Fracture risk, asthma management and effect of statins: Journals update January 2016

The latest research relevant to GPs

Patients who have depression may be at higher risk of fracture (Photo: iStock)
Patients who have depression may be at higher risk of fracture (Photo: iStock)


Previous research has demonstrated deficits in bone mineral density in individuals with depression, and this study carried out in Australia has tried to establish whether this means that depression is linked to increased risk of bone fracture.

Study aims, type, size and methods
The study was a population-based cross-sectional and longitudinal retrospective cohort/case-control study of more than 1,000 women, who were enrolled in an osteoporosis study and had a history of depression.

A history of bone fractures was established by using radiological reports, and bone mineral density was measured at the femoral neck. Lifestyle factors and previous medication use were integrated in the analysis.

Key findings
Analysing 179 found cases with a history of incident fracture demonstrated an association with depression when compared with 914 controls, so that the risk of fracture appeared to be increased by up to 68%. Interestingly, psychotropic medication use seemed to attenuate the association.

Practice changes and comment
The results of this study add to the existing evidence to suggest that significant clinical depression is an independent risk factor for radiologically confirmed incident fracture due to declining bone health.

This is a fascinating and clinically relevant insight, which may help to increase awareness for clinicians regarding the need to promote and practise preventive physical medicine in patients with mental health problems. This aspect of mental healthcare can easily be forgotten or overlooked.

Although the study does not provide solutions or specific advice on the practical aspects of this finding, it is likely to encourage further research into the topic.


Effective management and prevention of exacerbations is important for any patient with asthma, and of particular importance in specific patient groups, such as pregnant women.

Pregnant women receive regular reviews and follow-ups for their general health and existing chronic health conditions, such as diabetes or hypertension, but not routinely for asthma.

Study aims, type, size and methods
This prospective, observational cohort study followed up 89 pregnant women with asthma at 12, 20, 28 and 36 weeks’ gestation, at a new nurse-led asthma management clinic.

The prevalence of asthma exacerbations during pregnancy, asthma control throughout pregnancy and perinatal outcomes were observed, to investigate the impact and possible clinical and cost-effectiveness of a dedicated service.

Key findings
The RR for exacerbations, temporary loss of adequate asthma control and persistent uncontrolled asthma were all reduced by attendance at the asthma management service during pregnancy.

There appeared to be a non-statistically significant reduction in asthma exacerbations and uncontrolled asthma when participants visited the service at least twice.

Practice changes and comment
A challenge of this study is that the severity of asthma symptoms can be more subjective, variable and diverse than in other chronic conditions. In addition, any targeted health intervention or promotion can have a temporary beneficial impact on patients, whether they are pregnant or not.

During pregnancy, health awareness, as well as willingness and motivation for self-care, may be increased and this can provide an opportunity to review overall health and management of chronic conditions, but it remains unclear whether a dedicated service for pregnant women is needed and effective. Further research will be required to evaluate this.


Gall stones and gall bladder disease are a common and costly problem in developed societies, and modification of risk factors could be beneficial.

Statins decrease hepatic cholesterol biosynthesis and it has been suggested that they may lower the risk of developing gall stone disease.

Study aims, type, size and methods
This retrospective cohort study examined more than 43,000 patient records for the period October 2003 to March 2012.

Two groups were established to check a possible association between statin use (for at least 90 days) and no statin use with the incidence of cholelithiasis, biliary tract diseases and gall bladder procedures.

Key findings
A total of 6,342 pairs of statin users and non-users were matched, based on a propensity score. The ORs for cholelithiasis, biliary tract disease and gall bladder procedures were almost identical in both groups.

No specific association between statin use and gall bladder disease could be established.

Practice changes and comment
The development of gall bladder disease is multi-factorial and not easy to predict.

This study adds interesting insight into how much scope there might be for reducing the risk by taking specific and commonly used medication, known to be involved in hepatic cholesterol metabolism.

However, the outcome of the data analysis suggests that statins are unlikely to be useful in isolation to prevent gall stones, and that more detailed or diverse lifestyle modifications are required to possibly reduce the incidence of gall bladder disease.


There is a general understanding that good bone health is mainly achieved and maintained by weight-bearing exercise.

It could be a concern that non weight-bearing exercise, such as swimming or cycling, may be of value for cardiovascular health but lack benefits for bone health.

Non weight-bearing exercise, such as swimming, may lack benefits for bone health

Study aims, type, size and methods
This cross-sectional study compared three objective measurements of bone structure and strength between 79 adolescent swimmers (with or without present or past participation in other sports in addition to swimming) and 49 normally active adolescent controls, to evaluate the possible effect that non weight-bearing exercise might have on swimmers’ bone.

Key findings
This study found no apparent differences of bone strength indexes and bone mineral density between swimmers with or without participation in other weight-bearing exercises, at present or in the past, and the normally active control group.

Practice changes and comment
The findings of this study appear to be reassuring, although there could be questions about how much they can be generalised and translated into practical clinical advice, which promotes a degree of weight-bearing exercise for bone health.

The cohort examined here was somewhat restricted (adolescents) and only looked at a transitional phase in life, without considering significant and likely longer-lasting lifestyle factors, such as sedentary work, in adulthood.

There are also substantial differences between casual and competitive swimmers in terms of training intensity and subsequent muscle strength, which may have very different effects on bone health as a consequence.


It is known that anaemia and iron deficiency are important comorbidities in patients with chronic heart failure, because both may negatively affect exercise capacity.

However, patients with heart failure are not necessarily routinely screened or monitored for anaemia or low iron levels.

Study aims, type, size and methods
A group of 331 patients with stable chronic heart failure (New York Heart Association class 2.2 +/- 0.7) were checked for WHO criteria of anaemia (Hb <13g/dL in men, <12g/dL in women) or iron deficiency (serum ferritin less than 100 microgram/L or ferritin less than 300 microgram/L with transferrin saturation less than 20%).

Exercise capacity was assessed by measuring peak oxygen consumption at spiroergometry and by a six-minute walk test.

Key findings
In the study, a total of 98 (30%) of patients presented with anaemia and 149 (45%) with iron deficiency at baseline.

During a mean 18-month follow-up, 91 (27%) of all examined patients died from any cause.

Reduced exercise capacity associated with anaemia could be identified as an independent predictor of mortality in patients with heart failure, and patients with anaemia as well as iron deficiency did significantly worse than those with anaemia or iron deficiency only.

Practice changes and comment
This study demonstrated an important point regarding the impact of anaemia on reduced exercise capacity and subsequent mortality risk in patients with chronic heart failure.

It may be important to inform patients with heart failure about this and ensure that they undergo regular monitoring.

The association of low iron levels appears to be weaker than low Hb in this context, but it is interesting to note that there may be variable international or even regional thresholds for defining iron deficiency (less than 20 microgram/L or less than 100 microgram/L) which may affect clinical judgment of its significance.

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  1. J Affect Disord 2015; 192: 34-40
  2. Eur J Obstet Gynecol Reprod Biol 2015; 197: 48-53
  3. Ann Pharmacother 2015; pii: 1060028015622649
  4. J Sci Med Sport 2015; doi: 10.1016/j.jsams.2015.11.007
  5. Int J Cardiol 2015; 205: 6-12

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