Effects of an 18-month community-based, multifaceted, exercise program on patient-reported outcomes in older adults at risk of fracture: secondary analysis of a randomised controlled trial.

This study identified that an 18-month community-based, multifaceted, exercise program consisting of resistance, weight-bearing impact, and balance/mobility training combined with osteoporosis education and behavioural support can improve health-related quality of life (HRQoL) and osteoporosis knowledge in older adults at risk of fracture, but only for those adherent to the exercise regime. PURPOSE: To evaluate the effects of an 18-month community-based exercise, osteoporosis education and behaviour change program (Osteo-cise: Strong Bones for Life) on HRQoL, osteoporosis knowledge and osteoporosis health beliefs. METHODS: This was a secondary analysis of an 18-month randomised controlled trial in which 162 older adults aged ≥ 60 years with osteopenia or increased falls/fracture risk were randomized to the Osteo-cise program (n = 81) or control group (n = 81). The program consisted of progressive resistance, weight-bearing impact and balance training (3 days/week); osteoporosis education to facilitate self-management of musculoskeletal health and behavioural support to enhance adherence to exercise. HRQoL, osteoporosis knowledge and osteoporosis health beliefs were assessed using the EuroQoL questionnaire (EQ-5D-3L), Osteoporosis Knowledge Assessment Tool and Osteoporosis Health Belief Scale, respectively. RESULTS: Overall, 148 participants (91%) completed the trial. Mean exercise adherence was 55% and mean attendance for the three osteoporosis educational sessions ranged from 63-82%. After 12 and 18 months, there were no significant effects of the Osteo-cise program on HRQoL, osteoporosis knowledge or health beliefs relative to controls. Per protocol analyses (≥ 66% exercise adherence; n = 41) revealed a significant net benefit in EQ-5D-3L utility for the Osteo-cise group relative to controls after 12 months (P = 0.024) and 18 months (P = 0.029) and a significant net improvement in osteoporosis knowledge scores at 18 months (P = 0.014). CONCLUSION: This study supports the importance of adherence to exercise regimes, as adherence to the Osteo-cise: Strong Bones for Life program was associated with improvements in HRQoL and osteoporosis knowledge in older adults at increased risk for falls and fractures. TRIAL REGISTRATION NUMBER: ACTRN12609000100291.

An experience- and preference-based EQ-5D-3L value set derived using 18 months of longitudinal data in patients who sustained a fracture: results from the ICUROS.

INTRODUCTION: EQ-5D-3L preference-based value sets are predominately based on hypothetical health states and derived in cross-sectional settings. Therefore, we derived an experience-based value set from a prospective observational study. METHODS: The International Costs and Utilities Related to Osteoporotic fractures Study (ICUROS) was a multinational study on fragility fractures, prospectively collecting EQ-5D-3L and Time trade-off (TTO) within two weeks after fracture (including pre-fracture recall), and at 4, 12, and 18 months thereafter. We derived an EQ-5D-3L value set by regressing the TTO values on the ten impairment levels in the EQ-5D-3L. We explored the potential for response shift and whether preferences for domains vary systematically with prior impairment in that domain. Finally, we compared the value set to 25 other EQ-5D-3L preference-based value sets. RESULTS: TTO data were available for 12,954 EQ-5D-3L health states in 4683 patients. All coefficients in the value set had the expected sign, were statistically significant, and increased monotonically with severity of impairment. We found evidence for response shift in mobility, self-care, and usual activities. The value set had good agreement with the only other experience- and preference-based value set, but poor agreement with all hypothetical value sets. CONCLUSIONS: We present an experience- and preference-based value set with high face validity. The study indicates that response shift may be important to account for when deriving value sets. Furthermore, the study suggests that perspective (experienced versus hypothetical) is more important than country setting or demographics for valuation of EQ-5D-3L health states.

Effects of a multi-modal resistance exercise program and calcium-vitamin D3 fortified milk on blood pressure and blood lipids in middle-aged and older men: secondary analysis of an 18-month factorial design randomised controlled trial.

