Electronic letters to:

Research:
George Ioannidis, Alexandra Papaioannou, Wilma M. Hopman, Noori Akhtar-Danesh, Tassos Anastassiades, Laura Pickard, Courtney C. Kennedy, Jerilynn C. Prior, Wojciech P. Olszynski, Kenneth S. Davison, David Goltzman, Lehana Thabane, Amiran Gafni, Emmanuel A. Papadimitropoulos, Jacques P. Brown, Robert G. Josse, David A. Hanley, and Jonathan D. Adachi
Relation between fractures and mortality: results from the Canadian Multicentre Osteoporosis Study
CMAJ 2009; 181: 265-271 [Abstract] [Full text] [PDF]
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Electronic letters published:

[Read eLetter] Vertebral fractures and mortality
Vafa Rahimi-Movaghar   (21 December 2009)
[Read eLetter] What, I've been duped?
Andrew M Morris   (17 September 2009)

Vertebral fractures and mortality 21 December 2009
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Vafa Rahimi-Movaghar,
Sina Trauma and Surgery Research Center, Sina Hospital, Imam Khomeini Ave,Tehran, 11365-3876, Iran
Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences

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Re: Vertebral fractures and mortality

v_rahimi{at}sina.tums.ac.ir Vafa Rahimi-Movaghar

Ioannidis and his colleagues in a random sample of 7753 Canadian population older than 50 year-old demonstrated that there is a hazard ratio of 2.7 for death (95%CI: 1.1-6.6) in patients with vertebral fractures (1), but there are a few concerns.

Female male ratio in this random sample is 2.5, whereas F/M in Canadian population for older than 50 is about 1.1 (2). Also, the proportion of 25-50 years old to 25 years of age and older people in the sample (17.7 percent) is much lower than the similar proportion in the Canadian population (about 51.7 percent) (2). Thus, there might be a selection bias in their sample.

The authors provided an explanation for increased deaths after vertebral fractures which implies "the association with chronic back pain, immobility and change in posture", but it can not explain why there is no significant difference in any of the 5 years except the 2nd year.

Authors noticed the limited number of multiple fractures and ignored other associated injuries, however it seems that there are high proportions of associated injuries in patients with fractures. For example, in an Iranian national hospital-based sample of 16,321 injuries, we had overall 619 vertebral fractures (3) and among 50 years of age and older patients, they were associated with other injuries in 36.9 percent (59 out of 160). In all deceased cases of vertebral fractures, the death was resulted from the associated injuries which had an important role in the mortality.

Maziar Moradi Lakeh (1), Vafa Rahimi-Movaghar*(2, 3)

(1) Department of Community Medicine, School of Medicine, Iran University of Medical Sciences and Health Services, Tehran, Iran

(2) Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran

(3) Research Centre for Neural repair, University of Tehran, Tehran, Iran

References

1. Ioannidis G, Papaioannou A, Hopman WM, et al. Relation between fractures and mortality: results from the Canadian Multicenter Osteoporosis Study. CMAJ. 2009;181:265-71.

2. http://www40.statcan.ca/l01/cst01/demo10a-eng.htm Statistics Canada -Population estimates and projections - population by sex and age group. Date Modified: 2009-11-30

3. Heidari P, Zarei MR, Rasouli MR, et al. Spinal fractures resulting from traumatic injuries. Chinese J Traumatol. [In Press].

Conflict of Interest:

None declared
What, I've been duped? 17 September 2009
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Andrew M Morris
Mount Sinai Hospital/University of Toronto

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Re: What, I've been duped?

amorris{at}mtsinai.on.ca Andrew M Morris

When I was training in the mid-to-late 1990s, I was taught repeatedly that 50% of patients with hip fractures die after their first year (and, with bisphosphonates emerging, there were no shortage of teaching sessions on osteoporosis). I subsequently passed on this "crucial" knowledge to my own trainees, not really questioning that knowledge. I even lived in fear when a close relative age 80 or so had a hip fracture, knowing that the odds of him seeing his next birthday were stacked against him. After reading the results of the well-conducted study by Ioannidis et al., I am left to ask: should students believe anything they are taught without a valid reference in hand? I know I don't any longer.

Conflict of Interest:

None declared