A meta-analysis of previous falls and subsequent fracture risk in cohort studies.

The relationship between self-reported falls and fracture risk was estimated in an international meta-analysis of individual-level data from 46 prospective cohorts. Previous falls were associated with an increased fracture risk in women and men and should be considered as an additional risk factor in the FRAX® algorithm. INTRODUCTION: Previous falls are a well-documented risk factor for subsequent fracture but have not yet been incorporated into the FRAX algorithm. The aim of this study was to evaluate, in an international meta-analysis, the association between previous falls and subsequent fracture risk and its relation to sex, age, duration of follow-up, and bone mineral density (BMD). METHODS: The resource comprised 906,359 women and men (66.9% female) from 46 prospective cohorts. Previous falls were uniformly defined as any fall occurring during the previous year in 43 cohorts; the remaining three cohorts had a different question construct. The association between previous falls and fracture risk (any clinical fracture, osteoporotic fracture, major osteoporotic fracture, and hip fracture) was examined using an extension of the Poisson regression model in each cohort and each sex, followed by random-effects meta-analyses of the weighted beta coefficients. RESULTS: Falls in the past year were reported in 21.4% of individuals. During a follow-up of 9,102,207 person-years, 87,352 fractures occurred of which 19,509 were hip fractures. A previous fall was associated with a significantly increased risk of any clinical fracture both in women (hazard ratio (HR) 1.42, 95% confidence interval (CI) 1.33-1.51) and men (HR 1.53, 95% CI 1.41-1.67). The HRs were of similar magnitude for osteoporotic, major osteoporotic fracture, and hip fracture. Sex significantly modified the association between previous fall and fracture risk, with predictive values being higher in men than in women (e.g., for major osteoporotic fracture, HR 1.53 (95% CI 1.27-1.84) in men vs. HR 1.32 (95% CI 1.20-1.45) in women, P for interaction = 0.013). The HRs associated with previous falls decreased with age in women and with duration of follow-up in men and women for most fracture outcomes. There was no evidence of an interaction between falls and BMD for fracture risk. Subsequent risk for a major osteoporotic fracture increased with each additional previous fall in women and men. CONCLUSIONS: A previous self-reported fall confers an increased risk of fracture that is largely independent of BMD. Previous falls should be considered as an additional risk factor in future iterations of FRAX to improve fracture risk prediction.

Light Microscopy and Proteomic Patterns of Ovulation in Cervical Mucus.

There is an increasing number of couples interested in identifying the fertile window for the purpose of conceiving. From what has been published so far, it can be concluded that there are no reliable methods to predict ovulation, and, therefore, to predict the fertile window. Proteins of the cervical mucus (CM) could behave as biomarkers to allow the early and precise identification of ovulation. CM samples were collected from the lumen of the cervical canal from women of reproductive age, on three different days of the same menstrual cycle. Samples were first analyzed and classified by light microscopy. High-resolution mass spectrometry and bioinformatic analysis were performed afterwards to determine the in vivo changes of CM protein composition. CM underwent cyclical changes in its biophysical composition, which were evidenced by changes in the crystallographic patterns observed under the light microscope. The proteomic analysis revealed changes in the protein composition of CM along the cycle. Twenty-five out of the forty-eight total proteins identified could become potential biomarkers of ovulation. The coordinated changes in the composition of the CM around the time of ovulation could be happening to specifically grant access to a foreign body, such as the sperm might be.

[Amyotrophic lateral sclerosis (ALS) from the perspective of Primary Care. Epidemiology and clinical-care characteristics]. / La esclerosis lateral amiotrófica (ELA) desde la Atención Primaria. Epidemiología y características clínico-asistenciales.