PURPOSE: Physical activity and dietary interventions are recommended as front-line therapy for prevention and management of cardiovascular disease. This study investigated the independent and combined effects of low-fat, calcium-vitamin D3 fortified milk and multi-modal exercise training on blood pressure (BP) and blood lipids in middle-aged and older men. METHODS: This was a pre-planned secondary analysis of an 18-month, randomised controlled trial. Community-dwelling men aged 50-79 years (n = 180) were randomised into (i) exercise + fortified milk; (ii) fortified milk; (iii) exercise; or (iv) control. The low-fat milk (400 mL/day) was fortified with 1,000 mg/day calcium and 800 IU/day of vitamin-D3, whilst the exercise intervention consisted of three sessions/week of resistance- and weight-bearing impact exercises. Resting BP and fasting lipids were assessed at baseline, 6 (lipids only), 12 and 18 months. RESULTS: Mean ± SD serum 25(OH)D and calcium intake for the entire cohort at baseline was 86 ± 36 nmol/L and 1002 ± 397 mg/day, respectively, with 10% classified as vitamin-D insufficient and 58% reporting a calcium intake below 1000 mg/day. There were no exercise-by-fortified milk interactions, nor any main-group effects for exercise or milk on BP or lipids at any time. However, there were significant reductions from baseline to 18 months in systolic (mean change, 5-8 mmHg) and diastolic (4-6 mmHg) BP in the exercise, fortified milk and control groups. All results remained largely unchanged after adjusting for use of anti-hypertensive or lipid lowering medication, weight or fat mass, or only including men with hypertension (n = 89) or dyslipidemia (n = 130) at baseline. CONCLUSION: Supplementation with low-fat, calcium + vitamin D3 fortified milk and a multi-modal exercise program, alone or in combination, was not effective for improving BP or blood lipids in community-dwelling middle-aged and older men.

Do replicable profiles of multimorbidity exist? Systematic review and synthesis.

This systematic review aimed to synthesise multimorbidity profiling literature to identify replicable and clinically meaningful groupings of multimorbidity. We searched six electronic databases (Medline, EMBASE, PsycINFO, CINAHL, Scopus, and Web of Science) for articles reporting multimorbidity profiles. The identified profiles were synthesised with multidimensional scaling, stratified by type of statistical analysis used in the derivation of profiles. The 51 studies that met inclusion criteria reported results of 98 separate analyses of multimorbidity profiling, with a total of 407 multimorbidity profiles identified. The statistical techniques used to identify multimorbidity profiles were exploratory factor analysis, cluster analysis of diseases, cluster analysis of people, and latent class analysis. Reporting of methodological details of statistical methods was often incomplete. The discernible groupings of multimorbidity took the form of both discrete categories and continuous dimensions. Mental health conditions and cardio-metabolic conditions grouped along identifiable continua in the synthesised results of all four methods. Discrete groupings of chronic obstructive pulmonary disease with asthma, falls and fractures with sensory deficits and of Parkinson's disease and cognitive decline where partially replicable (identifiable in the results of more than one method), while clustering of musculoskeletal conditions and clustering of reproductive systems were each observed only in one statistical approach. The two most replicable multimorbidity profiles were mental health conditions and cardio-metabolic conditions. Further studies are needed to understand aetiology and evolution of these multimorbidity groupings. Guidelines for strengthening the reporting of multimorbidity profiling studies are proposed.

Strategies and challenges associated with recruiting retirement village communities and residents into a group exercise intervention.

BACKGROUND: Randomized controlled trials (RCTs) provide the highest level of scientific evidence, but successful participant recruitment is critical to ensure the external and internal validity of results. This study describes the strategies associated with recruiting older adults at increased falls risk residing in retirement villages into an 18-month cluster RCT designed to evaluate the effects of a dual-task exercise program on falls and physical and cognitive function. METHODS: Recruitment of adults aged ≥65 at increased falls risk residing within retirement villages (size 60-350 residents) was initially designed to occur over 12 months using two distinct cohorts (C). Recruitment occurred via a three-stage approach that included liaising with: 1) village operators, 2) independent village managers, and 3) residents. To recruit residents, a variety of different approaches were used, including distribution of information pack, on-site presentations, free muscle and functional testing, and posters displayed in common areas. RESULTS: Due to challenges with recruitment, three cohorts were established between February 2014 and April 2015 (14 months). Sixty retirement villages were initially invited, of which 32 declined or did not respond, leaving 28 villages that expressed interest. A total of 3947 individual letters of invitation were subsequently distributed to residents of these villages, from which 517 (13.1%) expressions of interest (EOI) were received. Across three cohorts with different recruitment strategies adopted there were only modest differences in the number of EOI received (10.5 to 15.3%), which suggests that no particular recruitment approach was most effective. Following the initial screening of these residents, 398 (77.0%) participants were deemed eligible to participate, but a final sample of 300 (58.0% of the 517 EOI) consented and was randomized; 7.6% of the 3947 residents invited. Principal reasons for not participating, despite being eligible, were poor health, lack of time and no GP approval. CONCLUSION: This study highlights that there are significant challenges associated with recruiting sufficient numbers of older adults from independent living retirement villages into an exercise intervention designed to improve health and well-being. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12613001 161718 . Date registered 23rd October 2013.

