老年髋部骨折患者抗骨质疏松的治疗

髋部骨折往往与高发病率、死亡率以及沉重的经济负担相联系,也是再次骨折的一个主要危险因素。因此加强老年髋部骨折患者的抗骨质疏松治疗及预防再次骨折成为提高该类人群生活质量的必要和关键,其中均衡的营养、补充钙和维生素D是基础,及早进行抗骨质疏松药物治疗是关键,而消除骨质疏松的继发原因、治疗并存疾病、适当的锻炼及防止跌倒则是重要的补充。总之,加强老年骨质疏松的多学科综合管理能够获得很好的临床效果。本文就抗骨质疏松药物在老年髋部患者和那些具有跌倒高风险人群中的疗效予以综述,以期为老年骨质疏松的管理提供借鉴。     

Childhood exposure to ultraviolet radiation and harmful skin effects: epidemiological evidence

We review the general amount and patterns of exposure to solar ultraviolet (UV) radiation that children and teenagers experience and the spectrum of UV-related skin damage that can occur as a result. Data about the amount of solar UV received by children and teenagers are relatively few but suggest that around 40–50% of total UV to age 60 occurs before age 20. Among white children, those with the palest complexions suffer the most damage. Comparisons of prevalence and incidence of outcomes in children and teenagers sharing common ancestry, but living at different latitudes, show that prevalence rates of photoaging and melanocytic naevi are higher in Australian compared with British children, and similarly for melanoma. Genetic risk for the majority of the melanomas in teens is a function of genes controlling naevus propensity and pigmentation in the skin. High numbers of naevi and freckles, red hair, blue eyes, inability to tan, as well as a family history are the primary determinants of melanoma among adolescents. Beyond the signs of skin damage seen in children are the latent effects observed later in adulthood. Childhood is believed to be a susceptible window for long-term harmful effects of UV, as evidenced by clear differences in skin cancer risk between child and adult migrants from high to low latitudes. Effective UV radiation protection from childhood is necessary to control both immediate and long-term harmful effects on children’s skin.     

Estimated benefit of increased vitamin D status in reducing the economic burden of disease in western Europe

Vitamin D has important benefits in reducing the risk of many conditions and diseases. Those diseases for which the benefits are well supported and that have large economic effects include many types of cancer, cardiovascular diseases, diabetes mellitus, several bacterial and viral infections, and autoimmune diseases such as multiple sclerosis. Europeans generally have low serum 25-hydroxyvitamin D [25(OH)D] levels owing to the high latitudes, largely indoor living, low natural dietary sources of vitamin D such as cold-water ocean fish, and lack of effective vitamin D fortification of food in most countries. Vitamin D dose–disease response relations were estimated from observational studies and randomized controlled trials. The reduction in direct plus indirect economic burden of disease was based on increasing the mean serum 25(OH)D level to 40 ng/mL, which could be achieved by a daily intake of 2000–3000 IU of vitamin D. For 2007, the reduction is estimated at €187,000 million/year. The estimated cost of 2000–3000 IU of vitamin D3/day along with ancillary costs such as education and testing might be about €10,000 million/year. Sources of vitamin D could include a combination of food fortification, supplements, and natural and artificial UVB irradiation, if properly acquired. Additional randomized controlled trials are warranted to evaluate the benefits and risks of vitamin D supplementation. However, steps to increase serum 25(OH)D levels can be implemented now based on what is already known.     

