Tobacco smoking and risk of hip fracture in men and women

The positive impact of smoking cessation on fracture risk in a nationwide cohort study

Many studies sought to demonstrate the association between smoking and fracture risk. However, the correlation between smoking and fractures remains controversial. This study aimed to examine the impact of smoking and smoking cessation on the occurrence of fractures using prospective nationwide cohort data. We enrolled those who underwent a National Health Insurance Service (NHIS) health checkup in 2009-2010 who had a previous health checkup 4-year prior (2005-2006). The study population of 4,028,559 subjects was classified into three groups (non-smoker, smoking cessation, current smoker). The study population was also analyzed according to fracture type (all fractures, vertebral fracture, hip fracture). Lastly, the smoking cessation group and current smoker group were divided into four subgroups based on a lifetime smoking amount cut-off of 20 pack-years (PY). Multivariate-adjusted hazard ratios (HRs) of fracture were examined through a Cox proportional hazards model. After multivariable adjustment, non-smokers showed the lowest risk of fracture (HR = 0.818, CI 0.807-0.828, p < 0.0001) and smoking cessation significantly lowered the risk of fracture (HR 0.938, 95% CI 0.917-0.959, p < 0.0001) compared to current smokers. Regardless of 20PY, all smoking cessation subgroups showed significantly less risk of fractures than current smokers with ≥ 20PYs. Smoking increases the risk of fracture, and smoking cessation lowers the risk of fracture.

Association between Smoking Status and the Risk of Hip Fracture in Patients with Type 2 Diabetes: A Nationwide Population-Based Study

BACKGRUOUND

Limited longitudinal evidence exists regarding the potential association between smoking status and hip fracture among individuals with type 2 diabetes. We investigated this association using large-scale, nationwide cohort data for the Korean population.

METHODS

This nationwide cohort study included 1,414,635 adults aged 40 and older who received Korean National Health Insurance Service health examinations between 2009 and 2012. Subjects with type 2 diabetes were categorized according to their smoking status, amount smoked (pack-years), number of cigarettes smoked per day, and duration of smoking. The results are presented as hazard ratios (HRs) and 95% confidence intervals (CIs) for the associations between smoking status parameters and risk of hip fracture in multivariable Cox proportional hazard regression analysis.

RESULTS

Compared with never-smokers, an increased adjusted HR (aHR) for hip fracture was observed in current smokers (1.681; 95% CI, 1.578 to 1.791), and a comparable aHR for hip fracture was found in former smokers (1.065; 95% CI, 0.999 to 1.136). For former smokers who had smoked 20 pack-years or more, the risk was slightly higher than that for never-smokers (aHR, 1.107; 95% CI, 1.024 to 1.196). The hip fracture risk of female former smokers was similar to that of female current smokers, but the hip fracture risk in male former smokers was similar to that of male never-smokers.

CONCLUSION

Smoking is associated with an increased risk of hip fracture in patients with type 2 diabetes. Current smokers with diabetes should be encouraged to quit smoking because the risk of hip fracture is greatly reduced in former smokers.

Prevention of Hip Fractures: Trade-off between Minor Benefits to Individuals and Large Benefits to the Community

Goeffrey Rose postulated that a population-based measure bringing a small benefit to each individual can yield large benefits to the community. We aimed to test this axiom by quantifying the relationship between change in bone mineral density (BMD) and hip fracture incidence between two prospective cohorts separated by ~10 years. In this prospective population-based Dubbo Osteoporosis Epidemiology Study (DOES), the participants aged 60+ were recruited in two waves: the initial cohort (1311 women, 842 men) in 1989 to 1992 and the second cohort (974 women, 544 men) in 1999 to 2001. The incident hip fracture was radiologically ascertained. Femoral neck BMD was measured biannually. Multivariable-adjusted Cox's proportional hazards models were adjusted for the predefined covariates such as age, BMI, lifestyle factors, falls, and prior fracture. Compared with the initial cohort, the second cohort had a higher femoral neck BMD by ~0.04 g/cm2 in women and 0.03 g/cm2 in men. However, the prevalence of osteoporosis in the second cohort was halved (prevalence ratio 0.51, 95% CI 0.36 to 0.73 in women; 0.45, 0.24 to 0.84 in men), and its hip fracture incidence was significantly reduced (hazard ratio 0.54, 95% CI, 0.38 to 0.78 in women; 0.39, 0.19 to 0.80 in men). Sensitivity analyses indicated that the "effect" was unlikely due to unmeasured confounders. These findings suggest that a population-wide strategy aimed at enhancing BMD across the entire population could lead to a substantial decrease in the incidence of hip fractures. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

The impact of COVID-19 on mortality after hip fracture : a population cohort study from England

AIMS

Hip fracture commonly affects the frailest patients, of whom many are care-dependent, with a disproportionate risk of contracting COVID-19. We examined the impact of COVID-19 infection on hip fracture mortality in England.

METHODS

We conducted a cohort study of patients with hip fracture recorded in the National Hip Fracture Database between 1 February 2019 and 31 October 2020 in England. Data were linked to Hospital Episode Statistics to quantify patient characteristics and comorbidities, Office for National Statistics mortality data, and Public Health England's SARS-CoV-2 testing results. Multivariable Cox regression examined determinants of 90-day mortality. Excess mortality attributable to COVID-19 was quantified using Quasi-Poisson models.

RESULTS

Analysis of 102,900 hip fractures (42,630 occurring during the pandemic) revealed that among those with COVID-19 infection at presentation (n = 1,120) there was a doubling of 90-day mortality; hazard ratio (HR) 2.09 (95% confidence interval (CI) 1.89 to 2.31), while the HR for infections arising between eight and 30 days after presentation (n = 1,644) the figure was greater at 2.51 (95% CI 2.31 to 2.73). Malnutrition (1.45 (95% CI 1.19 to 1.77)) and nonoperative treatment (2.94 (95% CI 2.18 to 3.95)) were the only modifiable risk factors for death in COVID-19-positive patients. Patients who had tested positive for COVID-19 more than two weeks prior to hip fracture initially had better survival compared to those who contracted COVID-19 around the time of their hip fracture; however, survival rapidly declined and by 365 days the combination of hip fracture and COVID-19 infection was associated with a 50% mortality rate. Between 1 January and 30 June 2020, 1,273 (99.7% CI 1,077 to 1,465) excess deaths occurred within 90 days of hip fracture, representing an excess mortality of 23% (99.7% CI 20% to 26%), with most deaths occurring within 30 days.

CONCLUSION

COVID-19 infection more than doubles the rate of early hip fracture mortality. Those contracting infection between 8 and 30 days after initial presentation are at even higher mortality risk, signalling the potential for targeted interventions during this period to improve survival.Cite this article: Bone Joint J 2022;104-B(10):1156-1167.

Smoking and fracture risk in men: a meta-analysis of cohort studies, using both frequentist and Bayesian approaches

Past studies indicate that men are more likely to smoke and be at higher risk of smoking-related conditions than women. Our research aimed, through meta-analysis, to assess the association between smoking and fracture risk in men. The following databases were searched, including MEDLINE, EMBASE, Scopus, PsycINFO, ISI Web of Science, Google Scholar, WorldCat, and Open Grey, for identifying related studies. A random-effects model was used to pool the confounder-adjusted relative risk (R.R.). Frequentist and Bayesian hierarchical random-effects models were used for the analysis. The heterogeneity and publication bias were evaluated in this study. Twenty-seven studies met the inclusion criteria. Overall, smoking is associated with a significantly increased risk of fracture in both the frequentist approach (R.R., 1.37; 95% confidence interval: 1.22, 1.53) and the Bayesian approach (R.R., 1.36; 95% credible interval: 1.22, 1.54). Significant heterogeneity was observed in the meta-analysis (Higgin's I² = 83%) and Cochran's Q statistic (p < 0.01). A significant association was also observed in multiple pre-specified sensitivity and subgroup analyses. Similar results were observed in the group containing a large sample size (≥ 10,000 participants), and the group has a small sample size (< 10,000 participants); the pooled R.R was 1.23 (95% confidence interval, 1.07–1.41) and 1.56 (95% confidence interval, 1.37–1.78), respectively. With the Bayesian method, the effect size was 1.23 (95% credible interval, 1.05, 1.45) for the large sample size group and 1.57 (95% credible interval, 1.35, 1.82) for the small sample size group. Smoking is associated with a significant increase in fracture risk for men. Thus, smoking cessation would also greatly reduce fracture risk in all smokers, particularly in men.

Gender differences in modifiable risk factors for hip fracture: 10-year follow-up of a prospective study of 0.5 million Chinese adults

BACKGROUND

Little is known about the incidence rates and importance of major modifiable risk factors for hip and major osteoporotic fractures in low- and middle-income countries. We estimated the age- and sex-specific incidence of hip, major osteoporotic, and any fractures and their associated risk factors in Chinese adults.