Quality of life after hip, vertebral, and distal forearm fragility fractures measured using the EQ-5D-3L, EQ-VAS, and time-trade-off: results from the ICUROS.

INTRODUCTION: The International Costs and Utilities Related to Osteoporotic fractures Study is a multinational observational study set up to describe the costs and quality of life (QoL) consequences of fragility fracture. This paper aims to estimate and compare QoL after hip, vertebral, and distal forearm fracture using time-trade-off (TTO), the EuroQol (EQ) Visual Analogue Scale (EQ-VAS), and the EQ-5D-3L valued using the hypothetical UK value set. METHODS: Data were collected at four time-points for five QoL point estimates: within 2 weeks after fracture (including pre-fracture recall), and at 4, 12, and 18 months after fracture. Health state utility values (HSUVs) were derived for each fracture type and time-point using the three approaches (TTO, EQ-VAS, EQ-5D-3L). HSUV were used to estimate accumulated QoL loss and QoL multipliers. RESULTS: In total, 1410 patients (505 with hip, 316 with vertebral, and 589 with distal forearm fracture) were eligible for analysis. Across all time-points for the three fracture types, TTO provided the highest HSUVs, whereas EQ-5D-3L consistently provided the lowest HSUVs directly after fracture. Except for 13-18 months after distal forearm fracture, EQ-5D-3L generated lower QoL multipliers than the other two methods, whereas no equally clear pattern was observed between EQ-VAS and TTO. On average, the most marked differences between the three approaches were observed immediately after the fracture. CONCLUSIONS: The approach to derive QoL markedly influences the estimated QoL impact of fracture. Therefore the choice of approach may be important for the outcome and interpretation of cost-effectiveness analysis of fracture prevention.

Calf muscle density is independently associated with physical function in overweight and obese older adults.

OBJECTIVES: To determine whether associations of calf muscle density with physical function are independent of other determinants of functional decline in overweight and obese older adults. METHODS: This was a secondary analysis of a cross-sectional study of 85 community-dwelling overweight and obese adults (mean±SD age 62.8±7.9 years; BMI 32.3±6.1 kg/m2; 58% women). Peripheral quantitative computed tomography assessed mid-calf muscle density (66% tibial length) and dual-energy X-ray absorptiometry determined visceral fat area. Fasting glucose, Homeostatic Model Assessment of Insulin Resistance (HOMA-IR) and C-reactive protein (CRP) were analysed. Physical function assessments included hand grip and knee extension strength, balance path length (computerised posturography), stair climb test, Short Physical Performance Battery (SPPB) and self-reported falls efficacy (Modified Falls Efficacy Scale; M-FES). RESULTS: Visceral fat area, not muscle density, was independently associated with CRP and fasting glucose (B=0.025; 95% CI 0.009-0.042 and B=0.009; 0.001-0.017, respectively). Nevertheless, higher muscle density was independently associated with lower path length and stair climb time, and higher SPPB and M-FES scores (all P⟨0.05). Visceral fat area, fasting glucose and CRP did not mediate these associations. CONCLUSIONS: Higher calf muscle density predicts better physical function in overweight and obese older adults independent of insulin resistance, visceral adiposity or inflammation.

Arthritis diagnosis and symptoms are positively associated with specific physical job exposures in lower- and middle-income countries: cross-sectional results from the World Health Organization's Study on global AGEing and adult health (SAGE).

