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Brandt IAG, Starup-Linde J, Andersen SS, Viggers R. Diagnosing Osteoporosis in Diabetes-A Systematic Review on BMD and Fractures. Curr Osteoporos Rep 2024; 22:223-244. [PMID: 38509440 DOI: 10.1007/s11914-024-00867-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/08/2024] [Indexed: 03/22/2024]
Abstract
PURPOSE OF REVIEW Recently, the American Diabetes Association updated the 2024 guidelines for Standards of Care in Diabetes and recommend that a T-score of - 2.0 in patients with diabetes should be interpreted as equivalent to - 2.5 in people without diabetes. We aimed to evaluate the most recent findings concerning the bone mineral density (BMD)-derived T-score and risk of fractures related to osteoporosis in subjects with diabetes. RECENT FINDINGS The dual-energy X-ray absorptiometry (DXA) scan is the golden standard for evaluating BMD. The BMD-derived T-score is central to fracture prediction and signifies both diagnosis and treatment for osteoporosis. However, the increased fracture risk in diabetes is not sufficiently explained by the T-score, complicating the identification and management of fracture risk in these patients. Recent findings agree that subjects with type 2 diabetes (T2D) have a higher T-score and higher fracture risk compared with subjects without diabetes. However, the actual number of studies evaluating the direct association of higher fracture risk at higher T-score levels is scant. Some studies support the adjustment based on the 0.5 BMD T-score difference between subjects with T2D and subjects without diabetes. However, further data from longitudinal studies is warranted to validate if the T-score treatment threshold necessitates modification to prevent fractures in subjects with diabetes.
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Affiliation(s)
- Inge Agnete Gerlach Brandt
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark.
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark.
| | - Jakob Starup-Linde
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Sally Søgaard Andersen
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | - Rikke Viggers
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
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Draghici AE, Zahedi B, Taylor JA, Bouxsein ML, Yu EW. Vascular deficits contributing to skeletal fragility in type 1 diabetes. FRONTIERS IN CLINICAL DIABETES AND HEALTHCARE 2023; 4:1272804. [PMID: 37867730 PMCID: PMC10587602 DOI: 10.3389/fcdhc.2023.1272804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 09/15/2023] [Indexed: 10/24/2023]
Abstract
Over 1 million Americans are currently living with T1D and improvements in diabetes management have increased the number of adults with T1D living into later decades of life. This growing population of older adults with diabetes is more susceptible to aging comorbidities, including both vascular disease and osteoporosis. Indeed, adults with T1D have a 2- to 3- fold higher risk of any fracture and up to 7-fold higher risk of hip fracture compared to those without diabetes. Recently, diabetes-related vascular deficits have emerged as potential risks factors for impaired bone blood flow and poor bone health and it has been hypothesized that there is a direct pathophysiologic link between vascular disease and skeletal outcomes in T1D. Indeed, microvascular disease (MVD), one of the most serious consequences of diabetes, has been linked to worse bone microarchitecture in older adults with T1D compared to their counterparts without MVD. The association between the presence of microvascular complications and compromised bone microarchitecture indicates the potential direct deleterious effect of vascular compromise, leading to abnormal skeletal blood flow, altered bone remodeling, and deficits in bone structure. In addition, vascular diabetic complications are characterized by increased vascular calcification, decreased arterial distensibility, and vascular remodeling with increased arterial stiffness and thickness of the vessel walls. These extensive alterations in vascular structure lead to impaired myogenic control and reduced nitric-oxide mediated vasodilation, compromising regulation of blood flow across almost all vascular beds and significantly restricting skeletal muscle blood flow seen in those with T1D. Vascular deficits in T1D may very well extend to bone, compromising skeletal blood flow control, and resulting in reduced blood flow to bone, thus negatively impacting bone health. Indeed, several animal and ex vivo human studies report that diabetes induces microvascular damage within bone are strongly correlated with diabetes disease severity and duration. In this review article, we will discuss the contribution of diabetes-induced vascular deficits to bone density, bone microarchitecture, and bone blood flow regulation, and review the potential contribution of vascular disease to skeletal fragility in T1D.
