Osteoporosis Program

BACKGROUND: In ambulatory care settings, patients with limited English proficiency receive lower quality of care. Limited information is available describing outcomes for inpatients. OBJECTIVE: To investigate the effect of English proficiency on length of stay (LOS) and in-hospital mortality. DESIGN: Retrospective analysis of administrative data at 3 tertiary care teaching hospitals (University Health Network) in Toronto, Canada. PARTICIPANTS: Consecutive inpatient admissions from April 1993 to December 1999 were analyzed for LOS differences first by looking at 23 medical and surgical conditions (59,547 records) and then by a meta-analysis of 220 case mix groups (189,119 records). We performed a similar analysis for in-hospital mortality. MEASUREMENTS: LOS and odds of in-hospital death for limited English-proficient (LEP) patients relative to English-proficient (EP) patients. RESULTS: LEP patients stayed in hospital longer for 7 of 23 conditions (unstable coronary syndromes and chest pain, coronary artery bypass grafting, stroke, craniotomy procedures, diabetes mellitus, major intestinal and rectal procedures, and elective hip replacement), with LOS differences ranging from approximately 0.7 to 4.3 days. A meta-analysis using all admission data demonstrated that LEP patients stayed 6% (approximately 0.5 days) longer overall than EP patients (95% confidence interval, 0.04 to 0.07). LEP patients were not at increased risk of in-hospital death (relative odds, 1.0; 95% confidence interval, 0.9 to 1.1). CONCLUSIONS: Patients with limited English proficiency have longer hospital stays for some medical and surgical conditions. Limited English proficiency does not affect in-hospital mortality. The effect of communication barriers on outcomes of care in the inpatient setting requires further exploration, particularly for selected conditions in which length of stay is significantly prolonged.

Health Issue: Cardiovascular disease (CVD) is the leading cause of death in Canadian women and men. In general, women present with a wider range of symptoms, are more likely to delay seeking medial care and are less likely to be investigated and treated with evidence-based medications, angioplasty or coronary artery bypass graft than men.

Studies have shown that women are less likely to receive several speci c medical interventions, including organ transplantation, cardiac diagnostic studies, and coronary artery bypass surgery. This study investigates the hypothesis that this inequity may be explained by gender differences in treatment decisions made by older adults. A self-report questionnaire using hypothetical situations, treatment choices, and in uencing factors was designed based on literature review and interviews with key informants. The questionnaire was administered to 250 nonpatient adults over the age of 50 in urban and rural settings in Ontario, Canada. Results revealed no signicant gender differences in hypothetical treatment decisions made by patients nor in the factors affecting those decisions. In the absence of evidence that patient choice accounts for gender differences in utilization rates, physicians need to carefully examine their assumptions about patient preference and gender in the provision of speci c interventions to male and female patients.

Objectives. Studies show that women with cancer want more information about and participation in all aspects of their healthcare including decision-making. However, most studies have been done on women with breast cancer, which often runs a lengthy course and has strong patient-advocacy groups. Little is known about the preferences of women with ovarian cancer, the fifth leading cause of cancer death in women, which often has a more rapidly fatal course.

A meta-analysis of prospective studies O R I G I N A L A R T I C L E OBJECTIVE -Women are at a much lower risk of coronary disease mortality than men are. It is widely believed that diabetes "erases" this female advantage, increasing the risk of heart disease much more in women than in men. In reality, the extent of this increased risk is controversial, with studies showing conflicting results and wide confidence intervals. Clarification of this issue has implications for the pathogenesis of coronary disease, and for public health efforts to reduce coronary disease in women.