BACKGROUND: In higher income countries, work-related squatting and heavy lifting have been associated with increased arthritis risk. Here, we address the paucity of data regarding associations between arthritis and work-related physical stressors in lower- and middle-income countries. METHODS: Data were extracted from the Study on global AGEing and adult health (SAGE) Wave 1 (2007-10) for adults (aged ≥50 years) from Ghana, India, Russia and South Africa for whom detailed occupation data was available (n = 21,389; 49.2% women). Arthritis cases were identified using a symptom-defined algorithm (current) and self-reported doctor-diagnosis (lifetime). A sex-specific Job Exposure Matrix was used to classify work-related stressors: heavy physical work, kneeling/squatting, heavy lifting, arm elevation and awkward trunk posture. Using the International Standard Classification of Occupations, we linked SAGE and the Job Exposure Matrix. Logistic regression was used to investigate associations between arthritis and work-related stressors, adjusting for age (10 year age groupings), potential socioeconomic-related confounders, and body mass index. Excess exposure risk due to two-way interactions with other risk factors were explored. RESULTS: Doctor-diagnosed arthritis was associated with heavy physical work (adjusted odds ratios [OR] 1.12, 95%CI 1.01-1.23), awkward trunk posture (adjusted OR 1.23, 95%CI 1.12-1.36), kneeling or squatting (adjusted OR 1.25, 95%CI 1.12-1.38), and arm elevation (adjusted OR 1.66, 95%CI 1.37-2.00). Symptom-based arthritis was associated with kneeling or squatting (adjusted OR 1.27, 95%CI 1.08-1.50), heavy lifting (adjusted OR 1.33, 95%CI 1.11-1.58), and arm elevation (adjusted OR 2.16, 95%CI 1.63-2.86). Two-way interactions suggested excess arthritis risk existed for higher body mass index, and higher income or education. CONCLUSIONS: Minimization of occupational health risk factors is common practice in higher income countries: attention should now be directed toward reducing work-related arthritis burden in lower- and middle-income countries.

Associations between illness duration and health-related quality of life in specified mental and physical chronic health conditions: results from a population-based survey.

PURPOSE: We compared health-related quality of life (HRQOL) in incident (≤1 year since diagnosis), mid-term (>1-5 years since diagnosis), and long-term (>5 years since diagnosis) cases of mental and physical chronic illness with the general population and assessed the modifying effects of age and gender on the association between HRQOL and illness duration. METHODS: Data from the 2007 Australian National Health and Mental Wellbeing Survey were used. HRQOL was captured by the Assessment of Quality of Life Scale 4D. Multivariable linear regression analyses compared HRQOL of individuals with different duration of illnesses with those who did not have the condition of interest. RESULTS: The 8841 survey respondents were aged 16-85 years (median 43 years, 50.3% female). For the overall sample, worse HRQOL was associated with incident (P = 0.049) and mid-term (P = 0.036) stroke and long-term depression (P < 0.001) and anxiety (P = 0.001). Age had moderating effect on the associations between HRQOL and duration of asthma (P < 0.001), arthritis (P = 0.001), diabetes (P = 0.004), stroke (P = 0.009), depression (P < 0.001), bipolar disorder (P < 0.001), and anxiety (P < 0.001), but not heart disease (P = 0.102). In older ages, the greatest loss in HRQOL was associated with incident asthma, depression, and bipolar disorder. In younger ages, the greatest loss in HRQOL was associated with arthritis (any duration) and incident diabetes and anxiety. Additionally, gender moderated the association between HRQOL and arthritis, with worse HRQOL among men with incident arthritis (P = 0.047). CONCLUSIONS: Loss of HRQOL associated with longer duration of chronic illness is most apparent in stroke and mental illness and differs between age groups.

A randomised controlled trial of low-dose aspirin for the prevention of fractures in healthy older people: protocol for the ASPREE-Fracture substudy.

