and three women) had osteoporosis. Mean BMD at the femoral neck was significantly lower than in healthy young adults and age- and sex-matched controls. By regression analysis, patients with decreased BMD were older than those with normal BMD (P = 0.02). Gender, body mass index, time from BMT to evaluation and presence of hypogonadism were not associated with decreased BMD. Treatment of decreased bone density was instituted and follow-up data were obtained 1 year after treatment in 22 of 39 patients with reduced BMD. Nineteen (86%) patients had stabilization or improvement of their bone density at follow-up. We conclude that, after ABMT, over half of the patients have evidence of osteopenia or osteoporosis. Men and women were equally affected. In our study, only older age at evaluation was predictive for loss of BMD. We recommend the measurement of BMD as an integral component to the follow-up of ABMT patients.

Measuring depression in women around menopausal age: towards a validation of the Edinburgh Depression Scale

BACKGROUND

The relationship between menopause and depression is still rather unclear. Studies using different methodology - especially those lacking a clear definition of depression - are hardly comparable. Since the Edinburgh Depression Scale (EDS) is not influenced by (menopause-related) somatic symptoms, the validity of the Dutch version of this instrument was investigated in a large community sample of menopausal women.

METHODS

In 951 women, aged between 47 and 56 years, depressive symptomatology was measured using the EDS, together with a syndromal diagnosis of depression using Research Diagnostic Criteria.

RESULTS

Twenty-two percent of the subjects had scores of 12 or higher on the EDS. With this cut-off point, depression (major or minor) was detected with a sensitivity of 66%, a specificity of 89%, and a positive predictive value (PPV) of 62%. A cut-off score of 15 or higher detected half of the women with major depression (sensitivity 73%, specificity 93%, PPV 53%).

LIMITATIONS

Screening of depressive symptomatology at menopausal age in women of the community can only partly detect women with clinical depression. The relation between menopausal status and depression should preferentially be investigated using a longitudinal rather than a cross-sectional design.

CONCLUSIONS

The EDS, which is easy to implement in both community and clinical settings (e.g., General Practice), might be used as an effective screening tool for detecting women at menopausal age who are at risk for depression, followed by clinical evaluation in those with high scores.

Hormonal substitution during menopause: what are we treating?

OBJECTIVES

It is suggested that during menopausal transition, women with vasomotor symptoms benefit from HRT, (hormone replacement therapy) whereas, the use of HRT for other cognitive-vegetative symptoms is questionable.

METHODS

The occurrence of menopausal complaints and depressive symptoms was assessed cross-sectionally in 5896 Dutch Caucasian women (47-54 years) of a large community sample in the city of Eindhoven, The Netherlands. Menopausal complaints were assessed using a 22 items self-rating scale (consisting of a vasomotor, uro-genital and a cognitive-vegetative subscale). Depressive symptoms were assessed using the Edinburgh depression scale (EDS). Differences in mean scores were analysed between groups using ANOVA. The independent relationship of depressive symptoms to the intensity of menopausal complaints was assessed, by multiple linear regression analysis.

RESULTS

Women using HRT showed the highest scores on all subscales. Oral contraceptive users had significantly lower scores on the vasomotor subscale compared to HRT users and to non users. Depressive symptoms contributed the most, to the explained variance on scores on the menopausal subscales.

CONCLUSIONS

Women during menopause presenting several complaints, other than vasomotor origin might be suffering from underlying depression which makes it questionable to prescribe HRT for the latter symptoms.