METHODS

This was a prospective study of 512,715 adults, aged 30-79 years, recruited from 10 diverse areas in China from 2004 to 2008 and followed up for 10 years. Age- and sex-specific incidence rates were estimated, and Cox regression was used to yield adjusted hazard ratios (HRs) and population attributable fractions for risk factors.

RESULTS

The incidence rates of hip fracture in Chinese adults were 5.1 (95% confidence interval [CI] 5.0-5.3) per 10,000 person-years; they were higher in women than in men and increased by two- to threefold per 10-year older age. Among men, five risk factors for hip fracture, including low education (HR = 1.23; 95% CI 1.04-1.45), regular smoker (1.22, 1.03-1.45), lower weight (1.59, 1.34-1.88), alcohol drinker (1.18, 1.02-1.36), and prior fracture (1.62, 1.33-1.98), accounted for 44.3% of hip fractures. Among women, lower weight (1.30, 1.15-1.46), low physical activity (1.22, 1.10-1.35), diabetes (1.62, 1.41-1.86), prior fracture (1.54, 1.33-1.77), and self-rated poor health (1.29, 1.13-1.47) accounted for 24.9% of hip fractures. Associations of risk factors with major osteoporotic or any fractures were weaker than those with hip fractures.

CONCLUSIONS

The age- and sex-specific incidence rates of hip fracture in Chinese adults were comparable with those in Western populations. Five potentially modifiable factors accounted for half of the hip fractures in men and one quarter in women.

Decreasing hip fracture rates among older adults in Chile, 2001-2019

Our aim was to analyze trends in hip fracture rates in people aged ≥ 65 years, from 2001 to 2019 in Chile. Age-standardized incidence rates decreased significantly in both genders over the study period.

PURPOSE

To describe and analyze the characteristics and trends of osteoporotic hip fractures in Chile from 2001 to 2019, by age and sex.

METHODS

We assessed hip fractures in people aged ≥ 65 years using data from the hospital discharge register of Chile's Department of Statistics and Health. The Joinpoint regression analysis software was used to perform a trend analysis.

RESULTS

From 2001 to 2019, a total of 107.972 patients aged ≥ 65 years were hospitalized in Chile with a diagnosis of hip fracture (S72.0, S72.1, and S72.2). 77.4% of the patients were females, and 63.7% were adults aged ≥ 80 years. The average annual incidence rate over this period was 358.3/100.000 in the whole population (95% CI: ± 12.8), 195.2/100.000 in men (95% CI: ± 9), and 482/100.000 in women (95% CI: ± 15.5). After an adjustment for age, hip fracture rates decreased annually on average by 1.0% (p < 0.001, 95% CI: - 1.4%, - 0.7%), from 358.5/100.000 in 2001 to 331.7/100.000 in 2019. Hip fracture rates decreased annually in both men (- 1.4%, p < 0.001) and women (- 0.9%, p < 0.001).

CONCLUSION

The incidence of osteoporotic hip fractures has been decreasing annually and significantly in Chile since 2001, both in men and women. This may be caused by increased levels of obesity and a lower risk of falling among older adults. We recommend further studies to assess all factors contributing to this change in hip fracture rates.

Smoking is associated with impaired verbal learning and memory performance in women more than men

Vascular contributions to cognitive impairment and dementia (VCID) include structural and functional blood vessel injuries linked to poor neurocognitive outcomes. Smoking might indirectly increase the likelihood of cognitive impairment by exacerbating vascular disease risks. Sex disparities in VCID have been reported, however, few studies have assessed the sex-specific relationships between smoking and memory performance and with contradictory results. We investigated the associations between sex, smoking, and cardiovascular disease with verbal learning and memory function. Using MindCrowd, an observational web-based cohort of ~ 70,000 people aged 18-85, we investigated whether sex modifies the relationship between smoking and cardiovascular disease with verbal memory performance. We found significant interactions in that smoking is associated with verbal learning performance more in women and cardiovascular disease more in men across a wide age range. These results suggest that smoking and cardiovascular disease may impact verbal learning and memory throughout adulthood differently for men and women.

Cigarette smoke-associated inflammation impairs bone remodeling through NFκB activation

Background

Cigarette smoking constitutes a major lifestyle risk factor for osteoporosis and hip fracture. It is reported to impair the outcome of many clinical procedures, such as wound infection treatment and fracture healing. Importantly, although several studies have already demonstrated the negative correlation between cigarette consume and impaired bone homeostasis, there is still a poor understanding of how does smoking affect bone health, due to the lack of an adequately designed animal model. Our goal was to determine that cigarette smoke exposure impairs the dynamic bone remodeling process through induction of bone resorption and inhibition of bone formation.

Methods

We developed cigarette smoke exposure protocols exposing mice to environmental smoking for 10 days or 3 months to determine acute and chronic smoke exposure effects. We used these models, to demonstrate the effect of smoking exposure on the cellular and molecular changes of bone remodeling and correlate these early alterations with subsequent bone structure changes measured by microCT and pQCT. We examined the bone phenotype alterations in vivo and ex vivo in the acute and chronic smoke exposure mice by measuring bone mineral density and bone histomorphometry. Further, we measured osteoclast and osteoblast differentiation gene expression levels in each group. The function changes of osteoclast or osteoblast were evaluated.

Results

Smoke exposure caused a significant imbalance between bone resorption and bone formation. A 10-day exposure to cigarette smoke sufficiently and effectively induced osteoclast activity, leading to the inhibition of osteoblast differentiation, although it did not immediately alter bone structure as demonstrated in mice exposed to smoke for 3 months. Cigarette smoke exposure also induced DNA-binding activity of nuclear factor kappaB (NFκB) in osteoclasts, which subsequently gave rise to changes in bone remodeling-related gene expression.

Conclusions

Our findings suggest that smoke exposure induces RANKL activation-mediated by NFκB, which could be a “smoke sensor” for bone remodeling.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12967-021-02836-z.

Preexisting dementia is associated with higher mortality rate in patients with femoral neck fracture

OBJECTIVE

This study aimed to assess the mortality and the influence of age, Abbreviated Mental Test (AMT) scores, and American Society of Anesthesiologists (ASA) grades on patients with dementia and femoral neck fracture (FNF) at 30 days, 4 months, 1 year, and 2 years after undergoing surgery.

METHODS

Of 1296 patients admitted with FNF, 180 had had prefracture dementia. A retrospective study of these 180 patients was carried out. The patient demographics, including age, sex, presence of diabetes mellitus (DM), lipid profile, AMT score, preoperative comorbidities, ASA grade, and incidence of postoperative delirium, were documented.

RESULTS

A total of 113 patients (62.8%) died postoperatively. The mortality rate was 17.7% (20 patients) at 30 days, 54.9% (62 patients) at 4 months, 77.9% (88 patients) at 1 year, and 87.6% (99 patients) at 2 years. The mortally rate in dementia with FNF was three times higher than that in FNF without dementia and was independent of age, ASA grades, DM, lipid profile, AMT scores, and development of postoperative delirium.

CONCLUSIONS

Dementia should be a principal predictive factor in mortality of FNF and should be a key determinant in all frailty scores.

Prevalence, Characteristics, and Associated Risk Factors of the Elderly with Hip Fractures: A Cross-Sectional Analysis of NHANES 2005-2010

Objective

This cross-sectional study was aimed to update the assessment of prevalence, characteristics, and risk factors of the elderly with hip fractures in a non-institutionalized American population.

Methods

This current study included a total of 31,034 participants from the existing National Health and Nutritional Examination Survey (NHANES) database from 2005 to 2010, and 4,265 participants aged 65 years and older were ultimately identified. Their condition of hip fractures was determined by method of questionnaires according to the orthopedic surgeons' diagnosis, and related epidemiological and demographic data were further collected. The univariate analysis was used to screen the risk factors of hip fractures in the elderly, and the logistic regression model was established to conduct the multivariate analysis.

Results

Of the total 4,265 participants with clear information of hip fractures in elderly, 127 individuals with hip fractures were identified according to results of questionnaires, exhibiting a prevalence of 28.49 per 1,000 (95% confidence interval [CI]=21.38-35.60) for males and 31.03 per 1,000 (95% CI=23.72-38.35) for females. The mean age of the elderly with hip fractures was 77.12±5.88 years and tumble (48.0%) was the primary factor. In univariate analysis, age, race, smoking, drinking alcohol, and combined with osteoporosis were regarded as risk factors. Multivariate analysis showed that age (80 years and older), living alone, smoking, combined with diabetes and osteoporosis were the independent risk factors.

Conclusion

Our nationwide data indicate the prevalence of hip fractures in the elderly is generally on the rise, and the female occupies a higher proportion. Age (especially aged 80 years and older), race (mainly Non-Hispanic white), smoking, drinking alcohol, living alone, combined with diabetes and osteoporosis may be closely linked to the occurrence of hip fractures in the elderly, although these variables still need to be verified in further prospective investigations.