BACKGROUND: Disability, mortality and healthcare burden from fractures in older people is a growing problem worldwide. Observational studies suggest that aspirin may reduce fracture risk. While these studies provide room for optimism, randomised controlled trials are needed. This paper describes the rationale and design of the ASPirin in Reducing Events in the Elderly (ASPREE)-Fracture substudy, which aims to determine whether daily low-dose aspirin decreases fracture risk in healthy older people. METHODS: ASPREE is a double-blind, randomised, placebo-controlled primary prevention trial designed to assess whether daily active treatment using low-dose aspirin extends the duration of disability-free and dementia-free life in 19 000 healthy older people recruited from Australian and US community settings. This substudy extends the ASPREE trial data collection to determine the effect of daily low-dose aspirin on fracture and fall-related hospital presentation risk in the 16 500 ASPREE participants aged ≥70 years recruited in Australia. The intervention is a once daily dose of enteric-coated aspirin (100 mg) versus a matching placebo, randomised on a 1:1 basis. The primary outcome for this substudy is the occurrence of any fracture-vertebral, hip and non-vert-non-hip-occurring post randomisation. Fall-related hospital presentations are a secondary outcome. DISCUSSION: This substudy will determine whether a widely available, simple and inexpensive health intervention-aspirin-reduces the risk of fractures in older Australians. If it is demonstrated to safely reduce the risk of fractures and serious falls, it is possible that aspirin might provide a means of fracture prevention. TRIAL REGISTRATION NUMBER: The protocol for this substudy is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12615000347561).

Few geographic and socioeconomic variations exist in primary total shoulder arthroplasty: a multi-level study of Australian registry data.

BACKGROUND: Associations between socioeconomic position (SEP) and the uptake of primary total shoulder arthroplasty (TSA) is not well understood in the Australian population, thus potentially limiting equitable allocation of healthcare resources. We used the Australian Orthopaedic Association National Joint Replacement Registry (AOA NJRR) to examine whether geographic or socioeconomic variations exist in TSA performed for a diagnosis of osteoarthritis 2007-11 for all Australians aged ≥40 years. METHODS: Primary anatomical and reverse TSA data were extracted from the AOA NJRR which captures >99 % of all TSA nationally. Residential addresses were cross-referenced to Australian Bureau of Statistics 2011 Census data to identify SEP measured at the area-level (categorised into deciles), and geographic location defined as Australian State/Territory of residence. We used a Poisson distribution for the number of TSA over the study period, and modelled the effects of age, SEP and geographic location using multilevel modelling. RESULTS: During 2007-11, we observed 6,123 TSA (62.2 % female). For both sexes, TSA showed a proportional increase with advancing age. TSA did not vary by SEP or geographic location, with the exception of greater TSA among men in New South Wales. CONCLUSIONS: Using a national registry approach we provide the first reliable picture of TSA at a national level. The uptake of TSA was equitable across SEP; however, there was some variation between the States/Territories. With an aging population, it is imperative that monitoring of major surgical procedures continues, and be focused toward determining whether TSA uptake correlates with need across different social and area-based groups.

A pooled analysis of vitamin D dose requirements for fracture prevention.

BACKGROUND: The results of meta-analyses examining the relationship between vitamin D supplementation and fracture reduction have been inconsistent. METHODS: We pooled participant-level data from 11 double-blind, randomized, controlled trials of oral vitamin D supplementation (daily, weekly, or every 4 months), with or without calcium, as compared with placebo or calcium alone in persons 65 years of age or older. Primary end points were the incidence of hip and any nonvertebral fractures according to Cox regression analyses, with adjustment for age group, sex, type of dwelling, and study. Our primary aim was to compare data from quartiles of actual intake of vitamin D (including each individual participant's adherence to the treatment and supplement use outside the study protocol) in the treatment groups of all trials with data from the control groups. RESULTS: We included 31,022 persons (mean age, 76 years; 91% women) with 1111 incident hip fractures and 3770 nonvertebral fractures. Participants who were randomly assigned to receive vitamin D, as compared with those assigned to control groups, had a nonsignificant 10% reduction in the risk of hip fracture (hazard ratio, 0.90; 95% confidence interval [CI], 0.80 to 1.01) and a 7% reduction in the risk of nonvertebral fracture (hazard ratio, 0.93; 95% CI, 0.87 to 0.99). By quartiles of actual intake, reduction in the risk of fracture was shown only at the highest intake level (median, 800 IU daily; range, 792 to 2000), with a 30% reduction in the risk of hip fracture (hazard ratio, 0.70; 95% CI, 0.58 to 0.86) and a 14% reduction in the risk of any nonvertebral fracture (hazard ratio, 0.86; 95% CI, 0.76 to 0.96). Benefits at the highest level of vitamin D intake were fairly consistent across subgroups defined by age group, type of dwelling, baseline 25-hydroxyvitamin D level, and additional calcium intake. CONCLUSIONS: High-dose vitamin D supplementation (≥800 IU daily) was somewhat favorable in the prevention of hip fracture and any nonvertebral fracture in persons 65 years of age or older. (Funded by the Swiss National Foundations and others.).