Public awareness regarding UV risks and vitamin D--the challenges for UK skin cancer prevention campaigns

Since 1970s, incidence rates for malignant melanoma have been among the fastest rising of all cancers in the UK. Compared to other cancers, melanoma affects disproportionately more young people, and non-melanoma skin cancers are the most commonly diagnosed, with over 100,000 new cases estimated in the UK annually. Government targets to reduce skin cancer incidence have led working groups and prevention campaigns to be set up in the belief that moderating UV exposure will help. An increased awareness of skin cancer has clearly played a role in curbing mortality from the disease, but translating knowledge into behaviour change in this context is a slow and complex process, and campaigns need to be sustained if they are to impact on incidence. A growing body of literature suggesting a cancer protective role for vitamin D and sun exposure presents further challenges for skin cancer prevention campaigns, no more so than when exaggerated claims for the health benefits of sunbathing make the media spotlight. The UK population tend to need little encouragement to make the most of sunshine, and this is especially true for the younger generation who most need to take care. Public health messages to avoid the midday sun, not to burn and to protect children should not adversely affect outdoor activity or population vitamin D levels, but it is important that they are targeted to those most at risk and are consistent. More research is required to establish optimal levels of vitamin D and how to safely achieve them in a heterogeneous population. In the meantime, hasty alterations of public health messages are likely to prove counterproductive.     

内固定与关节置换手术治疗骨质疏松性髋部骨折的临床效果及术后并发症的影响因素分析

目的:分析内固定与关节置换手术治疗骨质疏松性髋部骨折的临床效果及其术后并发症的影响因素。方法:将2017年4月至2018年5月因骨质疏松性髋部骨折于我院进行手术治疗的78例患者作为研究对象,参考患者自身意愿按照采取手术方案的不同将所有患者分为内固定组与关节置换组。内固定组主要采用动力髋螺钉内固定治疗;关节置换组采用全髋关节置换术治疗。对比分析两组治疗后并发症的发生情况及关节功能恢复程度。结果:关节置换组手术治疗后关节功能的恢复情况显著优于内固定组(P0.05),术后并发症发生率低于内固定组(P0.05);患者术后并发症发生的主要影响因素包括:术前存在合并症、手术时机≥2h、采用内固定手术。结论:与内固定术相比,关节置换手术治疗骨质疏松性髋部骨折患者的疗效和安全性均更高,但采用该手术治疗时需注意手术操作的规范性及手术时机。     

Long-term health risk to the skin of ultraviolet radiation

The major well-proven long-term health risks of excessive exposure to ultraviolet (UV) radiation relate to the skin. Premalignant skin lesions are seen very much earlier in white skinned populations exposed to excessive sunlight, and over time these same individuals develop larger numbers of all of the three major skin cancers than individuals who do not experience excessive UV exposure. These three skin cancers are squamous cell carcinoma (SCC), basal cell carcinoma (BCC), and malignant melanoma. In the case of SCC the major aetiological pattern is chronic long-term exposure, but for BCCs the pattern appears to be slightly different with short-term burning episodes being more important. In the case of melanomas, there is evidence that for the 4 main types of melanomas, the pattern of excess UV exposure which is most injurious varies.     

Vitamin D intakes in North America and Asia-Pacific countries are not sufficient to prevent vitamin D insufficiency

Worldwide, vitamin D status is suboptimal relative to circulating levels of 25-hydroxyvitamin D (25OHD) needed to prevent a variety of chronic conditions, however, it has long been assumed that dietary intake is sufficient to meet needs when sun exposure is limited. In the USA, mean vitamin D intake from foods is close to 5 μg, the Dietary Reference Intake (DRI) recommendation for persons up to 50 years; however, the amount of vitamin D needed to maintain a sufficient 25OHD level during winter is >12.5 μg, and that needed for darkly pigmented, veiled, or sun protected persons is >50 μg. In the USA, most vitamin D intake from foods is provided by fortification. Canada and New Zealand have fewer fortified choices, and intakes are correspondingly lower. Supplement use can increase mean intake to >12.5 μg but does not always reach those who need it most. Serum 25OHD levels in New Zealand reveal much more insufficiency than expected, especially for Pacific people and Mäori; low serum 25OHD concentrations are seen throughout the Asia-Pacific region. Fortification and supplementation may be effective to achieve intakes of 12.5 μg vitamin D in some of the population, but for many achieving the amount needed in the absence of skin synthesis requires intakes above the current upper level for vitamin D of 50 μg.     