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Affiliation(s)
- Adina E. Draghici
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States
- Cardiovascular Research Laboratory, Schoen Adams Research Institute at Spaulding Rehabilitation, Cambridge, MA, United States
| | - Bita Zahedi
- Endocrine Unit, Massachusetts General Hospital, Boston, MA, United States
| | - J. Andrew Taylor
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, United States
- Cardiovascular Research Laboratory, Schoen Adams Research Institute at Spaulding Rehabilitation, Cambridge, MA, United States
| | - Mary L. Bouxsein
- Endocrine Unit, Massachusetts General Hospital, Boston, MA, United States
- Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Elaine W. Yu
- Endocrine Unit, Massachusetts General Hospital, Boston, MA, United States
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3
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Sun J, Li Q, Wang S, Wang G, Zhao J, Li H, Liu C, Shi Y, Li Z, Yu H. Establishment and Evaluation of a Rat Model of Medial Malleolar Fracture with Vascular Injury. Orthop Surg 2022; 14:2701-2710. [PMID: 36098492 PMCID: PMC9531110 DOI: 10.1111/os.13455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 07/12/2022] [Accepted: 07/25/2022] [Indexed: 11/30/2022] Open
Abstract
Objective A stable animal model was needed to study bone non‐union caused by insufficient blood supply, the main object of this paper is to develop a medial malleolar fracture model with controllable arterial vascular injuries in rats for revealing the biochemical mechanism of non‐union by insufficient blood supply. Methods A total of 18 rats were randomly divided into three equal groups: the Sham group, the Fracture group, and the Fracture + Vascular group. The animals were subjected to unilateral medial malleolar bone fracture and vascular injury using customized molding equipment. The fracture site was scanned by micro‐CT, and vascular injury was evaluated by laser Doppler flowmetry (LDF) 24 h after modeling. Histological examination (HE), alkaline phosphatase (ALP) and tartrate‐resistant acid phosphatase (TRAP) staining, immunohistochemistry and immunofluorescence were conducted on the medial malleolar fracture tissues of three rats randomly selected from each group 24 h after modeling. Subsequently, to further confirm the success of fracture modeling, the fracture sites of three other rats in each group underwent micro‐CT scanning again 6 weeks after surgery. Results The results of a 24 h micro‐CT showed that all rats used to create the fracture models showed controlled injury of the medial malleolus. The model was stable, and the satisfaction of the homemade equipment agreed with the expectation. LDF showed that the blood flow of rats in the Fracture + Vascular group decreased significantly 24 h after fracture injury, while collateral blood flow perfusion increased by 50% on average. The results of HE, ALP and TRAP staining in the medial malleolus showed that the number of osteoblasts (OBs) and osteoclasts (OCs) in the Fracture group increased significantly, but the number of OBs and OCs in the Fracture + Vascular group decreased sharply relative to the number in the Sham group 24 h later. Furthermore, immunohistochemistry and immunofluorescence results showed that the number of neovessels in the Fracture group was significantly increased, while the number of neovessels in the Fracture + Vascular group was significantly decreased, which was consistent with the above results. After 6 weeks of modeling, the micro‐CT results showed that the fractures in the Fracture group had healed substantially, while those in the Fracture + Vascular group had not. Conclusion This study provided a reproducible and stable experimental animal model for medial malleolar fractures with arterial injury.