Dietary α-Linolenic Acid and Total ω-3 Fatty Acids Are Inversely Associated with Abdominal Aortic Calcification in Older Women, but Not in Older Men.

BACKGROUND: Associations of α-linolenic acid (ALA), eicosapentaenoic acid (EPA) plus decosahexaenoic acid (DHA), and total omega-3 (n-3) fatty acid (FA) intakes with abdominal aortic calcification (AAC) are not well understood. OBJECTIVE: This study explored the associations between baseline and long-term changes in ω-3 FA consumption and AAC severity among community-dwelling older men and women. METHODS: The present study used a subset of the Melbourne Collaborative Cohort Study in which participants were interviewed in 1990-1994 and again in 2010-2011. Dietary intake was evaluated at both baseline and follow-up with use of food-frequency questionnaires. AAC severity was assessed by both lateral thoraco-lumbar radiography and dual-energy X-ray absorptiometry (DXA) at follow-up. RESULTS: A total of 312 participants aged 45-64 y old at baseline were followed for a duration of (mean ± SD) 18 ± 1 y. Baseline energy-adjusted ALA intake tended to be inversely associated with AAC severity by radiography [OR (95% CI) for tertile 3 vs. tertile 1: 0.49 (0.23, 1.02), P-trend: 0.06] and was inversely associated with AAC severity by DXA [OR (95% CI) for tertile 3 vs. tertile 1: 0.37 (0.16, 0.83)] in women, after adjustment for confounders. Women in the third tertile of total ω-3 FA intake had significantly lower AAC severity by radiography [OR (95% CI): 0.33 (0.16, 0.71)] and DXA [OR (95% CI): 0.27 (0.12, 0.62)] than those in the first tertile. Changes in tertile of ω-3 FA intake over 18 y were not found to be associated with AAC severity in either men or women. CONCLUSION: The results of our study suggest that dietary ALA and total ω-3 FA intakes are both important predictors of the development of AAC in older women, but not in older men.

Humeral Fractures in South-Eastern Australia: Epidemiology and Risk Factors.

In this study, we report the epidemiology and risk factors for humeral fractures (proximal humerus and shaft) among men and women residing in south-eastern Australia. Incident fractures during 2006 and 2007 were identified using X-ray reports (Geelong Osteoporosis Study Fracture Grid). Risk factors were identified using data from case-control studies conducted as part of the Geelong Osteoporosis Study. Median age of fracture was lower in males than females for proximal humerus (33.0 vs 71.2 years), but not for humeral shaft (8.9 vs 8.5 years). For females, proximal humerus fractures occurred mainly in the 70-79 and 80+ years age groups, whereas humeral shaft fractures followed a U-shaped pattern. Males showed a U-shaped pattern for both proximal humerus and humeral shaft fractures. Overall age-standardised incidence rates for proximal humerus fractures in males and females were 40.6 (95% CI 32.7, 48.5) and 73.2 (95% CI 62.2, 84.1) per 100,000 person years, respectively. For humeral shaft fractures, the age-standardised rate was 69.3 (95% CI 59.0, 79.6) for males and 61.5 (95% CI 51.9, 71.0) for females. There was an increase in risk of proximal humerus fractures in men with a lower femoral neck BMD, younger age, prior fracture and higher milk consumption. In pre-menopausal women, increased height and falls were both risk factors for proximal humerus fractures. For post-menopausal women, risk factors associated with proximal humerus fractures included a lower non-milk dairy consumption and sustaining a prior fracture. Humeral shaft fractures in both sexes were sustained mainly in childhood, while proximal humerus fractures were sustained in older adulthood. The overall age-standardised rates of proximal humerus fractures were nearly twice as high in females compared to males, whereas the incidence rates of humeral shaft fractures were similar.