Lung-Specific Risk Factors Associated With Incident Hip Fracture in Current and Former Smokers

Hip fractures are associated with significant morbidity and mortality in smokers with lung disease, but whether lung-specific factors are associated with fracture risk is unknown. Our goal was to determine whether lung-specific factors associate with incident hip fracture and improve risk discrimination of traditional fracture risk models in smokers. The analysis consisted of a convenience sample of 9187 current and former smokers (58,477 participant follow-up years) participating in the Genetic Epidemiology of chronic obstructive pulmonary disease (COPD) longitudinal observational cohort study. Participants were enrolled between 2008 and 2011 with follow-up data collection through July 2018. Traditional risk factors associated with incident hip fracture (n = 361) included age, female sex, osteoporosis, prevalent spine and hip fracture, rheumatoid arthritis, and diabetes. Lung-specific risk factors included post-bronchodilator percent forced expiratory volume in 1 s (FEV₁ %) predicted (OR, 0.95; 95% CI, 0.92-0.99 for each 10% increase), Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification (OR, 1.09; 95% CI, 1.002-1.19 for each higher stage), presence of CT-determined emphysema (OR, 1.34; 95% CI, 1.06-1.69), symptom scores (OR, 1.10; 95% CI, 1.03-1.19 for each higher unit score), 6-min walk distance (OR, 0.92; 95% CI, 0.90-0.95 for each 30-m increase), body mass index, airflow obstruction, dyspnea, and exercise (BODE) index (OR, 1.07; 95% CI, 1.01-1.13 for each higher unit score), total exacerbations (OR, 1.13; 95% CI, 1.10-1.16 per exacerbation), and annual exacerbations (OR, 1.37; 95% CI, 1.21-1.55 per exacerbation). In multivariable modeling, age, black race, osteoporosis, prevalent hip and spine fracture, rheumatoid arthritis, and diabetes were associated with incident hip fracture. The presence of emphysema, 6-min walk distance, and total number of exacerbations added to traditional models improved risk discrimination (integrated discrimination improvement [IDI] values 0.001 [95% CI, 0.0003-0.002], 0.001 [95% CI, 0.0001-0.002], and 0.008 [95% CI, 0.003-0.013], corresponding to relative IDIs of 12.8%, 6.3%, and 34.6%, respectively). These findings suggest that the incorporation of lung-specific risk factors into fracture risk assessment tools may more accurately predict fracture risk in smokers. © 2020 American Society for Bone and Mineral Research.

Ethnic differences in risk of hip fracture in Norway: a NOREPOS study

Hip fracture is a major public health problem, and the incidence rates vary considerably between countries. Ethnic differences in bone mineral density have been identified as a factor to explain some of the geographical differences in rates of hip fracture. In this Norwegian register-based study, we found that all immigrant groups experienced lower risk of hip fracture than individuals born in Norway.

INTRODUCTION

Norway is among the countries with the highest incidence rates. The aim of this study was to investigate differences in risk of hip fracture between ethnic groups living in Norway.

METHODS

We linked individuals in the Norwegian Population and Housing Census conducted in 2001 and a database consisting of all hip fractures in Norway in the period 2001-2013. Residents (n = 1,392,949) between 50 and 89 years and born in nine different geographical regions of the world were examined, and we computed age-standardized incidence rates for the different geographic regions-denoted ethnic groups in the paper. Gender-stratified Cox regression analysis, adjusted for age, was used to model risk of hip fracture as a function of region of birth.

RESULTS

Age-standardized incidence rates of hip fracture varied considerably between regions of birth living in Norway, in both genders. All immigrant groups had lower risk of hip fracture compared to the Norwegian-born population. Immigrants from Central and Southeast Asia had the lowest risk of hip fracture when compared to individuals born in Norway (HR = 0.2, 95% CI 0.1-0.3 and HR =0.2, 95% CI 0.2-0.4 in men and women, respectively).

CONCLUSION

Lower risk of hip fracture was found in all immigrant groups compared to the Norwegian-born majority population.

Survival analysis of patients with hip fracture, Shiraz, Iran

This study aimed to determine factors affecting the survival of patients with hip fracture in Shiraz, Iran. Alzheimer's disease, hypertension, and cardiovascular diseases were risk factors, while female gender and living with family members or in nursing homes were protective factors against mortality following hip fracture.

PURPOSE

Hip fractures are the most common orthopedic fractures in elderly. This study aimed to determine the factors affecting the survival of patients with hip fracture in Shiraz.

METHODS

This historical cohort study was conducted in Shiraz, Iran. All patients with hip fracture who were admitted to any of the hospitals providing orthopedic services in Shiraz, from September 1, 2011, to August 30, 2012, were included in the study. The log rank test, Kaplan-Meier methods, and the univariate and multivariate Cox regression model were used for data analysis.

RESULTS

A total of 631 patients were enrolled, of these, 264 (41.8%) were male. The mean age of patients was 74.9 ± 11.5. The patients' survival rate after the 1st, 2nd, 3rd, 4th, and 5th year were 81.1%, 73.7%, 69.4%, 64.8%, and 60.2%, respectively. After adjusting data for age, Alzheimer's disease (HR = 4.9, 95% CI 1.4-7.3, P = 0.023), hypertension (HR = 2.27, 95% CI 1.3-3.8, P = 0.003), and cardiovascular diseases (HR = 2.02, 95% CI 1.04-3.09, P = 0.039) remained as risk factors for mortality in patients with hip fracture. However, female patients (HR = 0.46, 95% CI 0.27-0.8, P = 0.006) and those who lived with family members or in nursing homes (HR = 0.43, 95% CI 0.19-0.92, P = 0.03) were protective factors.

CONCLUSION

This study showed that women are more likely to have hip fractures, but mortality among men is more observable. Alzheimer's disease, hypertension, and cardiovascular diseases were considered as risk factors, while patients who were female and those who lived with the family member or in nursing homes had better survival.

Pharmacological and Non-pharmacological Means for Prevention of Fractures among Elderly

Fractures are major cause of morbidity, mortality, and healthcare and social services expenditure in elderly. Fractures often have multifactorial etiologies and the condition emerges due to the interaction between the different predisposing and precipitating factors. One of the most common causes leading to fractures after minimal trauma in older people is osteoporosis. The objective of this article is to describe the clinical concept and summarize the evidence and to explain the future directions for research, focusing on specific issues related to prevent fracture in the elderly. This study reviewed the scientific literature addressing strategies for primary and secondaryprevention of fractures among elderly in the context of pharmacological and non-pharmacological means. A growing body of scientific evidence supports the use of both non-pharmacological and pharmacological interventions for the prevention of fracture. Research on these interventions has yielded positive outcomes in fracture rates. The bisphosphonates and vitamin D and calcium suppliments are the preferred therapy for prevention of osteoporotic fractures. Weight-bearing exercise and reducing home hazards have beneficial effects in reducing the incidence of falls and consequently reduce fractures. Prevention of fractures in elderly consists of therapy and prevention of osteoporosis, fall prevention, and using injury-site protection by high-risk elderly patients. Special consideration needs to be taken to reduce home hazard, and falls prevention education can be recommended to the elderly with history of fall or mobility limitations. Future research to prevent fractures in elderly population should not only concentrate on improving bone density and strength but also need to be focused on falls reduction strategies.

Current and former smokers and hip fractures

The purpose of this review is to examine the correlation between tobacco smoking and hip fractures. The literature that was used for this article was based on studies that investigated not only the direct correlation between smoking and hip fractures but also the effect of smoking on bone mineral density. In general, the incidence of hip fracture was found to be higher in current smokers in both genders. Compared with never smokers, former smokers had a slightly higher risk of hip fracture that was inversely proportional to the cessation span. The relative risk (RR) of hip fracture in current male smokers was higher than the RR for nonsmokers (never and former smokers). In postmenopausal women former and current smoking increased the RR. In premenopausal and postmenopausal women, cessation of smoking decreases the risk of hip fracture. Risk rises with greater cigarette consumption. Risk declines among former smokers, but the benefit is not observed until 10 years after cessation.

Changes over time in hip fracture risk: Greater improvements in men compared to women

PURPOSE

The aim of this study was to determine whether there has been a change in the mean age and age-standardized incidence of minimal trauma hip fractures in the Newcastle and Lake Macquarie population of Australia between 1998 and 2015.

METHOD

Patients with neck of femur fractures over 50 who presented to the regional referral centre were retrospectively identified using the ICD-9 and ICD-10 coding system.

RESULTS

There were 233 and 308 eligible patients in 1998 and 2015, respectively. For females, the mean age for hip fracture of 83.2 years in 1998 was not significantly different from the mean age of 84.5 years in 2015 (P = .16). For males, the mean age for hip fracture was significantly older at 84.6 years in 2015 compared to 80.4 years in 1998 (P = .005). For females, the decrease in the rate of hip fracture from 1998 to 2015 was 13% and was weakly statistically significant (IRR = 0.86, P = .05). For males, there was a statistically significant decrease in the rate of hip fractures from 1998 to 2015 by 33% (IRR = 0.67, P = .001).