Objectives: Studies indicate that men with prostate cancer (MPC) adopt passive roles in cancer management; however, increasing public awareness of prostate cancer and advocacy by MPC and their allies suggest otherwise. This study looks at the information that is important to MPC; their preferred participation in decision making; and the influence of sociodemographic, disease, and psychological factors on information needs and decision preferences. Method: Consecutive men diagnosed with prostate cancer and attending two tertiary care cancer clinics completed questionnaires on information needs and decision preferences. Questions included demographic information, health and disease status, psychosocial functioning, optimism, and decisional preferences and information preferences for content, type, focus, format, and amount. Results: Questionnaires were completed by 101 MPC. Their mean age was 70 years and most were married and well-educated. Over 70% wanted detailed information at all illness stages focusing on their disease, treatment, survival, self-care, and empowerment. Over 60% of MPC wanted shared decision making with their physician. Psychological variables were found to influence information needs but not involvement in decision making. Conclusion: These results represent a challenge to health-care providers for accomodating the informational needs and decision preferences of individual MPC. D

Women are bombarded with information about the purported causes and the prevention of breast cancer. This survey sought to determine to what women survivors of breast cancer attributed the cause and lack of recurrence of their breast cancer, and whether these views were associated with specific health behaviors.

Osteoporosis is becoming a major cause of morbidity in the post-liver transplantation population. It is a systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fractures . Data from observational studies suggest that bone loss postliver transplantation is greatest within the ®rst 3±6 months post-transplantation, and can be as high as 48% within the ®rst year [2±6]. The etiology is often multifactorial; both preexisting diseases and post-transplantation factors contribute to the problem. Recognized pre-existing risk factors in this population include cholestatic liver disease, alcoholism, hypogonadism, and abnormal hepatic vitamin D metabolism. The use of high dose steroids and other immunosuppressants such as cyclosporin and tacrolimus (FK506), immobility, and poor nutrition contribute to the excessive bone loss posttransplantation. Low-trauma or atraumatic fractures most often occur within the ®rst 6 months post-transplantation, and can affect 7±65% of the population [5±15]. The most common sites affected are spine, ribs, wrist, hip and pelvis. As the long-term survival of liver transplantation patients increase, one important question is whether these undesirable effects of liver transplantation on bone can be avoided.

Flaxseed is the richest source of the plant lignan secoisolariciresinol diglycoside ( SDG) , which is converted to the two major mammalian lignans, enterodiol ( ED) and enterolactone ( EL) , by colonic bacteria. Because both ED and EL can produce biological effects similar to estrogen, exposure to lignans during early stages of development may adversely alter the normal development of bone in males since bone is a hormone-sensitive tissue. To determine whether early exposure to flaxseed or its lignan compromised the acquisition of bone mass or reduced bone strength, male offspring were exposed to one of three diets during lactation only ( birth through postnatal day [PND] 21) via mother's milk or continuously from the start of lactation through to adolescence ( PND 50) or young adulthood ( PND 132) . The diets were a basal diet ( BD) that was devoid of phytoestrogens, BD containing 10% flaxseed, or BD containing the equivalent quantity of SDG present in a 10% flaxseed diet. To assess bone quantity, the bone mineral content ( BMC) and bone mineral density ( BMD) of femurs were assessed by dual-energy x-ray absorptiometry. Since the biomechanical properties of bone are indicators of the microarchitecture and thus bone quality, the biomechanical strength of femurs was assessed by three-point bending. At PND 50, ultimate bending stress and Young's modulus, measures of bone strength, were reduced among rats that received the 10% flaxseed diet from PND 0 through PND 50, while there were no marked differences in bone size, BMC, or BMD among groups. Interestingly, this effect does not appear to be due to the 53 lignan in flaxseed, as continuous exposure to the diet containing the equivalent quantity of lignan ( 10 S diet) did not alter any measures of bone strength. In contrast to PND 50, bone strength did not differ among groups at PND 132, indicating that the compromise in bone strength was not sustained into early adulthood. Bone size, BMC, and BMD continued to be similar among treatment groups at PND 132. In conclusion, exposing male rats to a diet containing 10% flaxseed or an equivalent quantity of lignan either during lactation only or through to early adulthood is safe with respect to bone health, as measures of bone mass and strength were similar to control rats.

