Warren S. Browner

Risk factors for hip fracture in white women. Study of Osteoporotic Fractures Research Group.

BACKGROUND Many risk factors for hip fractures have been suggested but have not been evaluated in a comprehensive prospective study. METHODS We assessed potential risk factors, including bone mass, in 9516 white women 65 years of age or older who had had no previous hip fracture. We then followed these women at 4-month intervals for an average of 4.1 years to determine the frequency of hip fracture. All reports of hip fractures were validated by review of x-ray films. RESULTS During the follow-up period, 192 women had first hip fractures not due to motor vehicle accidents. In multivariable age-adjusted analyses, a maternal history of hip fracture doubled the risk of hip fracture (relative risk, 2.0; 95 percent confidence interval, 1.4 to 2.9), and the increase in risk remained significant after adjustment for bone density. Women who had gained weight since the age of 25 had a lower risk. The risk was higher among women who had previous fractures of any type after the age of 50, were tall at the age of 25, rated their own health as fair or poor, had previous hyperthyroidism, had been treated with long-acting benzodiazepines or anticonvulsant drugs, ingested greater amounts of caffeine, or spent four hours a day or less on their feet. Examination findings associated with an increased risk included the inability to rise from a chair without using ones arms, poor depth perception, poor contrast sensitivity, and tachycardia at rest. Low calcaneal bone density was also an independent risk factor. The incidence of hip fracture ranged from 1.1 (95 percent confidence interval, 0.5 to 1.6) per 1,000 woman-years among women with no more than two risk factors and normal calcaneal bone density for their age to 27 (95 percent confidence interval, 20 to 34) per 1,000 woman-years among those with five or more risk factors and bone density in the lowest third for their age. CONCLUSIONS Women with multiple risk factors and low bone density have an especially high risk of hip fracture. Maintaining body weight, walking for exercise, avoiding long-acting benzodiazepines, minimizing caffeine intake, and treating impaired visual function are among the steps that may decrease the risk.

Case-Finding Instruments for Depression: Two Questions Are as Good as Many

ObjectiveTo determine the validity of a two-question case-finding instrument for depression as compared with six previously validated instruments.DesignThe test characteristics of a two-question case-fidning instrument that asks about depressed mood and anhedonia were compared with six common case-finding instruments, using the Quick Diagnostic Interview Schedule as a criterion standard for the diagnosis of major depression.SettingUrgent care clinic at the San Francisco Department of Veterans Affairs Medical Center.ParticipantsFive hundred thirty-six consecutive adult patients without mania or schizophrenia.Measurements and main resultsMeasurements were two questions from the Primary Care Evaluation of Mental Disorders patient questionnaire, both the long and short forms of the Center for Epidemiologic Studies Depression Scale, both the long and short forms of the Beck Depression Inventory, the Symptom-Driven Diagnostic System for Primary Care, the Medical Outcomes Study depression measure, and the Quick Diagnostic Interview Schedule. The prevalence of depression, as determined by the standardized interview, was 18% (97 of 536). Overall, the case-finding instruments had sensitivities of 89% to 96% and specificities of 51% to 72% for diagnosing major depression. A positive response to the two-item instrument had a sensitivity of 96% (95% confidence interval [CI], 90–99%) and a specificity of 57% (95% CI 53–62%). Areas under the receiver operating characteristic curves were similar for all of the instruments, with a range of 0.82 to 0.89.ConclusionsThe two-question case-finding instrument is a useful measure for detecting depression in primary care. It has similar test characteristics to other case-finding instruments and is less time-consuming.

BMD at multiple sites and risk of fracture of multiple types: long-term results from the Study of Osteoporotic Fractures.

In a large cohort of U.S. women aged 65 and older, we report the relationships of BMD measured at several sites, and subsequent fracture risk at multiple sites over >8 years of follow‐up. Although we found almost all fracture types to be related to low BMD, the overall proportion of fractures attributable to low BMD is modest.