CONCLUSION

Our study shows a decrease in age-standardized rates of hip fractures for men and women and suggests that men are demonstrating a greater improvement in bone health compared to women.

The Combined Effect of Cigarette Smoking and Fitness on Injury Risk in Men and Women

Background

Prior studies have identified cigarette smoking and low fitness as independent risk factors for injury; however, no studies have evaluated the combined effect of cigarette smoking and fitness on injury risk.

Objective

To evaluate the combined effect of cigarette smoking and fitness on injury risk in men and women.

Design

This is a secondary analysis of data collected from US Army recruits (n = 2000) during basic combat training within the United States in 2007. Physical training and fitness, cigarette smoking, and prior injury data were obtained from questionnaires, whereas demographic and injury data were obtained from medical and basic combat training unit records. Chi-squared tests were used to assess differences in injury risk by fitness level and cigarette smoking. Relative risk values were calculated with 95% confidence intervals.

Results

The primary findings showed that smokers experienced 20%–30% higher risk of injury than nonsmokers. In addition, higher aerobic and muscular fitness was generally not protective against injury between least fit and more fit smokers. However, higher fitness was protective against injury between least and more fit nonsmokers, with least fit nonsmokers being 30%–50% more likely to experience an injury than fit nonsmokers.

Conclusion

This study revealed that higher aerobic and muscular fitness was not protective against injury among smokers; however, it was protective against injury among nonsmokers. Further implementation of smoking cessation programs may be beneficial for military and civilian personnel who are required to be physically fit in order to carry out their job responsibilities.

Implications

Male and female smokers experienced significantly higher risk of injury than nonsmokers. Although higher fitness is protective against injury in nonsmokers, the protective effect of fitness is lost among smokers. In an attempt to reduce injury risk among military and emergency personnel, smoking cessation programs should be further implemented among both more fit and less fit smokers.

A profiling analysis of contributions of cigarette smoking, dietary calcium intakes, and physical activity to fragility fracture in the elderly

Fragility fracture and bone mineral density (BMD) are influenced by common and modifiable lifestyle factors. In this study, we sought to define the contribution of lifestyle factors to fracture risk by using a profiling approach. The study involved 1683 women and 1010 men (50+ years old, followed up for up to 20 years). The incidence of new fractures was ascertained by X-ray reports. A "lifestyle risk score" (LRS) was derived as the weighted sum of effects of dietary calcium intake, physical activity index, and cigarette smoking. Each individual had a unique LRS, with higher scores being associated with a healthier lifestyle. Baseline values of lifestyle factors were assessed. In either men or women, individuals with a fracture had a significantly lower age-adjusted LRS than those without a fracture. In men, each unit lower in LRS was associated with a 66% increase in the risk of total fracture (non-adjusted hazard ratio [HR] 1.66; 95% CI, 1.26 to 2.20) and still significant after adjusting for age, weight or BMD. However, in women, the association was uncertain (HR 1.30; 95% CI, 1.11 to 1.53). These data suggest that unhealthy lifestyle habits are associated with an increased risk of fracture in men, but not in women, and that the association is mediated by BMD.

Effect of Cigarette Smoking on Risk of Hip Fracture in Men: A Meta-Analysis of 14 Prospective Cohort Studies

BACKGROUND

Several observational studies have suggested an association between cigarette smoking and risk of hip fracture. However, no formal systematic review or meta-analysis was performed to summarize this risk in men.

MATERIALS AND METHODS

A search was applied to MEDLINE, EMBASE, and web of science (up to November 1 2016). All prospective cohort studies assessing risk of hip fracture with the factor of cigarette smoking in men without language restriction were reviewed, and qualities of all included studies were assessed using the Newcastle-Ottawa Scale. Two authors independently assessed literatures and extracted information eligibility, and any disagreement was resolved by consensus. Newcastle-Ottawa quality assessment scale was used to evaluate studies' quality in meta-analyses. We calculated the RR with 95% CIs in a random-effects model as well as the fixed-effects model using the metan command in the STATA version 12.0 (StataCorp, USA).

RESULTS

Fourteen prospective cohort studies were eligible for the present analysis. A meta-analysis of 12 prospective studies showed that the relative risk (RR) for current male smoking was 1.47 [95% confidence interval (CI) (1.28-1.66), p = 0.54; I2 = 0%]. Subgroup analyses show study characteristics (including geography region, length of follow-up, size of cohorts and study quality) did not substantially influence these positive associations. Eight studies reported the RRs for former smokers compared with never smokers and the pooled RR was 1.15 [95% CI, (0.97-1.34), (I2 = 0%, p = 0.975)].

CONCLUSIONS

The present meta-analysis of 14 prospective studies suggests that, compared with never smokers, cigarette smoking increases risk of hip fracture in man, specifically in current smokers. However, further larger prospective cohorts with more power or meta-analysis of individual patient data are needed to confirm this association.

Heavy Cigarette Smokers in a Chinese Population Display a Compromised Permeability Barrier

Cigarette smoking is associated with various cutaneous disorders with defective permeability. Yet, whether cigarette smoking influences epidermal permeability barrier function is largely unknown. Here, we measured skin biophysical properties, including permeability barrier homeostasis, stratum corneum (SC) integrity, SC hydration, skin surface pH, and skin melanin/erythema index, in cigarette smokers. A total of 99 male volunteers were enrolled in this study. Smokers were categorized as light-to-moderate (<20 cigarettes/day) or heavy smokers (≥20 cigarettes/day). An MPA5 was used to measure SC hydration and skin melanin/erythema index on the dorsal hand, forehead, and cheek. Basal transepidermal water loss (TEWL) and barrier recovery rates were assessed on the forearm. A Skin-pH-Meter pH900 was used to measure skin surface pH. Our results showed that heavy cigarette smokers exhibited delayed barrier recovery after acute abrogation (1.02% ± 13.06 versus 16.48% ± 6.07), and barrier recovery rates correlated negatively with the number of daily cigarettes consumption (p = 0.0087). Changes in biophysical parameters in cigarette smokers varied with body sites. In conclusion, heavy cigarette smokers display compromised permeability barrier homeostasis, which could contribute, in part, to the increased prevalence of certain cutaneous disorders characterized by defective permeability. Thus, improving epidermal permeability barrier should be considered for heavy cigarette smokers.

Measurements in Mandibular Pantomographic X-rays and Relation to Skeletal Mineral Densitometric Values

The gold standard diagnostic modality for osteoporosis is dual-energy X-ray absorptiometry (DXA). But it is expensive and often unavailable. Studies have demonstrated that decreased bone mineral density (BMD) may affect mandibular bone morphometrically on radiographs. Such studies are rare in the Indian population. This study was conducted to evaluate correlation between radiomorphometric markers on digital orthopantomograms (OPGs) and BMD measurements done by DXA in an Indian population. A total of 344 subjects aged 45 years or above, who visited a dental outpatient department over a period of 6 years were included in the study after obtaining ethical committee approval and informed consent. Digital OPG and DXA BMD measurements were obtained. Subjects' T-scores were obtained, on the basis of which they were divided into osteoporotic, osteopenic, and normal. OPGs were evaluated to obtain the mandibular cortical index (MCI) and the panoramic mandibular index (PMI). Correlations of MCI and PMI with BMD were analyzed statistically with SPSS (version 16.0; SPSS, Chicago, IL). In the osteoporotic group, there was no subject with MCI finding of C1, and 77.42% prevalence of C3 finding was found. C2 finding was in highest proportion in the osteopenic group (p<0.05). Normal BMD group was associated with the C1 finding of 76.47%. Almost 48% of the osteoporotic group had a PMI score of <0.40, whereas 50% of osteopenic subjects had a PMI score of 0.4-0.44. Normal subjects having a PMI score of >0.44 constituted 49.1% of the population. Mean BMD scores decreased significantly with increasing MCI stage and increased significantly with increasing PMI (p<0.05). Significant correlations between PMI and MCI were obtained with DXA BMD. Digital OPGs may provide an economical and reliable diagnostic tool to rule out osteoporosis or osteopenia in undiagnosed patients, where DXA screening may not be available or is financially nonviable.

Smoking, smoking cessation, and fracture risk in elderly women followed for 10 years

This study examines the impact of smoking and smoking cessation on fracture risk in 75-year-old women followed for 10 years. Smoking increased fracture risk, especially for vertebral fractures. Smoking cessation decreased the risk for vertebral fractures but not for other fracture types.

INTRODUCTION

The purpose of this study was to examine effects of smoking and smoking cessation on fracture risk.

METHODS

This prospective observational population-based study followed 1033 women during 10 years from age 75. Data regarding smoking were collected at age 75. Hazard ratios (HRs) and 95 % confidence intervals for fracture were calculated using competing risks proportional hazards regression.