Amyotrophic Lateral Sclerosis (ALS) is a rare disease in primary care (PC), it represents a challenge for the family doctor, especially in home care. OBJECTIVE: To know the incidence and prevalence of ALS in an area of ??PA management, the clinical characteristics and use of health resources. DESIGN: Observational study. LOCATION: PC-Direction Costa de Ponent, South Metropolitan Health Region, Barcelona, Catalonia, Spain. PARTICIPANTS: Patients with ALS ≥18 years diagnosed until 03/01/2017. Main measurements Age, sex, characteristics: form of appearance (spinal, bulbar, others), interval between onset of symptoms and diagnosis, percutaneous gastrostomy carriers, ventilation non-invasive or invasive. Identification in PC as a Complex Chronic Patient or with palliative needs (CCP). Inclusion in home care programs (PAD). Model of attention hospitable. RESULTS: 81 patients, mean age 65.6 years (± 11.7), men 49.4%. Shape of onset: spinal 69%, bulbar 21%, another 4%. Interval between the onset of symptoms and diagnosis 12 months. Identified as a CCP 13.6%, 29 patients (35.8%) included in PAD. Attended in comprehensive hospital model 79 patients (97.5%). Prevalence 6.1/100,000 inhabitants in 2017. Annual incidence between 1.2 cases/100,000 inhabitants/year in 2012 and 3.5 cases/100,000 inhabitants/year in 2016. CONCLUSIONS: The use of percutaneous gastrostomy in ALS favors the identification as CCP or with palliative needs and inclusion in PAD. The use of non-invasive ventilation favors inclusion in PAD. The incidence and prevalence data for ALS are higher than those described above in the same area. Early identification is necessary of these patients in the chronic care models in PC teams.

High Effectiveness of a 14-Day Concomitant Therapy for Helicobacter pylori Treatment in Primary Care. An Observational Multicenter Study.

BACKGROUND: The current cure rates with triple therapy combining a proton-pump inhibitor, amoxicillin and clarithromycin are unacceptably low. AIMS: To evaluate the efficacy of a 14-day concomitant therapy as an empirical first-line treatment for curing Helicobacter pylori (Hp) infection in primary care. METHODS: Patients from six primary care centers in Catalonia -Spain- were included consecutively. Hp status pre and post treatment was assessed according to local clinical practice protocol. A 14-day concomitant therapy (amoxicillin 1 g, clarithromycin 500 mg and metronidazole 500 mg plus omeprazole 20 mg, all drugs administered twice daily) was prescribed. Adherence to therapy and adverse events were assessed by personal interview. RESULTS: 112 patients were enrolled. Mean age was 46.7 ± 16.1 years. Main indication for treatment was non-investigated dyspepsia (83%). Hp eradication was achieved in 100 of the 112 patients. Eradication rates were 89.3% (95% CI: 81.7-94.1) by intention-to-treat (ITT) analysis and 91.7% (95% CI; 84.6-95.9) per protocol (PP). No major side effects were reported; 104 (92.8%) patients complete the treatment. Forty-seven patients (42%) complained of mild side effects (metallic taste, nausea). Low adherence to treatment (p = 0.004) and significant adverse events (p = 0.004) were the variables associated with treatment failure. CONCLUSIONS: In primary care, a 14-day concomitant therapy is highly effective and well tolerated.

Effectiveness of the Epley manoeuvre in posterior canal benign paroxysmal positional vertigo: a randomised clinical trial in primary care.

BACKGROUND: Evidence on the effectiveness of the Epley manoeuvre in primary care is scarce. AIM: To evaluate effectiveness at 1 week, 1 month, and 1 year of a single Epley manoeuvre versus a sham manoeuvre in primary care. DESIGN AND SETTING: Multicentre, double-blind randomised controlled trial in two primary care practices in Spain from November 2012 to January 2015. METHOD: Patients were ≥18 years diagnosed with subjective or objective posterior benign paroxysmal positional vertigo (vertigo only, or vertigo and nystagmus after a Dix-Hallpike test [DHT]). The intervention group received the Epley manoeuvre, and the control group received a sham manoeuvre. Betahistine was prescribed following the same regimen in both groups. The main outcome measures were the DHT result classified as negative (neither vertigo nor nystagmus) or positive. Positive results were further divided into a positive result for both vertigo and nystagmus (positive DHT with nystagmus), and a positive result for vertigo only (positive DHT without nystagmus); self-reported resolution of vertigo; and self-reported severity of vertigo evaluated on a 10-point Likert scale (10 = worst imaginable vertigo). RESULTS: In total, 134 patients were randomised to either the intervention group (n = 66) or the sham group (n = 68). The intervention group showed better results in the unadjusted analyses at 1 week, with a lower rate of positive DHT with nystagmus (P = 0.022). A positive baseline DHT with nystagmus was associated with a reduction in vertigo severity (marginal effect for 10-point Likert-like question -1.73, 95% confidence interval [CI] = -2.95 to -0.51) and better positive DHT rates in the intervention group (adjusted odds ratio 0.09, 95% CI = 0.01 to 0.92) in the multivariate analyses. CONCLUSION: A single Epley manoeuvre performed in primary care is an effective treatment for reversing a positive DHT and reducing vertigo severity in patients with baseline nystagmus in the DHT.

