To analyze the benefits and risks of three common treatments, we randomly assigned 179 patients with Graves' hyperthyroidism as follows: 60 patients, 20-34 yr of age (young adults), received antithyroid drugs for 18 months (medical) or subtotal thyroidectomy (surgical), and 119 patients, 35-55 yr of age (old adults), received medical, surgical, or radioiodine (iodine-131) treatment. The follow-up time was at least 48 months. Antithyroid drugs, surgery, or iodine-131 treatment normalized the mean serum hormone levels within 6 weeks. The risk of relapse was highest in the medically treated young and old adults (42% vs. 34%), followed by that in those treated with iodine-131 (21%) and that in the surgically treated young and old adults (3% vs 8%), respectively. Elevated TSH receptor antibodies at the end of medical therapy or increasing TSH receptor antibodies values after medical or surgical treatment increased the probability of relapse. Development or worsening of ophthalmopathy was not associated with relapse per se. Ninety percent of the subjects in all groups were satisfied with the treatment they received. No significant difference in sick-leave due to Graves' or other diseases was seen during the first 2 yr after initiation of therapy. The increased risk of ophthalmopathy in patients with high serum T3 levels, especially when treated with iodine-131, and the relatively high frequency of relapse after treatment with antithyroid drugs are important factors to consider when selecting therapy for Graves' disease.

The seasonal changes in serum levels of 25OHD, PTH, and ionized calcium and the positive correlation between femoral neck BMD and 25OHD indicate that regular outdoor daylight exposure during the summer could enhance calcium homeostasis and possibly bone health, even among very old people living at northerly latitudes.

With 1 s longer OLST, the risk of a hip fracture decreased significantly by 5%. This risk reduction was not explained by differences in the classic fracture risk factors included in FRAX. OLST had a predictive ability similar to FRAX. OLST is an easily performed balance test which may prove to be valuable in the assessment of hip fracture risk.

Compare quantitative ultrasound (QUS) of calcaneus and dual energy X-ray absorptiometry (DXA) as measurements of bone density, calculate 20-year fracture incidence in patients with T1DM and T2DM and multiple complications, and compare the methods' predictive ability.Methods: Sixty-two hospital foot clinic patients with T1DM or T2DM and complications were followed (1995-2015; 610 person-years). Clinical assessments and QUS of calcaneus were performed on all at inclusion and DXA of the spine and femoral neck on a subgroup (n = 34). Fracture incidence was assessed at follow-up and compared to incidence in the general population. We evaluated the correlation between QUS of calcaneus and DXA (Pearson's correlation test) and the association between bone density and fracture incidence at follow-up (logistic regression).Results: Bone density (QUS of calcaneus) correlated with hip bone density (DXA). Incidence of all fractures (30/62 patients; 48%) and hip fractures (6/62 patients; 10%) was higher in patients than the general population. Twelve (19%) experienced foot fracture. QUS of calcaneus predicted hip, lower leg, and foot fractures; DXA did not.Conclusions: Because QUS of calcaneus predicted fractures in patients with diabetes and multiple complications, it seems appropriate to test QUS of calcaneus as a fracture risk predictor in primary care.

Objective: To investigate the relationship between osteoporosis and nutritional status as determined by the Mini-Nutritional Assessment (MNA). Design: A cross-sectional study. Setting: Stockholm, Sweden. Subjects: A total of 351 elderly free-living women (mean age 7372.3 years). Methods: MNA (range 0-30 points; o17 indicates malnutrition, 17.5-23.5 risk of malnutrition and X24 well nourished), measurements of bone mineral density of the left hip and lumbar spine using Hologic QDR 4500, and of the heel using Calscan DEXA-T. Results: The median MNA score was 27 (range 12.5-30). One woman was classified as malnourished and 7.4% were at risk of malnutrition. Osteoporosis of the femoral neck was observed in 22% and a fracture after the age of 50 was reported by 31% of the participants. The following items in the MNA questionnaire exhibited an increased risk of having osteoporosis in the femoral neck and/or total hip: an MNA score of o27 (odds ratio (OR) ¼ 2.09; CI ¼ 1.14-3.83); a mid-arm circumference of less than 28 cm (OR ¼ 2.97; CI ¼ 1.29-6.81); and regular use of more than 3 drugs each day (OR ¼ 2.12; CI ¼ 1.00-4.50). A body weight of more than 70 kg exhibited a decreased risk of having osteoporosis (OR ¼ 0.31; CI ¼ 0.14-0.70). Conclusions: In general, the nutritional status was good in this population of free-living elderly women. Nevertheless, half of the women who displayed an MNA score o27 points had a twofold increased risk of having osteoporosis.