RESULTS

Both former smokers and current smokers had an increased risk for any fracture (HR 1.30; 1.03-1.66, and HR 1.32; 1.01-1.73, respectively) and any osteoporotic fracture (hip, proximal humerus, distal radius, vertebra) (HR 1.31; 1.01-1.70 and HR 1.49; 1.11-1.98, respectively) compared to non-smokers. Former smokers had an increased risk for proximal humerus fractures (HR 2.23; 1.35-3.70), and current smokers had an increased risk for vertebral fractures (HR 2.30; 1.57-3.38) compared to non-smokers. After adjustment for weight, previous fractures, alcohol habits, bone mineral density (BMD), use of corticoids, vitamin D, bisphosphonates, and previous falls, former smokers had an increased risk for proximal humerus fracture (HR 2.07; 1.19-3.57) and current smokers had an increased risk for osteoporotic (HR 1.47; 1.05-2.05) and vertebral fractures (HR 2.50; 1.58-3.95) compared to non-smokers. Former smokers had a decreased risk for vertebral fractures, but not for other types of fractures, compared to current smokers.

CONCLUSIONS

Smoking increased the risk for fracture among elderly women, especially vertebral fractures. Smoking cessation decreased the risk for vertebral fractures but not for other types of fractures.

The relevance of gender in the care of hip fracture patients

As in many conditions, gender interplays with other social structures of inequality to impact upon women's and men's health and healthcare. This narrative review examines knowledge about sex, gender and hip fracture and suggests ways of highlighting the influence of gender in hip fracture healthcare. These will be considered in relation to two areas. Firstly the multifactorial dimension of hip fractures which identifies ethnicity, marital status, lifestyle, co-morbidities, environment in relation to falls and osteoporosis as important factors influencing the experience of hip fracture. Secondly the importance of acknowledging gender as a key element within research and management of care. Implications for practice are that we need a raised awareness of gender when we assess and care for patients, to ask critical questions about the gender bias in the evidence we use and reflect on how services and care practices may be biased towards gendered assumptions.

Declining incidence trends for hip fractures have not been accompanied by improvements in lifetime risk or post-fracture survival--A nationwide study of the Swedish population 60 years and older

BACKGROUND

Hip fracture is a common cause of disability and mortality among the elderly. Declining incidence trends have been observed in Sweden. Still, this condition remains a significant public health problem since Sweden has one of the highest incidences worldwide. Yet, no Swedish lifetime risk or survival trends have been presented. By examining how hip fracture incidence, post-fracture survival, as well as lifetime risk have developed between 1995 and 2010 in Sweden, this study aims to establish how the burden hip fractures pose on the elderly changed over time, in order to inform initiatives for improvements of their health.

MATERIAL AND METHODS

The entire Swedish population 60 years-old and above was followed between 1987 and 2010 in the National Patient Register and the Cause of Death Register. Annual age-specific hip fracture cumulative incidence was estimated using hospital admissions for hip fractures. Three-month and one-year survival after the first hip fracture were also estimated. Period life table was used to assess lifetime risk of hip fractures occurring from age 60 and above, and the expected mean age of the first hip fracture.

RESULTS

The age-specific hip fracture incidence decreased between 1995 and 2010 in all ages up to 94 years, on average by 1% per year. The lifetime risk remained almost stable, between 9% and 11% for men, and between 18% and 20% for women. The expected mean age of a first hip fracture increased by 2.5 years for men and by 2.2 years for women. No improvements over time were observed for the 3-month survival for men, while for women a 1% decrease per year was observed. The 1-year survival slightly increased over time for men (0.4% per year) while no improvement was observed for women.

CONCLUSIONS

The age-specific hip fracture incidence has decreased over time. Yet the lifetime risk of a hip fracture has not decreased because life expectancy in the population has increased in parallel. Overall, survival after hip fracture has not improved.

Cigarette smoking and risk of hip fracture in women: a meta-analysis of prospective cohort studies

BACKGROUND AND OBJECTIVES

Whether cigarette smoking can increase the risk of hip fracture in women is unclear. This meta-analysis, which pooled results from 10 prospective cohort studies, was performed to derive a more precise estimation between cigarette smoking and the risk of hip fracture in women.

MATERIALS AND METHODS

Pubmed, Cochrane Central Register of Controlled Trials and ISI Web of Science were systematically searched to identify relevant studies. A meta-analysis was performed to examine the association among 10 studies. The pooled risk estimates were calculated by using both random- and fixed-effects model. Heterogeneity among articles and their publications bias were also tested. All of the statistical analyses were performed using the software programs STATA (version 12.0).

RESULTS

Relative risk was significantly increased in current female smokers (pooled RR, 1.30; 95%CI, 1.16-1.45). The association was significant among the high-dose smokers (more than 15 cigarettes per day) while not among the low-does smokers (less than 15 cigarettes per day). Omission of any single study had little effect on the pooled risk estimate. Former smokers had a similar RR of hip fracture (RR, 1.02; 95%CI, 0.93-1.11) to published papers. Smoking cessation for ≥10 years leads to a significant decline in risk.

CONCLUSIONS

Smoking is associated with an increased hip fracture risk in women. Cessation of smoking for ≥10 years had a decreased impact on risk of hip fracture. Given the inconsistency among the studies in the choice of adjustments, the associations between cigarette smoking and risk of hip fracture in women await further investigation.

Developing a Tailored Smoking Cessation Intervention for Rheumatoid Arthritis Patients

PURPOSE

Smoking is associated with an increased risk of comorbidities in rheumatoid arthritis (RA) and may reduce the efficacy of anti-rheumatic therapies. Smoking cessation is therefore an important goal in RA. Our previous qualitative research identified five RA-related barriers to smoking cessation: lack of support; limited knowledge of the relationship between smoking and RA; uncontrolled pain; inability to exercise; and using smoking as a coping strategy. The aim of this article is to describe the process of developing a smoking cessation intervention for RA patients based on these themes.

METHODS

A comprehensive review of the literature on smoking cessation was undertaken. A tailored smoking cessation programme was designed to address each RA-specific barrier. A meeting was convened with key staff of Arthritis New Zealand to develop a consensus on feasible design to deliver a smoking cessation programme based on existing best practice and smoking cessation resources, and tailored within existing Arthritis New Zealand service delivery frameworks.

RESULTS

A three-month intervention was designed to be delivered by trained arthritis educators, with the following key components: nicotine replacement therapy for eight weeks; a telephone or face-to-face interview with each patient to determine their individual specific RA-related barriers to smoking cessation; and individualized education and support activities which addressed these barriers. The intervention also included three follow-up telephone calls; a support website; and 12 weekly smoking cessation advice emails.

CONCLUSIONS

A RA-specific smoking cessation invention was developed, matching support to specific issues within each patient's experience. A pilot study is in progress to evaluate the programme's efficacy. Copyright © 2015 John Wiley & Sons, Ltd.

A review of lifestyle, smoking and other modifiable risk factors for osteoporotic fractures

Although many strong risk factors for osteoporosis-such as family history, fracture history and age-are not modifiable, a number of important risk factors are potential targets for intervention. Thus, simple, non-pharmacological intervention in patients at increased risk of osteoporotic fractures could include reduction of excessive alcohol intake, smoking cessation, adequate nutrition, patient education, daily physical activity and a careful review of medications that could increase the risk of falls and fractures. There remains, however, an unmet need for high-quality intervention studies in most of these areas.

Secular trends in hip fractures worldwide: opposing trends East versus West

Despite wide variations in hip rates fractures worldwide, reasons for such differences are not clear. Furthermore, secular trends in the age-specific hip fracture rates are changing the world map of this devastating disease, with the highest rise projected to occur in developing countries. The aim of our investigation is to systematically characterize secular trends in hip fractures worldwide, examine new data for various ethnic groups in the United States, evidence for divergent temporal patterns, and investigate potential contributing factors for the observed change in their epidemiology. All studies retrieved through a complex Medline Ovid search between 1966 and 2013 were examined. For each selected study, we calculated the percent annual change in age-standardized hip fracture rates de-novo. Although occurring at different time points, trend breaks in hip fracture incidence occurred in most Western countries and Oceania. After a steep rise in age-adjusted rates in these regions, a decrease became evident sometimes between the mid-seventies and nineties, depending on the country. Conversely, the data is scarce in Asia and South America, with evidence for a continuous rise in hip fracture rates, with the exception of Hong-Kong and Taiwan that seem to follow Western trends. The etiologies of these secular patterns in both the developed and the developing countries have not been fully elucidated, but the impact of urbanization is at least one plausible explanation. Data presented here show close parallels between rising rates of urbanization and hip fractures across disparate geographic locations and cultures. Once the proportion of the urban population stabilized, hip fracture rates also stabilize or begin to decrease perhaps due to the influence of other factors such as birth cohort effects, changes in bone mineral density and BMI, osteoporosis medication use and/or lifestyle interventions such as smoking cessation, improvement in nutritional status and fall prevention.