Endogenous Hormones and the Risk of Hip and Vertebral Fractures among Older Women

BACKGROUND AND METHODS In postmenopausal women, the serum concentrations of endogenous sex hormones and vitamin D might influence the risk of hip and vertebral fractures. In a study of a cohort of women 65 years of age or older, we compared the serum hormone concentrations at base line in 133 women who subsequently had hip fractures and 138 women who subsequently had vertebral fractures with those in randomly selected control women from the same cohort. Women who were taking estrogen were excluded. The results were adjusted for age and weight. RESULTS The women with undetectable serum estradiol concentrations (<5 pg per milliliter [18 pmol per liter]) had a relative risk of 2.5 for subsequent hip fracture (95 percent confidence interval, 1.4 to 4.6) and subsequent vertebral fracture (95 percent confidence interval, 1.4 to 4.2), as compared with the women with detectable serum estradiol concentrations. Serum concentrations of sex hormone-binding globulin that were 1.0 microg per deciliter (34.7 nmol per liter) or higher were associated with a relative risk of 2.0 for hip fracture (95 percent confidence interval, 1.1 to 3.9) and 2.3 for vertebral fracture (95 percent confidence interval, 1.2 to 4.4). Women with both undetectable serum estradiol concentrations and serum sex hormone-binding globulin concentrations of 1 microg per deciliter or more had a relative risk of 6.9 for hip fracture (95 percent confidence interval, 1.5 to 32.0) and 7.9 for vertebral fracture (95 percent confidence interval, 2.2 to 28.0). For those with low serum 1,25-dihydroxyvitamin D concentrations (< or =23 pg per milliliter [55 pmol per liter]), the risk of hip fracture increased by a factor of 2.1 (95 percent confidence interval, 1.2 to 3.5). CONCLUSIONS Postmenopausal women with undetectable serum estradiol concentrations and high serum concentrations of sex hormone-binding globulin have an increased risk of hip and vertebral fracture.

Depressive Symptoms, Health Behaviors, and Risk of Cardiovascular Events in Patients With Coronary Heart Disease

CONTEXT Depressive symptoms predict adverse cardiovascular outcomes in patients with coronary heart disease, but the mechanisms responsible for this association are unknown. OBJECTIVE To determine why depressive symptoms are associated with an increased risk of cardiovascular events. DESIGN AND PARTICIPANTS The Heart and Soul Study is a prospective cohort study of 1017 outpatients with stable coronary heart disease followed up for a mean (SD) of 4.8 (1.4) years. SETTING Participants were recruited between September 11, 2000, and December 20, 2002, from 12 outpatient clinics in the San Francisco Bay Area and were followed up to January 12, 2008. MAIN OUTCOME MEASURES Baseline depressive symptoms were assessed using the Patient Health Questionnaire (PHQ). We used proportional hazards models to evaluate the extent to which the association of depressive symptoms with subsequent cardiovascular events (heart failure, myocardial infarction, stroke, transient ischemic attack, or death) was explained by baseline disease severity and potential biological or behavioral mediators. RESULTS A total of 341 cardiovascular events occurred during 4876 person-years of follow-up. The age-adjusted annual rate of cardiovascular events was 10.0% among the 199 participants with depressive symptoms (PHQ score > or = 10) and 6.7% among the 818 participants without depressive symptoms (hazard ratio [HR], 1.50; 95% confidence interval, [CI], 1.16-1.95; P = .002). After adjustment for comorbid conditions and disease severity, depressive symptoms were associated with a 31% higher rate of cardiovascular events (HR, 1.31; 95% CI, 1.00-1.71; P = .04). Additional adjustment for potential biological mediators attenuated this association (HR, 1.24; 95% CI, 0.94-1.63; P = .12). After further adjustment for potential behavioral mediators, including physical inactivity, there was no significant association (HR, 1.05; 95% CI, 0.79-1.40; P = .75). CONCLUSION In this sample of outpatients with coronary heart disease, the association between depressive symptoms and adverse cardiovascular events was largely explained by behavioral factors, particularly physical inactivity.