Proteomic Markers in Cervical Mucus.

BACKGROUND: Cervical Mucus (CM) is a viscous fluid produced by the secretory cells of the cervical crypts. The CM undergoes modifications throughout the cycle that make it have different biochemical and biophysical characteristics, becoming a crucial element for the identification of ovulation. Since CM is rich in secreted proteins, it may represent moreover a source of biomarkers for female reproductive tract diseases. OBJECTIVE: This review is an attempt to collect relevant knowledge about the physicochemical properties and functions of the cervical mucus, including its important role as a clinical marker of female fertility, and draws attention to CM as a source of potential proteomic biomarkers. FINDINGS: All the assessed studies evidenced that the observation of the CM allows the identification of the days with the highest probability of pregnancy. CM proteome changes throughout the menstrual cycle have been revealed. Few proteomic studies on the constitutive protein composition of CM of fertile women have been conducted to date. In the CM of patients affected by endometriosis have been identified some proteins that could represent potential biomarkers of the disease. CONCLUSION: There is still limited knowledge about the physicochemical properties and functions of the CM and how these undergo to changes during menstrual cycle. CM is a reliable predictor of fertility. Further characterization of CM proteins would contribute to a better understanding of the key role they have on fertility, reproduction and biological regulation. CM may represent moreover a source of biomarkers for gynecological diseases.

Evaluación de competencias en comunicación clínica en estudiantes de medicina con paciente simulado / Evaluation of clinical communication skills in medical students with simulated patients

Background: Communication skills are not learnt innately. It is therefore necessary to both train and evaluate medical students in this area. Aim: To evaluate communication skills of fourth-year medical students with the use of a simulated patient (SP). Material and Methods: Four clinical scenarios (CS) for clinical interviews with simulated patients were designed: chronic and acute diseases, difficult and functional patients. Each student performed the four CS, and his communication skills were evaluated using our own questionnaire as agreed with the SP. The questionnaire included items on verbal and nonverbal communication, warmth, respect, specificity, assertiveness and empathy (rated from 0 to 10). The response variable was the arithmetic mean of the scores on each item. All students received a detailed evaluation report. Results: Sixty one students (32 men) performing 244 interviews, were evaluated. The overall mean score was 7.87 (4.62 to 9.03). The highest scores were for respect and specificity (7.57 and 7.15 respectively). The lowest were for empathy and nonverbal communication (6.44 and 6.84 respectively). The CS evaluations were 7.87 (chronic disease), 7.02 (difficult patient), 6.46 (acute disease) and 6.14 (functional pathology). Women had higher overall scores compared to men (7.26 and 6.51 respectively; p < 0.01) and a significantly higher score in all communication variables (p < 0.01). Conclusions: The overall assessment in clinical communication with SP is satisfactory although there is room for improvement, especially in empathy and nonverbal communication. Women had significantly higher scores than men.

Rationale of the Spanish FRAX model in decision-making for predicting osteoporotic fractures: an update of FRIDEX cohort of Spanish women.