Effect of nicotine on RANKL and OPG and bone mineral density

AIM

The signaling pathway OPG/RANK/RANKL is a key in maintaining the balance between the activity of osteoblasts and osteoclasts in order to prevent bone loss. In this study, our aim was to assess the effects of long-term nicotine exposure on plasma RANKL and OPG levels, tissue RANKL and OPG immunoreactivities, and bone mineral density (BMD) scores in rats.

MATERIALS AND METHODS

Thirty-six Swiss Albino rats weighing 70 ± 10 g were divided into three groups. While the controls (n = 12) were only given normal drinking water, for low-dose nicotine (LDN) group (n = 12) 0.4 mg/kg/day; for high-dose nicotine (HDN) group (n = 12), 6.0 mg/kg/day nicotine was added to drinking water for a year. At the end of 12th month, BMD scores were measured using an X-ray absorptiometry and bone turnover was assessed by measuring plasma RANKL and OPG levels and RANKL and OPG immunoreactivities in tail vertebrae of the rats.

RESULTS

There was no statistically significant difference in BMD scores of lumbar spine and femoral regions of the nicotine groups in comparison to controls. Plasma OPG levels were found to be significantly higher in HDN group, in comparison to the controls and LDN groups (p = .001) unlike plasma RANKL levels. Tissue RANKL and OPG immunoreactivities decreased significantly in the LDN and HDN groups (p < .001, p < .01, respectively).

CONCLUSIONS

The results of this study show that nicotine is not primarily responsible for the decrease in BMD frequently seen in smokers. Measuring plasma RANKL and OPG levels did not reflect tissue immunoreactivities.

Smoking and body fat mass in relation to bone mineral density and hip fracture: the Hordaland Health Study

Lower bone mineral density (BMD) in smokers may be attributable to lower body weight or fat mass, rather than to a direct effect of smoking. We analyzed the effects of smoking exposure, assessed by plasma cotinine, and body fat on BMD and the risk of subsequent hip fracture. In the community-based Hordaland Health Study (HUSK), 3003 participants 46-49 years and 2091 subjects 71-74 years were included. Cotinine was measured in plasma and information on health behaviors was obtained from self-administered questionnaires. BMD and total body soft tissue composition were measured by dual X-ray absorptiometry. Information on hip fracture was obtained from computerized records containing discharge diagnoses for hospitalizations between baseline examinations 1997-2000 through December 31st, 2009. In the whole cohort, moderate and heavy smokers had stronger positive associations between fat mass and BMD compared to never smokers (differences in regression coefficient (95% CI) per % change in fat mass = 1.38 (0.24, 2.52) and 1.29 (0.17, 2.4), respectively). In moderate and heavy smokers there was a nonlinear association between BMD and fat mass with a stronger positive association at low compared to high levels of fat mass (Davies segmented test, p<0.001). In elderly women and men, heavy smokers had an increased risk of hip fracture compared to never smokers (hazard ratio = 3.31, 95% CI: 2.05, 5.35; p<0.001). In heavy smokers there was a tendency of a lower risk of hip fracture with higher percentage of fat mass. The deleterious effect of smoking on bone health is stronger in lean smokers than in smokers with high fat mass.

Dementia and hip fractures: development of a pathogenic framework for understanding and studying risk

Dementia and hip fractures are 2 conditions that are seen primarily in older adults, and both are associated with substantial morbidity and mortality. An individual with dementia is up to 3 times more likely than a cognitively intact older adult to sustain a hip fracture. This may occur via several mechanisms, including (1) risk factors that are common to both outcomes; (2) the presence of dementia increasing hip fracture incidence via intermediate risk factors, such as falls, osteoporosis, and vitamin D; and (3) treatment of dementia causing side effects that increase hip fracture risk. We describe a model that applies these 3 mechanisms to explain the relationship between dementia and hip fractures. Comprehensive understanding of these pathways and their relative influence on the outcome of hip fracture will guide the development of effective interventions and potentially improve prevention efforts.

The musculoskeletal effects of cigarette smoking

➤ Cigarette smoking decreases bone mineral density and increases the risk of sustaining a fracture or tendon injury, with partial reversibility of these risks with long-term cessation of smoking. ➤ Cigarette smoking increases the risk for perioperative complications, nonunion and delayed union of fractures, infection, and soft-tissue and wound-healing complications. ➤ Brief preoperative cessation of smoking may mitigate these perioperative risks. ➤ Informed-consent discussions should include notification of the higher risk of perioperative complications with cigarette smoking and the benefits of temporary cessation of smoking.

Functional gait rehabilitation in elderly people following a fall-related hip fracture using a treadmill with visual context: design of a randomized controlled trial

Background

Walking requires gait adjustments in order to walk safely in continually changing environments. Gait adaptability is reduced in older adults, and (near) falls, fall-related hip fractures and fear of falling are common in this population. Most falls occur due to inaccurate foot placement relative to environmental hazards, such as obstacles. The C-Mill is an innovative, instrumented treadmill on which visual context (e.g., obstacles) is projected. The C-Mill is well suited to train foot positioning relative to environmental properties while concurrently utilizing the high-intensity practice benefits associated with conventional treadmill training. The present protocol was designed to examine the efficacy of C-Mill gait adaptability treadmill training for improving walking ability and reducing fall incidence and fear of falling relative to conventional treadmill training and usual care. We hypothesize that C-Mill gait adaptability treadmill training and conventional treadmill training result in better walking ability than usual care due to the enhanced training intensity, with superior effects for C-Mill gait adaptability treadmill training on gait adaptability aspects of walking given the concurrent focus on practicing step adjustments.

Methods/design

The protocol describes a parallel group, single-blind, superiority randomized controlled trial with pre-tests, post-tests, retention-tests and follow-up. Hundred-twenty-six older adults with a recent fall-related hip fracture will be recruited from inpatient rehabilitation care and allocated to six weeks of C-Mill gait adaptability treadmill training (high-intensity, adaptive stepping), conventional treadmill training (high-intensity, repetitive stepping) or usual care physical therapy using block randomization, with allocation concealment by opaque sequentially numbered envelopes. Only data collectors are blind to group allocation. Study parameters related to walking ability will be assessed as primary outcome pre-training, post-training, after 4 weeks retention and 12 months follow-up. Secondary study parameters are measures related to fall incidence, fear of falling and general health.

Discussion

The study will shed light on the relative importance of adaptive versus repetitive stepping and practice intensity for effective intervention programs directed at improving walking ability and reducing fall risk and fear of falling in older adults with a recent fall-related hip fracture, which may help reduce future fall-related health-care costs.

Trial registration

The Netherlands Trial Register (http://NTR3222).

Estimating the avoidable burden of certain modifiable risk factors in osteoporotic hip fracture using Generalized Impact Fraction (GIF) model in Iran

Backgrounds

The number of hip fractures, the most common complication of osteoporosis, has increased rapidly over the past decades. The goal of this study is to estimate the avoidable burden of certain modifiable risk factor of the condition using the Generalized Impact Fraction (GIF) model, which has been suggested and used by epidemiologists to overcome the drawbacks associated with the use of Attributable Fraction index. In addition to preventing a risk factor or the avoidable fraction of burden, this index can also calculate the change in the burden, when a risk factor is altered.

Methods

International databases were searched through PubMed, CINAHLD, Embase using OVID and Google scholar. National resources were searched through IranDoc, IranMedex, SID and Journal sites. Other resources include abstract books and articles sent to the IOF congress. The following search strategy was used: (“Osteoporotic fracture” OR “Fragility Hip fracture” OR “Calcium” OR “vitamin D” OR “BMI” OR “lean body weight” OR “Physical activity” OR “exercise” OR “Smoke”) AND (“prevalence” OR “incidence” OR “relative risk”) and limited to “humans.”

Results

With regards to different scenarios already explained in modifying the studied risk factors, the greatest impact in reducing the prevalence of risk factors on osteoporotic hip fractures, was seen in low serum vitamin D levels, low physical activity and low intake of calcium and vitamin D, respectively. According to the fact that interventions for low serum vitamin D and low intake of calcium and vitamin D, are related to each other, it can be concluded that implementing interventions to change these two risk factors, in the easy, moderate and difficult scenarios, would result in approximately a 5%, 11% and 17% decrease in the burden of osteoporotic hip fractures, respectively. The addition of interventions addressing low physical activity in the easy, moderate and difficult scenarios, an 8%, 21% and 35% reduction in the burden of osteoporotic hip fractures would be reported, respectively.

Conclusion

Improving serum vitamin D levels, recommending the consumption of calcium and vitamin D supplementations and advocating physical activity are the most effective interventions to reduce the risk of osteoporotic hip fractures.

Electronic supplementary material

The online version of this article (doi:10.1186/2251-6581-12-10) contains supplementary material, which is available to authorized users.

Hyperbaric oxygen therapy for promoting fracture healing and treating fracture non-union

BACKGROUND

Hyperbaric oxygen therapy (HBOT) consists of intermittently administering 100% oxygen at pressures greater than one atmosphere absolute (ATA) in a pressure vessel. This technology has been used to treat a variety of diseases and has been described as helping patients who have delayed healing or established non-union of bony fractures. This is an update of a Cochrane Review first published in 2005, and previously updated in 2008.