Prophylactic atenolol reduces postoperative myocardial ischemia

Background Perioperative myocardial ischemia occurs in 20–40% of patients at risk for cardiac complications and is associated with a ninefold increase in risk for perioperative cardiac death, myocardial infarction, or unstable angina, and a twofold long‐term risk. Perioperative atenolol administration reduces the risk of death for as long as 2 yr after surgery. This randomized, placebo‐controlled, double‐blinded trial tested the hypothesis that perioperative atenolol administration reduces the incidence and severity of perioperative myocardial ischemia, potentially explaining the observed reduction in the risk for death. Methods Two‐hundred patients with, or at risk for, coronary artery disease were randomized to two study groups (atenolol and placebo). Monitoring included a preoperative history and physical examination and daily assessment of any adverse events. Twelve‐lead electrocardiography (ECG), three‐lead Holter ECG, and creatinine phosphokinase with myocardial banding (CPK with MB) data were collected 24 h before until 7 days after surgery. Atenolol (0, 5, or 10 mg) or placebo was administered intravenously before induction of anesthesia and every 12 h after operation until the patient could take oral medications. Atenolol (0, 50, or 100 mg) was administered orally once a day as specified by blood pressure and heart rate. Results During the postoperative period, the incidence of myocardial ischemia was significantly reduced in the atenolol group: days 0–2 (atenolol, 17 of 99 patients; placebo, 34 of 101 patients; P = 0.008) and days 0–7 (atenolol, 24 of 99 patients; placebo, 39 of 101 patients; P = 0.029). Patients with episodes of myocardial ischemia were more likely to die in the next 2 yr (P = 0.025). Conclusions Perioperative administration of atenolol for 1 week to patients at high risk for coronary artery disease significantly reduces the incidence of postoperative myocardial ischemia. Reductions in perioperative myocardial ischemia are associated with reductions in the risk for death at 2 yr.

Association of renal insufficiency with treatment and outcomes after myocardial infarction in elderly patients