Parathyroid hormone response to vitamin D insufficiency in elderly males with chronic heart failure

Secondary hyperparathyroidism (SHPT) may contribute to the systemic illness that accompanies chronic heart failure (CHF). Healthy elderly with vitamin D deficiency who did not develop hyperparathyroidism (functional hypoparathyroidism, FHPT) had lower mortality than those who did. This study was designed to examine determinants of the PTH response in the vitamin D insufficient CHF patients. Sixty five vitamin D insufficient males with NYHA class II and III and 20 control subjects age >/=55 years were recruited. Echocardiography, physical performance, NT-pro-BNP, PTH, 25-hydroxyvitamin D (25(OH)D), adiponectin and bone activity surrogate markers (OPG, RANKL, OC, beta-CTx) were assessed. Increased NYHA class was associated with SHPT, while physical performance was inferior compared to FHPT. SHPT was associated with lower left ventricular ejection fraction (LVEF) and flow mediated dilatation, but with higher left heart dimensions, left ventricular mass index and right ventricular systolic pressure. CHF patients with SHPT had increased NT-pro-BNP, adiponectin and bone markers, but decreased 25(OH)D compared to those with FHPT. Independent determinants for SHPT in CHF patients with vitamin D insufficiency were LVEF, adiponectin and beta-CTx, irrespective of renal function and serum vitamin D levels. In conclusion, increased PTH levels, but not low vitamin D, demonstrated close relation to CHF severity.     

Seasonal variation in diagnosis of cutaneous invasive melanoma and cutaneous squamous cell carcinoma: A nationwide study in the Netherlands

BackgroundCurrently, there is no study that has reported on the seasonal trends of skin cancer in the Netherlands. This study aimed to investigate seasonal variation in diagnosis of cutaneous melanoma (CM) and cutaneous squamous cell carcinoma (cSCC) focusing on different subgroups.MethodsCM diagnosed from 2001 till 2019 and cSCCs from 2001 till 2015 were selected from the Netherlands Cancer Registry. The monthly distribution of CM and cSCC diagnoses were evaluated. Summer-to-winter ratios (SWRs) were calculated overall and stratified by patient and tumour characteristics.ResultsSignificant increases in melanoma incidence were noted over the summer months (SWR 1.39 (CI 1.37–1.40)). This increase was less apparent for cSCCs, as higher incidence rates were observed in the months September-November (SWR 1.13 (CI 1.12–1.14)). The seasonal variation of CM was greater in women and younger people, in superficial spreading melanoma and lentigo maligna melanoma, for the extremities, in thinner lesions, and for stage I at diagnosis. The seasonal variation of cSCC was similar for both sexes, most marked in patients 45‐69 and ≥ 70, and for the extremities.ConclusionsOur findings showed a pronounced seasonal variation in the diagnosis of CM with a peak in the summer months. For cSCC, no evident peak was observed, but an increase in diagnosis was noted in fall. Both CM and cSCC showed strong seasonal effects for the extremities.     

Association of vitamin D,BMD and knee osteoarthritis in postmenopausal women

Objectives:The aim of this study was to analyze the association of knee OA with bone mineral density (BMD) and vitamin D serum levels in postmenopausal women.Methods:A cross-sectional study including 240 postmenopausal women with knee OA was conducted. Demographic data were recorded along with balance and functionality scores. Knee OA severity was assessed by the radiological Kellgren & Lawrence scale. BMD and T-scores were calculated in hips and lumbar spine. Serum levels of vitamin D were also measured.Results:High BMI (p<0.005), high number of children (p=0.022) and family history of hip fracture (p=0.011) are significantly associated with knee OA severity. Lumbar spine OP is negatively associated with knee OA (p<0.005). A significant difference was detected between vitamin D deficiency and severe knee OA, adjusted for BMD [OR (95%CI); 3.1 (1.6-6.1), p=0.001]. BMD does not affect the relationship of vitamin D levels in relation to OA and vitamin D levels do not affect the relationship of BMD with OA.Conclusions:Low BMD has a protective role against knee OA while vitamin D deficiency contributes significantly to knee OA severity. However, the association between OA and OP is not affected by vitamin D deficiency and the association of OA and vitamin D serum levels is not affected by BMD.     