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Affiliation(s)
- Jinglai Sun
- Department of Biomedical Engineering, Tianjin Key Laboratory of Biomedical Detecting Techniques and Instruments, Tianjin University, Tianjin, China.,Tianjin Joint Laboratory of Intelligent Medicine, Tianjin 4TH Centre Hospital, Tianjin University, Tianjin, China
| | - Qifeng Li
- Department of Biomedical Engineering, Tianjin Key Laboratory of Biomedical Detecting Techniques and Instruments, Tianjin University, Tianjin, China
| | - Shuo Wang
- Department of Biomedical Engineering, Tianjin Key Laboratory of Biomedical Detecting Techniques and Instruments, Tianjin University, Tianjin, China.,Academy of Medical Engineering and Translation Medicine, Tianjin University, Tianjin, China
| | - Guangpu Wang
- Department of Biomedical Engineering, Tianjin Key Laboratory of Biomedical Detecting Techniques and Instruments, Tianjin University, Tianjin, China.,Tianjin Joint Laboratory of Intelligent Medicine, Tianjin 4TH Centre Hospital, Tianjin University, Tianjin, China
| | - Jing Zhao
- Department of Biomedical Engineering, Tianjin Key Laboratory of Biomedical Detecting Techniques and Instruments, Tianjin University, Tianjin, China.,Tianjin Joint Laboratory of Intelligent Medicine, Tianjin 4TH Centre Hospital, Tianjin University, Tianjin, China
| | - Huanming Li
- Tianjin Joint Laboratory of Intelligent Medicine, Tianjin 4TH Centre Hospital, Tianjin University, Tianjin, China.,Department of Cardiovascular, Tianjin 4TH Centre Hospital, Tianjin, China
| | - Chong Liu
- Tianjin Joint Laboratory of Intelligent Medicine, Tianjin 4TH Centre Hospital, Tianjin University, Tianjin, China.,Department of Central Laboratory, Tianjin 4TH Centre Hospital, Tianjin, China.,Department of Anesthesiology, Tianjin 4TH Centre Hospital, Tianjin, China
| | - Yifan Shi
- Department of Imaging, Tianjin 4TH Centre Hospital, Tianjin, China
| | - Zhigang Li
- Tianjin Joint Laboratory of Intelligent Medicine, Tianjin 4TH Centre Hospital, Tianjin University, Tianjin, China.,Department of Emergency Medicine, Tianjin 4TH Centre Hospital, Tianjin, China
| | - Hui Yu
- Department of Biomedical Engineering, Tianjin Key Laboratory of Biomedical Detecting Techniques and Instruments, Tianjin University, Tianjin, China.,Tianjin Joint Laboratory of Intelligent Medicine, Tianjin 4TH Centre Hospital, Tianjin University, Tianjin, China.,Academy of Medical Engineering and Translation Medicine, Tianjin University, Tianjin, China
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Alhuzaim ON, Lewis EJH, Lovblom LE, Cardinez M, Scarr D, Boulet G, Weisman A, Lovshin JA, Lytvyn Y, Keenan HA, Brent MH, Paul N, Bril V, Cherney DZI, Perkins BA. Bone mineral density in patients with longstanding type 1 diabetes: Results from the Canadian Study of Longevity in Type 1 Diabetes. J Diabetes Complications 2019; 33:107324. [PMID: 31003922 DOI: 10.1016/j.jdiacomp.2018.12.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 12/13/2018] [Accepted: 12/14/2018] [Indexed: 12/15/2022]
Abstract
AIM It is currently unclear if longstanding type 1 diabetes (T1D) affects bone mineral density (BMD). METHODS BMD measured by dual-energy X-ray absorptiometry and history of fragility fracture was determined in 75 T1D participants with ≥50 years of diabetes duration and 75 age- and sex-matched non-diabetic controls. BMD T-scores were determined for the lumbar spine (LS), total hip (TH) and femoral neck (FN). RESULTS T1D participants had median diabetes duration of 54 [52, 58] years, 41 (55%) were females, and mean A1c was 7.3 ± 0.8%. T1D females had higher LS T-scores compared to female controls (-0.3 ± 1.2 vs. -1.1 ± 1.4, p = 0.014), lower FN T-scores (-1.5 ± 1.0 vs. -1.2 ± 0.9, p = 0.042) and more fragility fractures (7 (17%) vs. 1 (2%), p = 0.021). In T1D, higher A1c was associated with higher adjusted odds of fragility fracture (p = 0.006). T1D males and controls showed no difference in BMD or fractures. CONCLUSIONS There were no substantial differences in T-score between T1D and matched controls; however, T1D females showed higher BMD at the LS and possibly paradoxically higher fragility fractures compared to matched controls. These findings suggest that lower T-scores may not be associated with a history of fragility fracture in females with longstanding T1D and that other factors should be investigated.
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Affiliation(s)
- Omar N Alhuzaim
- Obesity, Endocrine and Metabolism Center, King Fahad Medical City, Riyadh, Saudi Arabia; Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Evan J H Lewis
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Leif E Lovblom
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Marina Cardinez
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Daniel Scarr
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Genevieve Boulet
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Alanna Weisman
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Julie A Lovshin
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Yuliya Lytvyn
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Michael H Brent
- Department of Ophthalmology and Vision Sciences, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Narinder Paul
- Joint Department of Medical Imaging, Division of Cardiothoracic Radiology, University Health Network, Toronto, Ontario, Canada
| | - Vera Bril
- The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Krembil Neuroscience Centre, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - David Z I Cherney
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Bruce A Perkins
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada.