Context Renal insufficiency increases the risk for cardiovascular disease, but whether it affects survival after myocardial infarction is unknown. Contribution This large cohort study of Medicare beneficiaries hospitalized between April 1994 and July 1995 revealed the following: 1-year postmyocardial infarction mortality for no, mild, and moderate renal insufficiency was 24%, 46%, and 66%, respectively. Moderate renal insufficiency was more common in black and male patients and in patients with diabetes or previous stroke. Patients with moderate renal insufficiency received aspirin, -blockers, thrombolytic therapy, angiography, and angioplasty less often than patients with mild or no renal insufficiency. Implications Patients with moderate renal insufficiency have increased mortality after myocardial infarction. They also get fewer effective treatments for myocardial infarction, which may explain the higher death rate. The Editors Patients with end-stage renal disease who require dialysis have markedly increased mortality after myocardial infarction compared with other patients. One-year mortality in these patients is approximately 60% (1-3). After myocardial infarction, these patients are also unlikely to receive aggressive therapy, such as thrombolytic therapy and primary angioplasty, although these treatments have been associated with improved survival in these patients (4). Patients with renal insufficiency have a greater risk for cardiovascular disease events (5, 6), but the association between mild and moderate renal insufficiency and survival after myocardial infarction has not been evaluated in-depth (1, 7). Two earlier studies have included measures of renal function in prediction models for death after myocardial infarction. Normand and colleagues (8) incorporated both blood urea nitrogen and creatinine levels into a multivariate prediction model for 30-day mortality after myocardial infarction. Jacobs and colleagues included urea nitrogen levels as one of seven categories of predictors for death after hospital admission for acute coronary syndromes (9). However, studies have not compared survival after myocardial infarction among patients with and without renal insufficiency. In addition, the use of medical treatments and procedures after myocardial infarction among patients with and without renal insufficiency, and their association with survival, has not been studied. We hypothesized that patients with mild and moderate renal insufficiency would have substantially greater 1-year mortality than patients with no renal insufficiency. We also hypothesized that patients with renal insufficiency would be less likely to receive therapeutic interventions known to improve survival after myocardial infarction, such as -blockers, aspirin, angiotensin-converting enzyme (ACE) inhibitors, thrombolytic therapy, and primary angioplasty. Using data from the Cooperative Cardiovascular Project, we evaluated the treatment of patients with no renal insufficiency and patients with mild and moderate renal insufficiency. We also determined the independent association of renal insufficiency with survival after myocardial infarction. Methods Patients The Cooperative Cardiovascular Project collected data from all elderly (age 65 years) Medicare beneficiaries who were admitted between April 1994 and July 1995 to an acute-care hospital and discharged with the diagnosis of acute myocardial infarction (International Classification of Diseases, Ninth Revision, diagnosis code 410) (10). The diagnosis was confirmed by review of the medical records for each patient and required a serum creatine kinaseMB index greater than 5%; an elevated serum lactate dehydrogenase level with lactate dehydrogenase-1 greater than or equal to lactate dehydrogenase-2; or two of the following three criteria: chest pain, serum creatine kinase level more than twice the normal value, or electrocardiographic evidence of acute myocardial infarction (11). A total of 139 567 patients had confirmed myocardial infarction. Only the initial hospitalization for myocardial infarction during the period of evaluation was included. We excluded 6790 patients with severe renal insufficiency (serum creatinine level 4.0 mg/dL [354 mol/L]) or estimated creatinine clearance less than 0.17 mL/sec. We also excluded 10 570 patients (8.1%) for whom information on body weight was not available to estimate creatinine clearance. Measurements Within the Cooperative Cardiovascular Project, trained medical record abstracters collected the following data for each patient: date and location of hospitalization, demographic characteristics, comorbid conditions, severity of illness measures, electrocardiogram findings, laboratory values, results from invasive and noninvasive cardiac studies, contraindications to therapy, in-hospital treatments, and discharge medications (9). The reliability of the data abstraction process has been demonstrated (10, 12). We classified renal function using