Vitamin D receptor gene polymorphisms in relation to Vitamin D related disease states

The role in skeletal metabolism of the steroid hormone Vitamin D and its nuclear receptor (VDR) is well known. In addition, however, Vitamin D is also involved in a wide variety of other biological processes including modulation of the immune response and regulation of cell proliferation and differentiation. Variations in the Vitamin D endocrine system have thus been linked to several diseases, including osteoarthritis, diabetes, cancer, cardiovascular disease and tuberculosis. Evidence to support this pleiotropic character of Vitamin D has included epidemiological studies on circulating Vitamin D hormone levels, but also genetic epidemiological studies. Genetic studies provide excellent opportunities to link molecular insights with epidemiological data and have therefore gained much interest. DNA sequence variations which occur frequently in the population are referred to as "polymorphisms" and are usually suspected of having only modest and subtle effects. Recent studies have indicated many polymorphisms to exist in the VDR gene, but the influence of VDR gene polymorphisms on VDR protein function are largely unknown. Sofar, three adjacent restriction fragment length polymorphisms (RFLP) for BsmI, ApaI and TaqI, respectively, at the 3' end of the VDR gene have been the most frequently studied sofar. But because these polymorphisms are probably non-functional, linkage disequilibrium (LD) with one or more truly functional polymorphisms elsewhere in the VDR gene is assumed to explain the associations observed. Research is therefore focussed on documenting additional polymorphisms across the VDR gene to verify this hypothesis, and on trying to understand the functional consequences of the variations. Substantial progress has been made including the discovery of novel polymorphisms in the large promoter region of the VDR gene. Eventually, results of this research will deepen our understanding of variability in the Vitamin D endocrine system and might find applications in risk-assessment of disease and in predicting response-to-treatment.     

Annual cancer risks from chemicals in North Carolina community water systems

Motivated partly by concerns about cancer, the U.S. Congress in 1986 amended the Safe Drinking Water Act (SDWA) by requiring that community water systems monitor 81 chemicals and remove those detected at concentrations above health-based standards. No prior research has used the resulting 30 years of monitoring data to analyze cancer risks from chemicals in US drinking water. To fill this gap, this paper uses chemical monitoring data from North Carolina's (NC's) 2,120 community water systems along with a risk assessment approach commonly applied in global burden of disease studies to quantify cancer risks of regulated chemicals in drinking water. The results indicate that 0.30% of NC cancer deaths are attributable to regulated drinking water contaminants and that the average annual individual risk is 7.2 × 10^?6. More than 99% of this risk arises from disinfection by-products, with the remaining risk mostly attributable to arsenic and alpha particle radiation. In no water system does the combined risk from chemicals other than disinfection by-products, arsenic, or alpha particles exceed 10^?4. The results suggest that regulated chemicals pose very low cancer risks and that risks from chemicals other than disinfection by-products, arsenic, and alpha particles are negligible in NC community water systems.     

A novel methodology for generating 3D finite element models of the hip from 2D radiographs

Finite element (FE) modelling has been proposed as a tool for estimating fracture risk and patient-specific FE models are commonly based on computed tomography (CT). Here, we present a novel method to automatically create personalised 3D models from standard 2D hip radiographs. A set of geometrical parameters of the femur were determined from seven a–p hip radiographs and compared to the 3D femoral shape obtained from CT as training material; the error in reconstructing the 3D model from the 2D radiographs was assessed. Using the geometry parameters as the input, the 3D shape of another 21 femora was built and meshed, separating a cortical and trabecular compartment. The material properties were derived from the homogeneity index assessed by texture analysis of the radiographs, with focus on the principal tensile and compressive trabecular systems. The ability of these FE models to predict failure load as determined by experimental biomechanical testing was evaluated and compared to the predictive ability of DXA. The average reconstruction error of the 3D models was 1.77 mm (±1.17 mm), with the error being smallest in the femoral head and neck, and greatest in the trochanter. The correlation of the FE predicted failure load with the experimental failure load was r²=64% for the reconstruction FE model, which was significantly better (p<0.05) than that for DXA (r²=24%). This novel method for automatically constructing a patient-specific 3D finite element model from standard 2D radiographs shows encouraging results in estimating patient-specific failure loads.     