OBJECTIVES

The aim of this review is to assess the evidence for the benefit of hyperbaric oxygen treatment (HBOT) for the treatment of delayed bony healing and established non-union of bony fractures.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (July 2012), the Cochrane Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 7), MEDLINE (1946 to July Week 1 2012), EMBASE (1974 to 2012 July 16), CINAHL (1937 to 17 July 2012), the Database of Randomised Controlled Trials in Hyperbaric Medicine (accessed July 2012), the WHO International Clinical Trials Registry Platform (17 July 2012) and reference lists of articles.

SELECTION CRITERIA

We aimed to include all randomised controlled trials comparing the clinical effects of HBOT with no HBOT (no treatment or sham) for healing of bony fractures and fracture non-unions.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened electronic search results, and all three authors independently performed study selection. We planned independent data collection and risk of bias assessment by two authors using standardised forms.

MAIN RESULTS

No trials met the inclusion criteria. In this update, we identified three ongoing randomised controlled trials. Among the eight excluded studies were three randomised trials comparing HBOT with no treatment that included patients with fractures. One of these trials had been abandoned and the other two did not report on fracture healing outcomes.

AUTHORS' CONCLUSIONS

This systematic review failed to locate any relevant clinical evidence to support or refute the effectiveness of HBOT for the management of delayed union or established non-union of bony fractures. Good quality clinical trials are needed to define the role, if any, of HBOT in the treatment of these injuries. There are three randomised controlled trials underway and we anticipate these will help provide some relevant clinical evidence to address this issue in the future.

The effects of smoking on bone metabolism

Osteoporosis is a common, morbid and costly disorder characterized by deterioration in bone strength. Cigarette smoking is associated with reduced bone mineral density (BMD) and increased fracture risk. There are basic, clinical, and observational studies that define several of the underlying pathophysiologic mechanisms that predispose smokers to bone loss. Such mechanisms include alterations in calciotropic hormone metabolism and intestinal calcium absorption, dysregulation in sex hormone production and metabolism, alterations in adrenal cortical hormone metabolism and in the receptor activator of nuclear factor kappa-B (RANK), receptor activator of nuclear factor kappa-B ligand (RANKL), and osteoprotegerin (OPG) system (RANK-RANKL-OPG system), and direct cellular effects of cigarette use on bone cells. In addition, there is evidence of reversibility in the aforementioned mechanisms with smoking cessation. In summary, cigarette smoking is a reversible risk factor for osteoporosis and osteoporotic fractures through diverse pathophysiologic mechanisms.

Acetylcholinesterase inhibitors and the risk of hip fracture in Alzheimer's disease patients: a case-control study

Recent studies have reported the presence of acetylcholine (ACh) receptor subtypes in bone tissue, and have demonstrated that inhibition of the ACh receptors has negative effects on bone mass and fracture healing capacity. However, little is known about the potential clinical effects that increased ACh signaling might have on bone. Accordingly, this study was designed to determine whether the use of acetylcholinesterase inhibitors (AChEIs), a group of drugs that stimulate ACh receptors and are used to treat Alzheimer's disease (AD), is associated with a decreased risk of hip fracture in AD patients. To accomplish this objective, a case-control analysis was performed using the AD population, aged above 75 years, based in the local health area of the Carlos Haya Hospital, in Malaga, Spain. The cases were 80 AD patients that suffered a hip fracture between January 2004 and December 2008. The controls were 2178 AD patients without hip fracture followed at our health care area during the same period of time. Compared with patients who did not use AChEIs, the hip fracture adjusted odds ratio (OR) for users of AChEIs was 0.42 (95% confidence interval [CI], 0.24-0.72), for users of rivastigmine was 0.22 (95% CI, 0.10-0.45), and for users of donepezil was 0.39 (95% CI, 0.19-0.76). Data were adjusted for the following parameters: body mass index, fall risk, smoking habits, cognition, dependence, degree of AD, comorbidity score, treatment with selective serotonin reuptake inhibitors, age, and gender. Our data suggests that use of AChEIs donepezil and rivastigmine is associated with a reduced risk of fractures in AD patients. Many elderly patients with AD disease who are at risk of developing osteoporosis may potentially benefit from therapy with the AChEIs donepezil and rivastigmine.

WITHDRAWN: Hyperbaric oxygen therapy for promoting fracture healing and treating fracture non-union

BACKGROUND

Hyperbaric oxygen therapy (HBOT) consists of intermittently administering 100% oxygen at pressures greater than one atmosphere absolute (ATA) in a pressure vessel. This technology has been used to treat a variety of diseases and has been described as helping patients who have delayed healing or established non-union of bony fractures.

OBJECTIVES

The aim of this review was to assess the evidence for the benefit of hyperbaric oxygen treatment (HBOT) for the treatment of delayed bony healing and established non-union of bony fractures.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (April 2008), the Cochrane Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2008), MEDLINE (OVID 1966 to April week 3, 2008), CINAHL (OVID 1982 to April week 3, 2008), EMBASE (OVID 1980 to week 17 2008), the locally developed Database of Randomised Controlled Trials in Hyperbaric Medicine (available at www.hboevidence.com) from inception to May 2008, and reference lists of articles.

SELECTION CRITERIA

We aimed to include all randomised controlled trials that compared the effect of HBOT with no HBOT (no treatment or sham).

DATA COLLECTION AND ANALYSIS

We planned independent data collection by two authors using standardised forms.

MAIN RESULTS

No trials met the inclusion criteria. We excluded one trial that compared HBOT with no treatment because no clinical outcomes were reported.

AUTHORS' CONCLUSIONS

This systematic review failed to locate any relevant clinical evidence to support or refute the effectiveness of HBOT for the management of delayed union or established non-union of bony fractures. Good quality clinical trials are needed to define the role, if any, of HBOT in the treatment of these injuries.

Risk factors for fracture in elderly men: a population-based prospective study

SUMMARY

Risk factors for fractures were assessed in a random sample of 4,696 elderly men followed for 5.4 years. Results highlighted the importance of assessment of falls and dizziness as well as novel risk factors including frequent urination and erectile dysfunction.

INTRODUCTION

Knowledge about risk factors for fracture in men is limited. The aim of this study was to evaluate factors potentially associated with fracture risk in men.

METHODS

A questionnaire enquiring about potential risk factors for fractures in men was posted to a random sample of 9,314 men aged 60-74 years. A completed questionnaire was returned by 4,696 (50.4%). Follow-up on incident fractures over 5.4 years was performed using public registries.

RESULTS

During the study, 203 individuals experienced a first clinical fracture, of which 85 patients were considered osteoporotic (9 in humerus, 10 vertebral, 32 in the hip and 34 in the forearm). Cox proportional hazard regression models were used to evaluate risk factors for any and osteoporotic fractures. The following variables were found to be associated with increased risk of any fracture in adjusted models family history of a hip fracture (HR; 95%CI: 1.56; 1.05-2.33), falls (2-4/year: 2.10; 1.35-3.27, >4/year: 2.46; 1.12-5.41, both compared to no falls), dizziness (2.36; 1.51-3.71), erectile dysfunction (1.41; 1.06-1.87) and frequent urination (2.06; 1.26-3.39). Similarly, falls (2.36; 1.45-3.86), dizziness (2.83; 1.52-5.25), erectile dysfunction (2.01; 1.30-3.09) and pulmonary illness (1.90; 1.03-3.53) were associated with increased risk of osteoporotic fractures in adjusted models.

CONCLUSION

These results underline the importance of assessment of dizziness, falls and those with a family history of hip fracture. Frequent urination and erectile dysfunction were independently associated with increased fracture risk. Although the mechanism of association is unknown, these variables are likely to be indicators of frailty or hypogonadism.

Association between passive smoking in adulthood and phalangeal bone mineral density: results from the KRAM study--the Danish Health Examination Survey 2007-2008

The study investigates an association between phalangeal bone mineral density (BMD) and self-reported passive smoking using data on 15,038 persons (aged 18-95 years), who underwent a BMD scan in the Danish KRAM study. BMD was significantly lower in persons exposed to long-term passive smoking in their home during adulthood.

INTRODUCTION

Smoking is associated with decreased bone mineral density (BMD) and increased risk of osteoporotic fractures. This study aimed to investigate a possible association between BMD at the phalangeal bones and self-reported passive smoking.

METHODS

The study included a cohort of 15,544 men and women aged 18-95 years, who underwent a BMD scan in the Danish KRAM study. BMD scans of the middle phalanges of the second, third and fourth digits of the non-dominant hand were performed with a compact radiographic absorptiometry system (Alara MetriScan®). Also, height, weight and body fat percentage were measured and 96.7% (n = 15,038) of the participants answered a self-reported questionnaire with information on passive smoking, other lifestyle factors, education, etc. The association between passive smoking and BMD was examined using multiple linear regression analysis.