both the admission serum creatinine level and the estimated creatinine clearance. We defined no renal insufficiency as a serum creatinine level less than 1.5 mg/dL (<132 mol/L), mild renal insufficiency as a serum creatinine level between 1.5 and 2.4 mg/dL (132 to 212 mol/L), and moderate renal insufficiency as a serum creatinine level between 2.5 and 3.9 mg/dL (221 to 345 mol/L). We estimated creatinine clearance by using the CockroftGault equation (13) and divided patients into tertiles. Data on serum creatinine levels were available for all patients. Data on mortality during the first year after hospital admission were obtained from Social Security Administration records. Statistical Analysis We compared the characteristics and treatments of patients with no renal insufficiency, mild renal insufficiency, and moderate renal insufficiency using analysis of variance and chi-square tests. We compared the proportions of patients treated with -blockers among all patients in each category of renal function and in just the patients without relative contraindications to -blockers (previous heart failure, diabetes, chronic obstructive pulmonary disease, and pulmonary edema at presentation). We compared use of ACE inhibitors among all patients and then restricted the comparison to patients with hypertension or diabetes. For thrombolytic therapy, we compared treatment as a proportion of all patients treated and as a proportion of ideal patients treated. Ideal candidates were defined by ST-segment elevation or left bundle-branch block on the electrocardiogram; onset of chest pain within 6 hours of presentation; age of 80 years or younger; and the absence of peptic ulcer disease, chronic liver disease, metastatic cancer, and terminal illness (14). To determine the association of renal function with survival after myocardial infarction, we constructed KaplanMeier curves for the three groups of serum creatinine levels (and the tertiles of creatinine clearance); statistical significance was assessed by using the log-rank test. We repeated these analyses within subgroups of patients who presented without pulmonary edema or cardiogenic shock (Killip class I and class II) to determine whether the association of renal function with 1-year survival persisted among patients with less severe myocardial infarctions. We used Cox proportional-hazards models to determine whether mild and moderate renal insufficiency were independent predictors of 1-year mortality (15). These models were adjusted for patient demographic characteristics (age, sex, race, rural or urban setting, and region of the United States); comorbid conditions (history of diabetes mellitus, hypertension, hypercholesterolemia, tobacco use, congestive heart failure, stroke, peripheral vascular disease, angina, myocardial infarction, percutaneous transluminal coronary angioplasty, coronary artery bypass graft surgery, chronic obstructive pulmonary disease, dementia, inability to ambulate, depression, and incontinence); severity of clinical presentation (Killip class, electrocardiogram findings, heart rate, mean arterial blood pressure, alertness and orientation according to the Glasgow coma scale, duration of chest pain, and blood urea nitrogen level [< 30 mg/dL; <10.7 mmol/L as urea or 30 mg/dL; 10.7 mmol/L as urea]); hospital characteristics (capability to do coronary angiography and revascularization; volume of myocardial infarction admissions); in-hospital treatments (aspirin, -blockers, ACE inhibitors, thrombolytic therapy, intravenous nitroglycerin, coronary angiography, percutaneous transluminal coronary angioplasty, and coronary artery bypass graft surgery); and discharge medications (aspirin, -blockers, calcium-channel blockers, and ACE inhibitors). We evaluated the inclusion of a categorical variable for each hospital (n = 4200) in a 10% sample of our data set, but it had little effect on the association of renal function with survival after myocardial infarction. We also checked for violations of linearity by examining augmented models, which included quadratic terms for continuous predictors. We tested the validity of the proportional hazards assumption by determining whether the risk estimates for the renal function categories varied significantly over time. Because we found a significant interaction of the risk for renal function over time, we elected to explore stratified models over time. We separately evaluated the association of our renal function categories with survival after myocardial infarction for the following time intervals: months 1, 2 to 3, 4 to 6, 7 to 9, and 10 to 12. Because the association of renal insufficiency with mortality was the same for months 7 to 9 and 10 to 12, we combined these follow-up intervals. We confirmed that there were no residual violations of the proportional hazards assumption within each time strata by again testing for the presence of an interaction of each renal function predictor with time in predicting mor