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5
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Rubin MR. Skeletal fragility in diabetes. Ann N Y Acad Sci 2017; 1402:18-30. [PMID: 28926113 DOI: 10.1111/nyas.13463] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 08/07/2017] [Accepted: 08/07/2017] [Indexed: 02/06/2023]
Abstract
Fracture risk is heightened in patients with both type 1 diabetes (T1D) and type 2 diabetes (T2D). Although bone mineral density by dual-energy X-ray absorptiometry is decreased in T1D, it is paradoxically increased with T2D. To predict fracture risk, the Fracture Risk Assessment Tool (FRAX) can be used in diabetes patients, albeit with refinement. Skeletal abnormalities in diabetes include alterations in microarchitecture in T1D and T2D as well as compromised impact microindentation in T2D. Changes in bone microvasculature, advanced glycation end product accumulation, and bone formation may underlie these findings. When fractures occur in T1D and T2D, consequences are worse than in nondiabetic patients with regard to both morbidity and mortality. With regard to treatment, antiresorptive osteoporosis therapies appear to be effective in the setting of diabetes.
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Affiliation(s)
- Mishaela R Rubin
- Metabolic Bone Disease Unit, Columbia University, New York, New York
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6
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Abstract
In an increasingly obese and ageing population, type 2 diabetes (T2DM) and osteoporotic fracture are major public health concerns. Understanding how obesity and type 2 diabetes modulate fracture risk is important to identify and treat people at risk of fracture. Additionally, the study of the mechanisms of action of obesity and T2DM on bone has already offered insights that may be applicable to osteoporosis in the general population. Most available evidence indicates lower risk of proximal femur and vertebral fracture in obese adults. However the risk of some fractures (proximal humerus, femur and ankle) is higher, and a significant number fractures occur in obese people. BMI is positively associated with BMD and the mechanisms of this association in vivo may include increased loading, adipokines such as leptin, and higher aromatase activity. However, some fat depots could have negative effects on bone; cytokines from visceral fat are pro-resorptive and high intramuscular fat content is associated with poorer muscle function, attenuating loading effects and increasing falls risk. T2DM is also associated with higher bone mineral density (BMD), but increased overall and hip fracture risk. There are some similarities between bone in obesity and T2DM, but T2DM seems to have additional harmful effects and emerging evidence suggests that glycation of collagen may be an important factor. Higher BMD but higher fracture risk presents challenges in fracture prediction in obesity and T2DM. Dual energy X-ray absorptiometry underestimates risk, standard clinical risk factors may not capture all relevant information, and risk is under-recognised by clinicians. However, the limited available evidence suggests that osteoporosis treatment does reduce fracture risk in obesity and T2DM with generally similar efficacy to other patients.
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Affiliation(s)
- Jennifer S Walsh
- Academic Unit of Bone Metabolism, Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK.