RESULTS

A total of 39.1% (n = 5,829) of the participants had been exposed to passive smoking in adulthood at home. BMD was significantly lower in subjects exposed to passive smoking, 0.343 vs. 0.331 g/cm(2); p < 0.01 (unadjusted) and 0.339 vs. 0.337 g/cm(2); p < 0.05 (adjusted for age, gender, height and weight, and smoking). Multiple linear regression analysis showed that exposure to passive smoking for more than 20 years in adulthood at home was significantly related to BMD when adjusted for potential confounders (men, β = -4.4 × 10(-3); r = -0.05; p < 0.01 and women, β = -2.3 × 10 (-3); r = -0.03; p < 0.05). This relationship was also seen in the group of never smokers (β = -3.3 × 10(-3); r = -0.03; p = 0.01).

CONCLUSION

Our study supports a potential negative effect of long-term passive smoking in adulthood at home on phalangeal BMD.

Poor trabecular microarchitecture in male current smokers: the cross-sectional STRAMBO study

Current smoking (but not past smoking) is associated with higher risk of fracture independent of areal bone mineral density (aBMD); however, the pathophysiologic mechanism underlying this association is not clear. In 810 men aged 60-87, aBMD was measured by dual-energy X-ray absorptiometry. Bone microarchitecture at the distal radius and distal tibia was assessed by high-resolution peripheral quantitative computed tomography using the Xtreme CT Scanco device. Current smokers (n = 47) had lower trabecular volumetric density (Dtrab), lower trabecular number (TbN), more heterogenous trabecular network (higher trabecular spacing standard deviation [TbSpSD]), as well as higher urinary deoxypyridinoline and higher C-reactive protein levels in comparison with 261 men who never smoked (adjusted for age, weight, height, time spent outdoors, physical activity, and intake of alcohol, caffeine, and calcium). Abnormal values (lower Dtrab and TbN, higher TbSpSD, deoxypyridinoline, and C-reactive protein) were found mainly in 21 current smokers who smoked eight or more cigarettes per day. Cortical parameters and aBMD did not differ from the never-smokers. In 502 former smokers, aBMD and all bone microarchitectural parameters did not differ from the never-smokers. At the tibia (not radius), Dtrab decreased, whereas TbSpSD slightly increased across quartiles of smoking intensity (number of pack-years). In conclusion, older men who are moderate current smokers have poor trabecular (but not cortical) microarchitecture, which is not reflected by a decrease in aBMD.

An overview of osteoporosis for the practising prosthodontist

Osteoporosis is an insidious and common bone disorder of the modern age, as a result of the rapidly increasing number of older people in the total population. It has long been concluded that this disease has definite deleterious effects on the stomatognathic system and is therefore of major concern to a Prosthodontist. If features on a dental radiograph, which are the most commonly required radiographs, can be detected regularly and consistently, it would place a prosthodontist in a position to refer the patient for timely management and also modify his treatment plan, greatly improving the prognosis. Available literature was therefore reviewed for pathophysiology, dental radiographic screening measures, implications and management of osteoporosis from the perspective of a prosthodontist.

Association of osteoporotic fracture with smoking, alcohol consumption, tea consumption and exercise among Chinese nonagenarians/centenarians

OBJECTIVE

To observe the association of osteoporotic fracture with habits of smoking, alcohol consumption, tea consumption and exercise among very old people.

DESIGN AND SETTING

A cross-sectional study conducted in Dujiangyan Sichuan China.

PARTICIPANTS

703 unrelated Chinese nonagenarians and centenarians (67.76% women, mean age 93.48 years) resident in Dujiangyan.

MEASUREMENTS

Medical history of osteoporosis and the statement of fracture and habits (current and former) of smoking, alcohol consumption, tea consumption and exercise were collected.

RESULTS

In women, subjects with current or former habit of alcohol consumption had significantly higher prevalence osteoporotic fracture than those without this habit; but subjects with former habit of exercise had significantly lower prevalence osteoporotic fracture than those without this habit. However, in men, there was no significant difference in prevalence of these habits between subjects with and without osteoporotic fracture. After adjust for age, gender, sleep habits educational levels, religion habits and temperament, we found that former habit of alcohol consumption had a significant odds ratio (OR=2.473 95% CI (1.074, 5.526)) for osteoporotic fracture.

CONCLUSIONS

In summary, among nonagenarians and centenarians, among habits (current and former) of smoking, alcohol consumption, tea consumption and exercise, there seems to be significant association of osteoporotic fracture only with current or former habits of alcohol consumption, former habit of exercise. The habit of alcohol consumption might be associated with a greater risk of osteoporotic fracture, but the former habit of exercise might be associated with a lower risk of osteoporotic fracture.

Effects of nicotine administration and nicotine cessation on bone histomorphometry and bone biomarkers in Sprague-Dawley male rats

Nicotine is a major alkaloid of tobacco, which can increase free radical formation, leading to osteoporosis. The effects of nicotine administration and cessation on bone histomorphometry and biomarkers were studied in 28 Sprague-Dawley male rats. Rats aged 3 months and weighing 250-300 g were divided into four groups: control (C, normal saline for 4 months), nicotine for 2 months (N2), nicotine for 4 months (N4), and nicotine cessation (NC). The NC group was given nicotine for the first 2 months and then allowed to recover for the following 2 months without nicotine. Histomorphometric analysis was done using an image analyzer. ELISA kits were used to measure serum osteocalcin (bone formation marker) and pyridinoline (PYD, bone resorption marker) levels at month 0, month 2, and month 4. All test groups showed a significant decrease in BV/TV, Ob.S/BS, dLS/BS, MAR, BFR/BS, and osteocalcin levels and an increase in sLS/BS and PYD levels compared to group C. No significant differences were observed in all parameters measured among the test groups, except for MAR and BFR/BS. In conclusion, nicotine administration at a dose of 7 mg/kg for 2 and 4 months has detrimental effects on bone metabolism. Nicotine administration at 7 mg/kg for 2 months is sufficient to produce significant effects on bone histomorphometric parameters and biomarkers. In addition, prolonging the treatment for another 2 months did not show any significant differences. Cessation of nicotine for 2 months did not reverse the effects.

Intrinsic material properties of cortical bone

The G171V mutation (high bone mass, HBM) is autosomal dominant and is responsible for high bone mass in humans. Transgenic HBM mice in which the human LRP5 G171V gene is inserted also show a similar phenotype with greater bone mass and biomechanical performance than wild-type mice, as determined by whole bone testing. Whole bone mechanics, however, depend jointly on bone mass, architecture, and intrinsic bone tissue mechanical properties. To determine whether the HBM mutation affects tissue-level biomechanical performance, we performed nano-indentation testing of unembedded cortical bone from HBM mice and their nontransgenic (NTG) littermates. Femora from 17-week-old mice (female, 8 mice/genotype) were subjected to nano-indentation using a Triboscope (Hysitron, Minneapolis, MN, USA). For each femoral specimen, approximately 10 indentations were made on the midshaft anterior surface with a target force of either 3 or 9 mN at a constant loading rate of 400 mN/s. The load-displacement data from each test were used to calculate indentation modulus and hardness for bone tissue. The intrinsic material property that reflected the bone modulus was greater (48%) in the HBM as compared to the NTG mice. Our results of intrinsic properties are consistent with the published structural and material properties of the midshaft femur in HBM and NTG mice. The greater intrinsic modulus in HBM reflects greater bone mineral content as compared to NTG (wild-type, WT) mice. This study suggests that the greater intrinsic property of cortical bone is derived from the greater bone mineral content and BMD, resulting in greater bone strength in HBM as compared to NTG (WT) mice.

Morbidity figures from general practice: sex differences in traumatology

BACKGROUND

Trauma prevention starts with to find out the extent of the problem and who it affects. Insight into morbidity figures is therefore necessary.

AIM

To explore sex differences in traumatology and secondary medical care utilization in primary care related to age and socio-economic status (SES).

METHODS

Data were obtained from an academic continuous morbidity registration project in the Netherlands in the period from 1996 to 2006, in which 13,000 patients were followed in 10 successive years.

RESULTS

Sex differences showed a male excess from childhood to 45 years and women showing almost double trauma rates in the elderly. Low SES was associated with the greatest incidence of traumas. The largest sex difference in incidence above 65 years appeared in the high SES with more traumas in women compared with men. From this age on, female morbidity in traumatology outnumbered male morbidity regardless of SES. Considering use of referrals, we found that in the age group 15-45 years men made a greater use of secondary medical care. However, the vastest gender influence in medical care utilization was noticed in the age group over 65 years, outnumbered with women.

CONCLUSION

Young men and old women are the most at risk for traumatic health problems: men presenting with traumata of the skull, the tibia and ocular trauma's and women with fractures of the femur, humerus and wrist. For both men and women the greatest incidence is in the low SES. Family physicians can play a pivotal role in prevention to focus on their patients with high risks.