Factors associated with appendicular bone mass in older women

Fractures are an important cause of disability in elderly women, especially among those with osteopenia. Decreased bone mass increases the risk for most types of fractures [1-4]. In particular, we recently reported [5] that most fractures in elderly women are associated with low bone mass at appendicular sites (the radius and calcaneus). The risk for these fractures, including some fractures not previously linked to osteopenia, such as of the leg and hand, increased 40% to 80% for each standard deviation reduction in appendicular bone mass [5]. We also found that appendicular bone mass predicts the risk for all nonspine fractures as well as for bone mass measured at the hip and spine [6]. Despite the strong relation between appendicular bone mass and risk for fracture, little consensus exists about the many proposed risk factors for decreased bone mass [7, 8], perhaps because most studies have examined a limited number of risk factors in relatively small selected cohorts. To determine what factors might contribute to osteopenia in older women, we examined a wide variety of potential correlates of appendicular bone mass in the Study of Osteoporotic Fractures, a large multicenter, community-based study of elderly women. Methods Patients From September 1986 to October 1988, women who were at least 65 years old were recruited in four areas of the United States: Portland, Oregon; Minneapolis, Minnesota; Baltimore, Maryland; and the Monongahela Valley near Pittsburgh, Pennsylvania. Age-eligible women were identified from membership lists from several sources, as previously reported [1]. We excluded black women because of the reduced incidence of hip fractures in this group [9], and we excluded women who were unable to walk without the assistance of another person or who had bilateral hip replacements. Measurement of Bone Mass Bone mass (in g/cm2) was measured using OsteoAnalyzers (Siemens-Osteon, Wahiawa, Hawaii). We scanned three sites: the distal radius, the midradius, and the calcaneus. The protocol for the bone mass measurements has been described elsewhere [1]. To describe the reproducibility of these measurements, a participant in the study was measured five times on 5 consecutive days at each of the four clinical centers. The average coefficients of variation in these older women (standard deviation/mean for each subject) were 1.5% for the distal radius, 2.0% for the midradius, and 1.3% for the calcaneus. To assess variations between scanners at the four centers, two investigators were measured by all four machines; the mean of their coefficients of variation in these younger subjects was 0.4% for the distal radius, 0.5% for the midradius, and 1.2% for the calcaneus [10]. The correlation coefficients between the measurement sites were distal and midradius, 0.75; calcaneus and distal radius, 0.66; and calcaneus and midradius, 0.63. Predictor Variables Participants completed a self-administered questionnaire and were interviewed and examined at the clinical center. A selected medical history was obtained, including a history of a physician diagnosis of osteoporosis, spine fracture, arthritis, gastric surgery, hyperthyroidism, and stroke. Reproductive history, including age of last menstrual period, genitourinary surgery (hysterectomy, oophorectomy), number of pregnancies, and breast-feeding, was recorded. Previous fractures in subjects and their parents or sisters were noted. We collected detailed records about specific health habits including lifetime smoking history, alcohol use, and caffeine intake. Women who had smoked less than 100 cigarettes in their lifetime were considered nonsmokers. We assumed that a cup of coffee contained 95 mg of caffeine and that tea and cola drinks contained 55 mg and 45 mg, respectively. Participants were asked to bring all prescription and nonprescription medications with them to the interview for verification. The dose and duration of use of sex hormones, diuretics, corticosteroids, thyroid supplements, aluminum-containing antacids, vitamin D, sedative hypnotics, and antiepileptic medications were obtained. The frequency and duration of use of calcium supplements were recorded; use of TUMS (which can be taken as an antacid or calcium supplement) was recorded separately. Responses to the questionnaire were checked by a trained interviewer and were verified against the labels of medications that the subject brought to the interview. Recent dietary history (past 12 months), particularly calcium, phosphorus, and protein intake, was assessed by a checklist-interview method developed from the HANES-II survey [11]. Food models were used to estimate portion sizes, and foods that account for 80% of calcium intake in most adults were included. This instrument has a correlation of 0.76 with calcium intake assessed by a 7-day diet diary, but it tends to underestimate calcium intake by approximately 150 mg/day [12]. The frequency of milk consumption as a child and young adult was also assessed by questionnaire. Physical activity was examined with a modified Paffenbarger survey that has been validated in postmenopausal women [13-16]. The type and duration of weight-bearing recreational activities from the previous 12 months were recorded, and these were converted into weekly caloric expenditure. Other current activities, such as stair climbing, walking, and heavy household chores, were included. Intensity-weighted measures were calculated by designating activities as low (for example, walking or gardening), medium (dancing or tennis), or high intensity (jogging or skiing) and multiplying the reported frequency of the activity by 2.5, 5, and 7.5, respectively. Weight (in light indoor clothes with shoes removed) was recorded with a balance beam scale, and height was measured using a standard held-expiration technique with a wall-mounted Harpenden stadiometer [17]. Maximal right knee extension, triceps (arm extension), and hip abduction torque strength were measured with a hand-held isometric dynamometer (Sparks Instruments and Academics, Coralville, Iowa). Grip strength of the right and left hand was assessed as the average of two attempts with the dynamometer. Waist, hip, and abdominal circumferences were measured using standard methods [18]. Statistical Methods The cohort was randomly divided into equal-sized (n = 4852) training and validation groups. In the training group, we analyzed potential associations with bone mass in univariate analyses, adjusted for age. We then adjusted associations (P < 0.05) for other plausible confounding effects. For example, associations between the use of thiazide diuretics and bone mass were also adjusted for body weight, because those who were taking diuretics tended to be heavier. Potentially nonlinear associations between bone mass and continuous variables, such as calcium intake, were examined by plotting bone mass against the median of each decile of the predictor variable. Associations were tested for statistical significance with simple linear regression, Student t-test, or analysis of variance. Variables that were associated with bone mass in univariate analyses (P < 0.05) were examined by multivariate analyses using PROC GLM (SAS Institute, Inc., Cary, North Carolina). Some categories of predictor variables, such as calcium intake and muscle strength, contained several variables associated with bone mass in univariate analyses. After examining these variables for multicollinearity, separate models for strength, family history of fractures, dietary calcium, and physical activity were analyzed to determine the individual variables that explained most of the variance of bone mass within each category. For example, grip strength explained most of the variance for bone mass related to strength; thus, we selected this variable as the measure of strength for subsequent multivariate analyses. Both current dietary calcium and calcium from milk (ingested between ages 18 to 50 years) contributed to bone mass variance; therefore, both were included in the final multivariate models. A history of any maternal fracture after age 50 accounted for most of the bone mass variance from family history, and intensity-weighted lifetime physical activity accounted for most of the variance from physical activity. Selected variables (see Table 2) were then entered into a single multivariate model. We found that results from multivariate models were very similar in both training and validation groups; thus results are reported for the entire (combined) cohort. Results were generally similar for the three bone mass sites, and for those analyses that were concordant at all three sites, only the results for the distal radius are presented. We presented results at the other two sites only when they differed from the distal radius. Results The average age at enrollment was 71.1 years, and the age distributions were similar in the training and validation groups (Table 1). Thirteen percent of patients reported a previous wrist or hip fracture. Table 1. Baseline Characteristics of Patients Demographic and Anthropometric Data Bone mass was strongly and inversely associated with age, decreasing by approximately 5% with every additional 5 years of age after 65 years (Table 2). Northern European ancestry, hair color, and educational level were not associated with bone mass (Table 3). Table 2. Univariate and Multivariate Correlates of Distal Radius Bone Mass Table 3. Variables Not Associated with Distal Radius Bone Mass, Age-Adjusted Univariate Analyses* Several anthropometric measurements were strongly associated with bone mass (see Table 2). Both weight [in kilograms] and obesity (as Quetelet index, in kilograms per square meter) were associated with increased bone mass: after adjusting for age, bone mass increased 5.0% for every 10-kg increase in weight (Figure 1). Although weight and Quetelet were highly correlated (r = 0.91), weight was more strongly associated with bone mass than