As more women are diagnosed with breast cancer, more will survive the illness from a few years to a lifetime. This study sought to determine the experience of Canadian breast cancer survivors with respect to the impact of cancer on confidentiality, work and insurance.

Survivors of autologous blood or marrow transplantation (ABMT) are predisposed to decreased bone mineral density (BMD), but data are lacking on the incidence and risk factors for this condition. Therefore, we measured BMD in 64 of 68 consecutive ABMT survivors (35 men and 29 women) attending the University of Toronto ABMT long-term follow-up clinic. Patients were evaluated a median of 4.2 years (range: 4.9 months-11.4 years) after ABMT. Median age at evaluation was 49.6 years (range: 23.5-68.2 years). At the L1-L4 vertebrae, 17 (26%) patients (eight men and nine women) had osteopenia and one male (2%) had osteoporosis. Mean BMD at L1-L4 did not differ from healthy young adults or age and sex matched controls. At the femoral neck, 30 patients (46%) (18 men and 12 women) had osteopenia and five (8%) (two men and three women) had osteoporosis. Mean BMD at the femoral neck was significantly lower than in healthy young adults and age-and sex-matched controls. By regression analysis, patients with decreased BMD were older than those with normal BMD (P = 0.02). Gender, body mass index, time from BMT to evaluation and presence of hypogonadism were not associated with decreased BMD. Treatment of decreased bone density was instituted and follow-up data were obtained 1 year after treatment in 22 of 39 patients with reduced BMD. Nineteen (86%) patients had stabilization or improvement of their bone density at follow-up. We conclude that, after ABMT, over half of the patients have evidence of osteopenia or osteoporosis. Men and women were equally affected. In our study, only older age at evaluation was predictive for loss of BMD. We recommend the measurement of BMD as an integral component to the follow-up of ABMT patients. Bone Marrow Transplantation (2001) 28, 387-391.

Due to the potential oestrogenic effects of secoisolariciresinol diglycoside (SDG), the mammalian lignan precursor in flaxseed (Linum usitatissimum ), we hypothesized that exposure to purified SDG during early life would have a positive effect on developing bone. This present study determined whether exposure to SDG purified from flaxseed during suckling via mother's milk or continuously to adolescence (postnatal day (PND) 50) or adulthood (PND 132) increased bone mineral content (BMC) or bone strength in female rat offspring. Offspring were exposed to basal diet (BD) or one of two doses of SDG (50S, 100S) equivalent to that in a 50 or 100 g flaxseed/kg diet during lactation only or through to PND 50 or 132. At PND 50 and 132, femurs were analysed for BMC by dual energy X-ray absorptiometry and biomechanical strength by a 3-point bending test. Compared with BD group, rats exposed to continuous 50S or 100S diet had stronger femurs at PND 50 without changes in BMC. At PND 132 there were no differences in femur strength despite the fact that continuous exposure to BD resulted in a higher ðP , 0 : 05Þ BMC than rats exposed to 100S during lactation only or to 50S or 100S during lactation through to adulthood. In conclusion, female rat bone is more sensitive to the oestrogen-like action of lignans during early life when endogenous levels of sex hormones are low, but by adulthood the improved bone strength does not persist. Importantly, exposure to purified lignan does not have negative effects on bone strength.

The study objective was to determine if male and female rats fed a diet rich in fish oil had femurs and vertebrae that were stronger and more resistant to fracture than rats not fed omega-3 long chain polyunsaturated fatty acids. Weanling rats were randomized to a control or a fish oil diet for 5 weeks. Feeding fish oil to males had no effect on biomechanical strength properties of femurs and vertebrae as measured by three point bending and compression, respectively. In contrast, females fed fish oil had reduced length growth and a lower vertebral peak load. These effects may have been partly mediated by a lower food intake but were not associated with differences in serum IGF-I, estradiol or urinary calcium. The effect of consuming a fish oil diet into later adulthood should be investigated to determine if femur strength is also affected among females. r