Factors that influence the cutaneous synthesis and dietary sources of vitamin D

The major sources of vitamin D for most humans are casual exposure of the skin to solar ultraviolet B (UVB; 290-315 nm) radiation and from dietary intake. The cutaneous synthesis of vitamin D is a function of skin pigmentation and of the solar zenith angle which depends on latitude, season, and time of day. In order to mimic the natural environment of skin to sunlight exposure, we therefore measured serum 25-hydroxyvitamin D levels in volunteers with different skin types following repeated UV irradiation. Because melanin pigment in human skin competes for and absorbs the UVB photons responsible for the photolysis of 7-dehydrocholesterol to previtamin D3, we also studied the effect of skin pigmentation on previtamin D3 production in a human skin model by exposing type II and type V skin samples to noon sunlight in June when the solar zenith angle is most acute. Vitamin D is rare in food. Among the vitamin D-rich food, oily fish are considered to be one of the best sources. Therefore, we analyzed the vitamin D content in several commonly consumed oily and non-oily fish. The data showed that farmed salmon had a mean content of vitamin D that was approximately 25% of the mean content found in wild caught salmon from Alaska, and that vitamin D2 was found in farmed salmon, but not in wild caught salmon. The results provide useful global guidelines for obtaining sufficient vitamin D3 by cutaneous synthesis and from dietary intake to prevent vitamin D deficiency and its health consequences, ensuing illness, especially, bone fractures in the elderly.     

Epidemiology of damping-off disease (Pythium irregulare) in relation to density of Lepidium sativum seedlings

Controlled experiments on post-emergence damping-off, using small populations of garden cress seedlings (Lepidium sativum) inoculated with Pythium irregulare, demonstrate that planting density of the host population plays an important role in determining the rate of multiplication and the rate of advance of the disease. At high seedling densities the disease is transmitted readily between host plants, but at lower densities the greater distance between adjacent plants reduces the probability of successful transmissions, and this is reflected in the parameters of multiplication and advance. A simple negative relationship was found between the mean distance separating adjacent plants and both rate of advance of disease front and rate of multiplication of disease in a randomly inoculated seedling stand.     

The evolutionary significance of vitamin D, skin pigment, and ultraviolet light.

Vitamin D is essential for normal growth, calcuim absorption, and skeletal development. Vitamin D deficiency can cause death, immobilization, or pelvic deformities which prevent normal childbirth. In the past these problems were extremely common in North America and Europe, and were only elminated by adding vitamin D to food. Prior to that, variations in available vitamin D affected health, survival and reproductive efficiency sufficiently to have evolutionary significance. Vitamin D is naturally present in few foods; most comes from the photo-conversion of 7-dehydrocholesterol in skin. The limiting factor in this conversion is the availability of ultraviolet light less than310 nm. Seasonal and geographic variations in natural ultraviolet radiation cause parallel variations in blood vitamin D levels, intestinal calcuim absorption, and clinical vitamin D deficiency. These physiological variations can be abolished by exposure to comparable artificial ultraviolet radiation, or by dietary vitamin D supplements. Ultraviolet radiation less than310 nm is absorbed by skin pigment, but is also increases skin pigmentation. This has led to the hypothesis that skin pigment regulates skin vitamin D production. Little direct evidence exists to test this reasonable hypothesis, but necessary and sufficient conditions for establishing it can be outlined. Until this hypothesis is experimentally tested, it is impossible to evaluate the corollary hypothesis: that racial variations in the efficiency of cutaneous vitamin D production restricted the evolution of dark-skinned peoples to tropical latitudes and thereby caused the geographic distribution of the races.     

