1,721,167 research outputs found
Disparities in fragility fracture and osteoporosis care in Africa.
Full text linkOver coming decades, Africa is predicted to experience the greatest rise in the number of older people, who, in this region, spend longer living with disability and dependence than do those in high-income settings, impacting individuals, families, communities, and healthcare systems in some of the most resource-poor countries. As well as shifting demographics, rapid urbanisation, double and triple burdens of malnutrition, changing physical activity patterns, workplace environments, and climates change contribute to the growing prevalence of non-communicable diseases 1. NCDs include cardiometabolic and musculoskeletal diseases, which often coexist as multimorbidity, along with communicable diseases such as HIV – an emerging chronic disease of ageing. Growing evidence shows HIV and its treatment are important risk factors for fracture2. In the Global Burden of Disease study, fragility fractures and osteoporosis (defined as low bone mineral density (BMD) and structural deterioration of bone) contribute to ‘other’ musculoskeletal disorders, yet their important contribution to the rising prevalence of injury- and fracture-related disability, morbidity and mortality is increasingly recognised 3. To date, lack of awareness and hence healthcare prioritisation in Africa, plus a high income country-led focus on specialist techniques to assess BMD (that are unavailable across much of Africa), has likely led to wide-spread under-reporting of morbidity (e.g., disability) and mortality associated with fragility fractures, inevitably creating inequity in fracture prevention and care provision 3. Fractures of the proximal femur (hip) present a particular challenge to functional ability and survival. Hip fracture incidence is projected to double in South Africa between 2020-2050; a rise which will be seen across West, East and Southern African countries as populations continue to age and transition economically 4 5. In Black South African women and men, fracture outcomes are poorer, with much higher morbidity and mortality than is seen in other countries 6. Harmonisation of cohorts across South Africa, The Gambia, and Zimbabwe, confirmed that osteoporosis and osteopenia are just as common in ageing Black African populations, as their similarly aged US counterparts 1. Healthcare systems, increasingly managing age-related multimorbidity, need to adapt to manage osteoporosis and prevent fragility fractures, for example HIV services managing post-menopausal women should be routinely assessing fracture risk. Without such changes, exacerbating health inequities will continue to grow for ageing populations in these settings. Solutions lie in improving clinical awareness, primary care and specialist training, and expansion in access to potentially innovative diagnostic, treatment and rehabilitation services. Traditionally an osteoporosis diagnosis requires a dual energy X-ray absorptiometry (DXA) scan confirming a BMD T-Score ≤−2.5 (using internationally defined thresholds for diagnosis 1,7). Furthermore, DXA scanners are expensive, require specialist support, reliable electricity supply, and are very few (just three in Zimbabwe; population 15.2 million). Where they are available, costs can prove prohibitive to public healthcare users 8. Additionally, as most people who sustain a fragility fracture have a femoral neck BMD T-Score greater than −2.5, i.e., not in the osteoporotic range consideration of the many clinical risk factors besides BMD, for fragility fracture risk, is key. Widespread DXA scanning provision is not practical in resource-constrained public healthcare settings; hence, validation of methods for non-specialist fracture risk assessment should be a priority; options including FRAX®, Garvan and the vertebral fracture risk assessment calculator (VFRAC). Validation will necessitate collection of robust epidemiological data for fracture prevalence and incidence in different populations across Africa. Furthermore, evidence is lacking for the role of additional context-specific clinical risk factors such as HIV infection, which are likely to be important beyond age, BMD, prior fracture and alcohol intake (for men) 9. There will be few data regarding parental fracture in many populations due to historically low life expectancy. Further, research is needed to validate these new fracture risk assessment tools in African populations.A further inequality stems from differences in provision within public and private health care services where access to medicines, used commonly in high income countries for primary and secondary fracture prevention, is most often only possible in private healthcare systems. This largely reflects lack of prioritisation of osteoporosis medicines, as being ‘essential’, by the WHO. Where private healthcare plans exist in South Africa, osteoporosis is not considered a primary medical benefit, hence there is no incentive to assess and treat fracture risk, though those with more comprehensive medical insurance are reimbursed in the case of severe osteopenia, osteoporosis and fracture8. Medical pluralism is also common, particularly in West Africa where