SummaryGait speed or one-leg standing time (OLST) as additional predictors in FRAX. Population 351 elderly women followed 10 years. Both could improve predictions. The area under curve (AUC) for FRAX is 0.59, OLST is 0.69 and gait speed is 0.71. The net reclassification index (NRI) for classification to highest risk quartile or lowest three quartiles was 0.24 for gait speed and non-significant for OLST.IntroductionThe risk of falls and bone strength are two main determinants of hip fracture risk. The fracture risk assessment tool FRAX, however, lacks direct measures of fall risk1. A short OLST and a slow gait speed are both fall-related risk factors for hip fractures. The aim of this study was to investigate whether the addition to FRAX of either gait speed or OLST could improve the predictive ability for hip fractures, compared to FRAX alone.MethodsA population-based sample of 351 women aged between 69 and 79 years were tested for one-leg standing time with eyes open and mean gait speed over a 15 + 15-m walk. Fracture and mortality data were obtained from health care registers.ResultsThe AUC for the receiver operating characteristic (ROC) increased from 0.61 to 0.71 when gait speed was added to FRAX. The AUC was 0.69 for OLST added to FRAX. The highest quartile of hip fracture risks according to FRAX had an absolute 10-year risk of ≥15%. The population was divided into one group with a hip fracture risk of ≥15% and one group with a fracture risk of <15%. NRI for addition of gait speed to FRAX was 0.24 (p = 0.023), while NRI was 0.08 (p = 0.544) for addition of OLST to FRAX.ConclusionGait speed tended to improve the predictive ability of FRAX more than OLST, but they both added value to FRAX.

Abstract. Björnsdottir S, Sääf M, Bensing S, Kämpe O, Michaëlsson K, Ludvigsson JF (Karolinska Institutet, Stockholm; Uppsala University, Uppsala; and Ö rebro University Hospital, Ö rebro; Sweden). Risk of hip fracture in Addison's disease: a population-based cohort study. J Intern Med 2011; 270: 187-195.Objectives. The results of studies of bone mineral density in Addison's disease (AD) are inconsistent. There are no published data on hip fracture risk in patients with AD. In this study, we compare hip fracture risk in adults with and without AD.Design. A population-based cohort study.Methods. Through the Swedish National Patient Register and the Total Population Register, we identified 3219 patients without prior hip fracture who were diagnosed with AD at the age of ‡30 years during the period 1964-2006 and 31 557 age-and sex-matched controls. Time to hip fracture was measured.Results. We observed 221 hip fractures (6.9%) in patients with AD and 846 (2.7%) in the controls.Patients with AD had a higher risk of hip fracture [hazard ratio (HR) = 1.8; 95% confidence interval (CI), 1.6-2.1; P < 0.001]. This risk increase was independent of sex and age at or calendar period of diagnosis. Risk estimates did not change with adjustment for type 1 diabetes, autoimmune thyroid disease, rheumatoid arthritis or coeliac disease. Women diagnosed with AD £50 years old had the highest risk of hip fracture (HR = 2.7; 95 % CI, 1.6-4.5). We found a positive association between hip fracture and undiagnosed AD [odds ratio (OR) = 2.4; 95 % CI, 2.1-3.0] with the highest risk estimates in the last year before AD diagnosis (OR = 2.8; 95 % CI, 1.8-4.2).Conclusion. Both clinically undiagnosed and diagnosed AD was associated with hip fractures, with the highest relative risk seen in women diagnosed with AD £50 years of age.

We investigated the relationship between calcaneal and axial bone mineral density in an elderly female population. We also investigated the influence of changing the reference populations on T-score values. Bone mineral density (BMD) was determined in 388 women (mean age 73 years) participating in a cross-sectional study. BMD values were determined at the left hip and the lumbar spine, L1-L4, using Hologic QDR 4500 equipment for dual X-ray absorptiometry (DXA). The calcaneal measurements were made with DEXA-T, a device using a dual X-ray and laser (DXL) technique that combines DXA measurement with measurement of the heel thickness using a laser reflection technique. DEXA-T is an older version of the Calscan DXL device now commercially available. T-score values were calculated for hip measurements with both the original reference population of the Hologic device and the NHANES III reference population. T scores for heel measurements were calculated with the original reference population of the peripheral device and the Calscan database, a new calcaneal reference population. Changing the reference populations had a great influence on both the heel and the hip T scores, especially those of the femoral neck where the percentage of subjects identified as osteoporotic decreased from 53% to 23%. We conclude that, with the NHANES III and the larger Calscan database, using the cut-off point of -2.5 SD, the heel measurements had optimal accuracy for detecting osteoporosis at either the combination of the lumbar spine and the femoral neck or the combination of the lumbar spine, the femoral neck, the total hip and the trochanter. BMD measurements of the calcaneus with DXL correlated fairly well with measurements at axial sites at the group level, while in individual subjects large deviations were observed between all the measured sites. We also conclude that the influence of the reference populations on the T scores is substantial when different DXA methods are being compared; the total number of subjects classified as osteoporotic varied from 7% to 53% between the sites and with different reference populations.