Which Fractures Are Associated with Low Appendicular Bone Mass in Elderly Women

Abstract ▪Objective:To determine which types of fractures have an increased incidence in elderly women with low appendicular bone mass. ▪Design:Prospective cohort study. ▪Setting:Four clinical cent...

Lower-Extremity Amputation in People With Diabetes: Epidemiology and Prevention

The age-adjusted rate of lower-extremity amputation (LEA) in the diabetic population is ∼15 times that of the nondiabetic population. Over 50,000 LEAs were performed on individuals with diabetes in the United States in 1985. Among individuals with diabetes, peripheral neuropathy and peripheral vascular disease (PVD) are major predisposing factors for LEA. Lack of adequate foot care and infection are additional risk factors. Several large clinical centers have experienced a 44–85% reduction in the rate of amputations among individuals with diabetes after the implementation of improved foot-careprograms. Programs to reduce amputations among people with diabetes in primarycare settings should identify those at high risk; clinically evaluate individuals to determine specific risk status; ensure appropriate preventive therapy, treatment for foot problems, and follow-up; provide patient education;and, when necessary, refer patients to specialists, including health-care professionals for diagnostic and therapeutic interventions and shoe fitters for proper footwear. Programs should monitor and evaluate their activities andoutcomes. Many issues related to the etiology and prevention of LEAs requirefurther research.