| | - Tatiane Vilaca
- Academic Unit of Bone Metabolism, Mellanby Centre for Bone Research, University of Sheffield, Sheffield, UK
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7
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Scott D, Seibel M, Cumming R, Naganathan V, Blyth F, Le Couteur DG, Handelsman DJ, Waite LM, Hirani V. Sarcopenic Obesity and Its Temporal Associations With Changes in Bone Mineral Density, Incident Falls, and Fractures in Older Men: The Concord Health and Ageing in Men Project. J Bone Miner Res 2017; 32:575-583. [PMID: 27736026 DOI: 10.1002/jbmr.3016] [Citation(s) in RCA: 113] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 09/29/2016] [Accepted: 10/11/2016] [Indexed: 12/23/2022]
Abstract
Body composition and muscle function have important implications for falls and fractures in older adults. We aimed to investigate longitudinal associations between sarcopenic obesity and its components with bone mineral density (BMD) and incident falls and fractures in Australian community-dwelling older men. A total of 1486 men aged ≥70 years from the Concord Health and Ageing in Men Project (CHAMP) study were assessed at baseline (2005-2007), 2-year follow-up (2007-2009; n = 1238), and 5-year follow-up (2010-2013; n = 861). At all three time points, measurements included appendicular lean mass (ALM), body fat percentage and total hip BMD, hand-grip strength, and gait speed. Participants were contacted every 4 months for 6.1 ± 2.1 years to ascertain incident falls and fractures, the latter being confirmed by radiographic reports. Sarcopenic obesity was defined using sarcopenia algorithms of the European Working Group on Sarcopenia (EWGSOP) and the Foundation for the National Institutes of Health (FNIH) and total body fat ≥30% of total mass. Sarcopenic obese men did not have significantly different total hip BMD over 5 years compared with non-sarcopenic non-obese men (p > 0.05). EWGSOP-defined sarcopenic obesity at baseline was associated with significantly higher 2-year fall rates (incidence rate ratio [IRR] 1.66; 95% confidence interval [CI] 1.16-2.37), as were non-sarcopenic obesity (1.30; 1.04-1.62) and sarcopenic non-obesity (1.58; 1.14-2.17), compared with non-sarcopenic non-obese. No association with falls was found for sarcopenic obesity using the FNIH definition (1.01; 0.63-1.60), but after multivariable adjustment, the FNIH-defined non-sarcopenic obese group had a reduced hazard for any 6-year fracture compared with sarcopenic obese men (hazard ratio 0.44; 95% CI 0.23-0.86). In older men, EWGSOP-defined sarcopenic obesity is associated with increased fall rates over 2 years, and FNIH-defined sarcopenic obese men have increased fracture risk over 6 years compared with non-sarcopenic obese men. © 2016 American Society for Bone and Mineral Research.
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Affiliation(s)
- David Scott
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia.,Department of Medicine and Australian Institute of Musculoskeletal Science, Melbourne Medical School - Western Campus, The University of Melbourne, St Albans, Australia
| | - Markus Seibel
- Bone Research Program, ANZAC Research Institute, and Department of Endocrinology and Metabolism, Concord Hospital, The University of Sydney, Sydney, Australia
| | - Robert Cumming
- School of Public Health, University of Sydney, Sydney, Australia.,Centre for Education and Research on Ageing, Concord Hospital, University of Sydney, Sydney, Australia.,The ARC Centre of Excellence in Population Ageing Research, University of Sydney, Sydney, Australia
| | - Vasi Naganathan
- Centre for Education and Research on Ageing, Concord Hospital, University of Sydney, Sydney, Australia
| | - Fiona Blyth
- Centre for Education and Research on Ageing, Concord Hospital, University of Sydney, Sydney, Australia
| | - David G Le Couteur
- ANZAC Research Institute and Charles Perkins Centre, University of Sydney, Sydney, Australia
| | - David J Handelsman
- Department of Andrology, Concord Hospital and ANZAC Research Institute, University of Sydney, Sydney, Australia
| | - Louise M Waite
- Centre for Education and Research on Ageing, Concord Hospital, University of Sydney, Sydney, Australia
| | - Vasant Hirani
- Centre for Education and Research on Ageing, Concord Hospital, University of Sydney, Sydney, Australia.,School of Life and Environmental Sciences, Charles Perkins Centre, University of Sydney, Sydney, Australia
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Abstract
The skeleton is adversely affected by type 1 diabetes (T1D). Patients with T1D of both sexes have an increased risk of fracture that begins in childhood and extends across the entire lifespan. T1D is characterized by mild to modest deficits in bone density, structure, and microarchitecture. Current evidence suggests that the observed bone deficits in T1D are the result of impaired bone formation rather than increased bone resorption. There is emerging data that bone quality is impaired in T1D, which may explain the findings that fracture risk is elevated out of proportion to the degree of bone mineral deficit. In this review, we summarize the current knowledge regarding the epidemiology of skeletal health in T1D. Given the high individual and societal burden of osteoporotic fracture, there is an urgent need to better understand the etiology of T1D-related bone disease so that clinical strategies to prevent fracture can be developed.
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Affiliation(s)
- David R Weber
- Division of Pediatric Endocrinology, University of Rochester, 601 Elmwood Ave, Box 690, Rochester, NY, 14642, USA.
| | - George Schwartz
- Division of Pediatric Nephrology, University of Rochester, 601 Elmwood Ave, Box 690, Rochester, NY, 14642, USA
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