Changes in gait performance over several years are associated with recurrent falls status in community-dwelling older women at high risk of fracture.

BACKGROUND: Gait analysis is a recommended geriatric assessment for falls risk and sarcopenia; however, previous research utilises measurements at a single time point only. It is presently unclear how changes in gait over several years influence risk of recurrent falls in older adults. METHODS: We investigated 135 female volunteers (mean age±SD: 76.7±5.0 years; range: 70-92 years) at high risk of fracture. Gait parameters (speed, cadence, step length, step width, swing time and double support phase) were assessed using the GAITRite Electronic Walkway System at four annual clinics over ∼3.7±0.5 years. Participants reported incident falls monthly for 3.7±1.2 years. RESULTS: Increasing gait speed (odds ratio: 0.96; 95% confidence interval 0.93, 0.99) and step length (0.87; 0.77, 0.98) from baseline to final follow-up was associated with reduced likelihood of being a recurrent faller over the study period. No significant associations were observed for baseline gait parameters (all P≥0.05). At the second follow-up (2.8±0.6 years), an increase in swing time (0.65; 0.43, 0.98) was associated with reduced likelihood, while an increase in double support phase (1.31; 1.04, 1.66) was associated with increased likelihood, for being a recurrent faller in the subsequent 1.3 years following this time point. CONCLUSION: Changes in gait parameters over several years are significantly associated with the likelihood of being a recurrent faller among community-dwelling older women at high risk of fracture. Further research is required to develop gait monitoring guidelines and gait parameter decline cut points that may be utilised by clinicians to identify older adults at risk of incident falls and sarcopenia.

Fall and Fracture Risk in Sarcopenia and Dynapenia With and Without Obesity: the Role of Lifestyle Interventions.

Due to their differing etiologies and consequences, it has been proposed that the term "sarcopenia" should revert to its original definition of age-related muscle mass declines, with a separate term, "dynapenia", describing muscle strength and function declines. There is increasing interest in the interactions of sarcopenia and dynapenia with obesity. Despite an apparent protective effect of obesity on fracture, increased adiposity may compromise bone health, and the presence of sarcopenia and/or dynapenia ("sarcopenic obesity" and "dynapenic obesity") may exacerbate the risk of falls and fracture in obese older adults. Weight loss interventions are likely to be beneficial for older adults with sarcopenic and dynapenic obesity but may result in further reductions in muscle and bone health. The addition of exercise including progressive resistance training and nutritional strategies, including protein and vitamin D supplementation, may optimise body composition and muscle function outcomes thereby reducing falls and fracture risk in this population.

Serum selenium status in Graves' disease with and without orbitopathy: a case-control study.

OBJECTIVE: Selenium is effective in improving quality of life and reducing the progression of active Graves' orbitopathy. The effect of correcting relative selenium deficiency on improving Graves' orbitopathy is unknown, as baseline selenium levels have not previously been measured. The study aims to determine whether serum selenium levels are reduced in patients with Graves' disease with orbitopathy (GO) compared with without orbitopathy (GD). DESIGN: A prospective, case-control study performed between 2009 and 2012 at endocrine and ophthalmology clinics in Australia. PATIENTS: A total of 198 patients with Graves' disease participated in the study: 101 with Graves' orbitopathy and 97 without Graves' orbitopathy. MEASUREMENTS: Serum selenium levels in both groups. RESULTS: Mean serum selenium levels were significantly lower in GO (1·10 ± 0·18 µm) than in GD (1·19 ± 0·20 µm) (P = 0·001). Mean selenium levels appeared to decrease in parallel with increasing severity of GO; selenium level was 1·19 ± 0·20 µm in GD, 1·10 ± 0·19 µm in moderate-to-severe GO and 1·09 ± 0·17 µm in sight-threatening GO (P = 0·003). Serum selenium levels remained significantly lower in GO after adjusting for age, smoking status, thyroidectomy, radioactive iodine treatment and residential location. CONCLUSION: Serum selenium levels are lower in patients with GO compared with GD in an Australian study population with marginal selenium status. Relative selenium deficiency may be an independent risk factor for orbitopathy in patients with Graves' disease.