Strain energy in the femoral neck during exercise

Physical activity is recommended to mitigate the incidence of hip osteoporotic fractures by improving femoral neck strength. However, results from clinical studies are highly variable and unclear about the effects of physical activity on femoral neck strength. We ranked physical activities recommended for promoting bone health based on calculations of strain energy in the femoral neck. According to adaptive bone-remodeling theory, bone formation occurs when the strain energy (S) exceeds its homeostatic value by 75%. The potential effectiveness of activity type was assessed by normalizing strain energy by the applied external load. Tensile strain provided an indication of bone fracture. External force and joint motion data for 15 low- and high-load weight-bearing and resistance-based activities were used. High-load activities included weight-bearing activities generating a ground force above 1 body-weight and maximal resistance exercises about the hip and the knee. Calculations of femoral loads were based on musculoskeletal and finite-element models. Eight of the fifteen activities were likely to trigger bone formation, with isokinetic hip extension (ΔS=722%), one-legged long jump (ΔS=572%), and isokinetic knee flexion (ΔS=418%) inducing the highest strain energy increase. Knee flexion induced approximately ten times the normalized strain energy induced by hip adduction. Strain and strain energy were strongly correlated with the hip-joint reaction force (R²=0.90–0.99; p<0.05) for all activities, though the peak load location was activity-dependent. None of the exercises was likely to cause fracture. Femoral neck mechanics is activity-dependent and maximum isokinetic hip-extension and knee-flexion exercises are possible alternative solutions to impact activities for improving femoral neck strength.     

血清miR-148a、miR-122-5p水平与骨质疏松症患者髋部骨折的关系及其预测价值分析

摘要 目的：研究血清微小核糖核酸-148a（miR-148a)、miR-122-5p水平与骨质疏松症患者髋部骨折的关系及其预测价值。方法：选取吉林大学第一医院从2019年1月～2021年1月收治的102例骨质疏松症患者作为研究对象。将其按照是否并发髋部骨折分为骨折组45例以及无骨折组57例,另选取健康体检志愿者40例作为对照组。比较三组血清miR-148a、miR-122-5p水平。采用单因素和多因素Logistic回归模型分析骨质疏松症患者髋部骨折的影响因素。采用受试者工作特征（ROC）曲线分析血清miR-148a、miR-122-5p水平预测骨质疏松症患者髋部骨折的效能。结果：骨折组血清miR-148a表达水平为（1.25±0.29）,相较于无骨折组的（1.04±0.24）以及对照组的（0.66±0.13）更高,且无骨折组miR-148a表达水平相较对照组更高;骨折组血清miR-122-5p表达水平为（0.60±0.06）,相较于无骨折组的（0.74±0.12）以及对照组的（1.01±0.17）更低,且无骨折组miR-122-5p表达水平相较对照组更低（均P＜0.05）。骨折组血清PINP、β-CTX水平及年龄、女性人数占比均高于无骨折组,骨密度评分低于无骨折组（均P＜0.05）。经多因素Logistic回归分析可得：年龄偏大、女性、骨密度评分降低、血清PINP、β-CTX、miR-148a水平升高均是骨质疏松症患者发生髋部骨折的危险因素,血清miR-122-5p水平升高是其保护因素（均P＜0.05）。经ROC曲线分析发现,血清miR-148a、miR-122-5p联合预测骨质疏松症患者发生髋部骨折的效能优于上述两项指标单独预测。结论：血清miR-148a水平升高以及血清miR-122-5p水平降低均可能增加骨质疏松症患者发生髋部骨折的风险,两指标联合检测具有辅助预测骨质疏松症患者发生髋部骨折风险的潜在价值。