traditional bone setters are usually the first point-of-contact on a complex care pathway, which can result in treatment delays. Equitable access to affordable osteoporosis and fracture treatment should be a priority for health care providers and policy makers. The ultimate clinical manifestation of osteoporosis is a fragility fracture. Much of the available literature in Africa has been under powered to estimate fracture prevalence or incidence. Except for South Africa, there remains a paucity of robust epidemiological data to evidence the rise in fragility fractures and to determine context-specific clinical risk factors. Notably, of 131 fracture liaison services surveyed globally in 2020, only one was operational (in South Africa) across Western, Eastern and Southern Africa 10.In conclusion, ageing populations in Africa do not have equitable access to diagnostic and treatment options to reduce future fragility fracture risk and subsequent disability. Given the predicted exponential rise in demand placed by osteoporosis and fragility fractures on already stretched healthcare systems, this must be given attention. Awareness is certainly increasing, with recognition of the importance of appropriate diagnostic and management pathways. It will be important to ensure that communities and stakeholders are fully consulted, as pathways are co-developed, to ensure practical context-specific solutions are implemented. Focusing on equitable access to diagnostic services, creation of implementable tools for diagnosis and treatment monitoring, and building capacity in the provision of healthcare and specific expertise in osteoporosis care, should be key goals for healthcare services, policymakers and governments. <br/
The impact of vitamin D supplementation on musculoskeletal health outcomes in children, adolescents, and young adults living with HIV: a systematic review
No full textObjective:HIV-positive children, adolescents, and young adults are at increased risk poor musculoskeletal outcomes. Increased incidence of vitamin D deficiency in youth living with HIV may further adversely affect musculoskeletal health. We investigated the impact of vitamin D supplementation on a range of musculoskeletal outcomes among individuals aged 0–25 years living with HIV.Methods:A systematic review was conducted using databases: PubMed/Medline, CINAHL, Web of Knowledge, and EMBASE. Interventional randomised control trials, quasi-experimental trials, and previous systematic reviews/meta-analyses were included. Outcomes included: BMD, BMC, fracture incidence, muscle strength, linear growth (height-for-age Z-score [HAZ]), and biochemical/endocrine biomarkers including bone turnover markers.Results:Of 497 records, 20 studies met inclusion criteria. Thirteen studies were conducted in North America, one in Asia, two in Europe, and four in Sub-Saharan Africa. High-dose vitamin D supplementation regimens (1,000–7,000 IU/day) were successful in achieving serum 25-hydroxyvitamin-D (25OHD) concentrations above study-defined thresholds. No improvements were observed in BMD, BMC, or in muscle power, force and strength; however, improvements in neuromuscular motor skills were demonstrated. HAZ was unaffected by low-dose (200–400 IU/day) supplementation. A single study found positive effects on HAZ with high-dose supplementation (7,000 vs 4,000IU/day).Conclusions:Measured bone outcomes were unaffected by high-dose vitamin D supplementation, even when target 25OHD measurements were achieved. This may be due to: insufficient sample size, follow-up, intermittent dosing, non-standardised definitions of vitamin D deficiency, or heterogeneity of enrolment criteria pertaining to baseline vitamin D concentration. High-dose vitamin D may improve HAZ and neuromuscular motor skills. Adequately powered trials are needed in settings where HIV burden is greatest
Osteosarcopenia: where osteoporosis and sarcopenia collide
No full textThe coexistence of osteoporosis and sarcopenia has been recently considered in some groups as a syndrome termed ‘osteosarcopenia’. Osteoporosis describes low bone mass and deterioration of the micro-architecture of the bone, whereas sarcopenia is the loss of muscle mass, strength and function. With an ageing population the prevalence of both conditions is likely to increase substantially over the coming decades and is associated with significant personal and societal burden. The sequelae for an individual suffering from both conditions together include a greater risk of falls, fractures, institutionalization and mortality. The aetiology of ‘osteosarcopenia’ is multifactorial with several factors linking muscle and bone function, including genetics, age, inflammation and obesity. Several biochemical pathways have been identified that are facilitating the development of several promising therapeutic agents, which target both muscle and bone. In the current review we outline the epidemiology, pathogenesis and clinical consequences of ‘osteosarcopenia’ and explore current and potential future management strategies
Going Beyond Counting First Authors in Author Co-citation Analysis
Full text linkThe present study examines one of the fundamental aspects of author co-citation analysis (ACA) - the way co-citation
counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
Prevalence of HIV-associated osteoporosis and fracture risk in mid-life women: a cross-sectional study in Zimbabwe
No full textAntiretroviral therapy roll-out has dramatically reduced HIV related-mortality; more women are living to reach menopause. Menopausal estrogen loss causes bone loss, as does HIV and some of its treatments. However, data describing HIV’s impact on osteoporosis prevalence and fracture risk are scarce in southern Africa.A cross-sectional study of women aged 40-60 years (49% women living with HIV (WLH)) was conducted in Harare, Zimbabwe. Menopause, fracture and HIV history were collected, and anthropometry and bone mineral density (BMD, by dual-energy x-ray absorptiometry (DXA)) measured, and FRAX® 10-year fracture probabilities quantified. The FRAX® probability of a major osteoporotic fracture (MOF) included HIV as a risk factor for secondary osteoporosis. Linear and Poisson regression determined the relationships between clinical risk factors and both femoral neck (FN) BMD and the 10-year FRAX® probability of MOF respectively.The 393 participants had mean(SD) age of 49.6(SD = 5.8) years and mean(SD) BMI 29.1(6) kg/m2. 95% of WLH were ART established (85% TDF) and 81% had a viral load <50 copies/mL. A BMD T-Score ≤ -2.5 was more common in WLH than those without, at both FN and lumbar spine (LS) (FN 22[11.4%] vs 5[2.5%], LS 40[20.8%] vs 9[4.5%]; respectively). Prior fracture was more prevalent in WLH: any fracture type (27[14%] vs. 14[7%]); MOF (14[7.3%] vs. 5[2.5%]). WLH had a higher 10-year MOF probability [median 1.2%; IQR: 0.9-1.8] compared with those without HIV [1.0%; IQR: 0.9-1.5] (P<.001), although probabilities were low. Older age, low weight, and HIV infection were strongly associated with lower FN BMD. Higher probability of MOF was associated with older age, HIV infection, parental hip fracture and prior fracture, though adjustment attenuated the association with HIV. No woman reported anti-osteoporosis medication use.While osteoporosis and previous fractures were common and untreated in this relatively young population, particularly in WLH, the FRAX® predicted 10-year MOF risk was low. Clinical risk factors considered in fracture risk prediction tools in Zimbabwe may need contextual modification
Variations on the Author
Full text link“Variations on the Author” discusses two of Eduardo Coutinho’s recent films (Um Dia na Vida, from 2010, and Últimas Conversas, posthumously released in 2015) and their contribution to the general question of documentary authorship. The director’s filmography is characterized by a consistent yet self-effacing form of authorial self-inscription: Coutinho often features as an interviewer that rather than express opinions propels discourses; an interviewer that is good at listening. This mode of self-inscription characterizes him as an author who is not expressive but who is nonetheless markedly present on the screen. In Um Dia na Vida, however, Coutinho is completely absent form the image, while Últimas Conversas, on the contrary, includes a confessional prologue that moves the director from the margins to the center of his films. This article examines the ways in which these works stand out in the filmography of a director who offers new insights into the notion of cinematic authorship
Appropriate Similarity Measures for Author Cocitation Analysis
Full text linkWe provide a number of new insights into the methodological discussion about author cocitation analysis. We first argue that the use of the Pearson correlation for measuring the similarity between authors’ cocitation profiles is not very satisfactory. We then discuss what kind of similarity measures may be used as an alternative to the Pearson correlation. We consider three similarity measures in particular. One is the well-known cosine. The other two similarity measures have not been used before in the bibliometric literature. Finally, we show by means of an example that our findings have a high practical relevance.information science;Pearson correlation;cosine;similarity measure;author cocitation analysis
Friend or foe: high bone mineral density on routine bone density scanning, a review of causes and management
No full textA finding of high BMD on routine DXA scanning is not infrequent and most commonly reflects degenerative disease. However, BMD increases may also arise secondary to a range of underlying disorders affecting the skeleton. Although low BMD increases fracture risk, the converse may not hold for high BMD, since elevated BMD may occur in conditions where fracture risk is increased, unaffected or reduced. Here we outline a classification for the causes of raised BMD, based on identification of focal or generalized BMD changes, and discuss an approach to guide appropriate investigation by clinicians after careful interpretation of DXA scan findings within the context of the clinical history. We will also review the mild skeletal dysplasia associated with the currently unexplained high bone mass phenotype and discuss recent advances in osteoporosis therapies arising from improved understanding of rare inherited high BMD disorders
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