Shining the light on Sunshine: a systematic review of the influence of sun exposure on type 2 diabetes mellitus-related outcomes.

Prospective observational studies uniformly link vitamin D deficiency with the incidence of type 2 diabetes mellitus (T2DM), yet trials supplementing participants at risk of T2DM with vitamin D to reduce progression to T2DM have yielded inconsistent results. Inconsistencies between supplementation trials may be due to insufficient dosing or small sample sizes. Observational studies may also have reported spurious associations due to uncontrolled confounding by lifestyle or genetic factors. Alternatively, observational and intervention studies may not be entirely comparable. Observational studies show an association between higher vitamin D status, which is predominantly derived from sun exposure, and decreased incidence of T2DM. Trials intervene with vitamin D supplementation, and therefore may be missing alternate causes of the effect of sun exposure, as seen in observational studies. We propose that sun exposure may be the driving force behind the associations seen in observational studies; sun exposure may have additional benefits beyond increasing serum 25-hydroxyvitamin D (25OHD) levels. We performed an electronic literature search to identify articles that examined associations between sun exposure and T2DM and/or glucose metabolism. A best evidence synthesis was then conducted using outcomes from analyses deemed to have high methodological quality. Ten eligible full-text articles were identified, yielding 19 T2DM-related outcomes. The best evidence analysis considered 11 outcomes which were grouped into six outcome types: T2DM, fasting glucose, glucose tolerance, fasting insulin, insulin secretion and insulin sensitivity. There was moderate evidence to support a role of recreational sun exposure in reducing odds of T2DM incidence. High-level evidence was lacking; evidence presented for other outcomes was of low or insufficient level. This review highlights significant gaps in research pertaining to sun exposure and T2DM-related outcomes. Further research is encouraged as we aim to identify novel preventative strategies for T2DM.

Vitamin D deficiency and its role in muscle-bone interactions in the elderly.

In this commentary, we focus on common 'downstream' links of vitamin D between muscle and bone health. Both direct and indirect effects of 1,25 dihydroxyvitamin D (1,25(OH)D) link the mutual age-related decline in muscle function and bone density, independent of physical activity. Changes in calcium absorption associated with vitamin D deficiency affect both muscle and bone mass. The age-related decline in vitamin D receptor expression and 1,25(OH)D activity impact on proinflammatory cytokines such as tumor necrosis factor -α and interleukin-6 in skeletal muscle and vitamin D deficiency appears to enhance both bone marrow adipogenesis and intramuscular adipose tissue impacting as reduced functionality in both skeletal tissues. Controversial findings on the role of 1,25(OH)D on skeletal muscle may relate to differences in vitamin D receptor expression throughout different stages of muscle cell differentiation. Prolonged vitamin D insufficiency in the elderly is associated with reductions in both bone mineral density and type 2 muscle fibers with the outcomes of skeletal fragility in combination with reduced muscle power, leading to increased risk of falls and fracture.

Associations between socioeconomic status and primary total knee joint replacements performed for osteoarthritis across Australia 2003-10: data from the Australian Orthopaedic Association National Joint Replacement Registry.

BACKGROUND: Relatively little is known about the social distribution of total knee joint replacement (TKR) uptake in Australia. We examine associations between socioeconomic status (SES) and TKR performed for diagnosed osteoarthritis 2003-10 for all Australian males and females aged ≥ 30 yr. METHODS: Data of primary TKR (n=213,018, 57.4% female) were ascertained from a comprehensive national joint replacement registry. Residential addresses were matched to Australian Census data to identify area-level social disadvantage, and categorised into deciles. Estimated TKR rates were calculated. Poisson regression was used to model the relative risk (RR) of age-adjusted TKR per 1,000py, stratified by sex and SES. RESULTS: A negative relationship was observed between TKR rates and SES deciles. Females had a greater rate of TKR than males. Surgery utilisation was greatest for all adults aged 70-79 yr. In that age group differences in estimated TKR per 1,000py between deciles were greater for 2010 than 2003 (females: 2010 RR 4.32 and 2003 RR 3.67; males: 2010 RR 2.04 and 2003 RR 1.78). CONCLUSIONS: Identifying factors associated with TKR utilisation and SES may enhance resource planning and promote surgery utilisation for end-stage osteoarthritis.