BACKGROUND: The FRAX® tool estimates the risk of a fragility fracture among the population and many countries have been evaluating its performance among their populations since its creation in 2007. The purpose of this study is to update the first FRIDEX cohort analysis comparing FRAX with the bone mineral density (BMD) model, and its predictive abilities. METHODS: The discriminatory ability of the FRAX was assessed using the 'area under curve' of the receiver operating characteristic (AUC-ROC). Predictive ability was assessed by comparing estimated risk fractures with incidence fractures after a 10-year follow up period. RESULTS: One thousand three hundred eight women ≥ 40 and ≤ 90 years followed up during a 10-year period. The AUC for major osteoporotic fractures using FRAX without DXA was 0.686 (95 % CI 0.630-0.742) and using FN T-score of DXA 0.714 (95 % CI 0.661-0.767). Using only the traditional parameters of DXA (FN T-score), the AUC was 0.706 (95 % CI 0.652-0.760). The AUC for hip osteoporotic fracture was 0.883 (95 % CI 0.827-0.938), 0.857 (95 % CI 0.773-0.941), and 0.814 (95 % CI 0.712-0.916) respectively. For major osteoporotic fractures, the overall predictive value using the ratio Observed fractures/Expected fractures calculated with FRAX without T-score of DXA was 2.29 and for hip fractures 2.28 and with the inclusion of the T-score 2.01 and 1.83 respectively. However, for hip fracture in women < 65 years was 1.53 and 1.24 respectively. CONCLUSIONS: The FRAX tool has been found to show a good discriminatory capacity for detecting women at high risk of fragility fracture, and is better for hip fracture than major fracture. The test of sensibility shows that it is, at least, not inferior than when using BMD model alone. The predictive capacity of FRAX tool needs some adjustment. This capacity is better for hip fracture prediction and better for women < 65 years. Further studies in Catalonia and other regions of Spain are needed to fine tune the FRAX tool's predictive capability.

[Prevalence of non-alcoholic fatty liver disease in a population with elevated transaminases and level of accuracy of the diagnosis in Primary Care]. / Prevalencia de la esteatosis hepática no alcohólica en población con hipertransaminasemia y grado de adecuación del diagnóstico registrado en atención primaria.

UNLABELLED: Nonalcoholic fatty liver disease (NAFLD) is the most common cause of elevated transaminases in adults. AIM: Determine the prevalence of NASH in patients with sustained hypertransaminasemia, and Know the adequacy of the registered in Primary Care (AP) diagnosis. MATERIAL AND METHODS: 1) Cross-sectional study with a random sample of patients with elevated alanine aminotransferase (ALT) held (ALT> 32 for ≥6 months), ruling out other causes of liver disease, according to clinical, laboratory and ultrasound scan criteria in AP and 2) cross-sectional description of all cases diagnosed with NASH recorded (K76 - ICD10) with diagnostic adequacy analysis according to standard criteria. RESULTS: 290 patients were analyzed: 76 were diagnosed as NASH (26.1%), 44 women (57.9%). Multivariate analysis adjusted for age and sex showed no association between NASH and male gender (OR: 0.5; CI95%: 0.3-0.9), diabetes mellitus (DM) (OR: 2.42; CI95%: 1.2-4.9) and hypertension blood pressure (HBP) (OR: 3.07; CI 95% 1.6-5.6). Of the 209 diagnosed with NASH record: 51 (24.4%) met the criteria for NASH. The rest had insufficient records. HIGHLIGHTS: 53.1% lacked sustained hypertransaminasemia; 48% of viral serology; 11% supported and 53.1% abdominal ultrasound registration of alcohol. CONCLUSIONS: Severe NASH is frequent among patients with sustained hypertransaminasemia. The DM and hypertension significantly increase the risk of NASH. The diagnosis of NASH is recorded without considering all criteria and mainly NASH made by ultrasonography. They should unify diagnostic criteria in the register of NASH.

[Incidence of hip fracture in Spain (1997-2010)]. / Incidencia de la fractura de fémur en España (1997-2010).

BACKGROUND AND OBJECTIVE: To analyse differences in the incidence of hip fracture in people older than 65 years in the 17 autonomous communities (AA. CC.) (regions) of the Spanish state in the 1997-2010 period. MATERIAL AND METHODS: Ecological, observational and retrospective study that includes people≥65 year old who have suffered a hip fracture in Spain over 14 years. These records are taken from the minimum basic data set of patients treated in all hospitals of Spain. RESULTS: The analysis include 534,043 hip fractures in≥65 year olds (414,518 women and 119,525 men). A percentage of 85.4 of hip fractures occurred in people≥75 years (86.7% women; 80.7% men). The adjusted hip fracture rate/100,000/year was 722.6 in women and 284.8 in men. AA. CC. with women above the average of the country were 7, including Catalonia, Comunidad Valenciana and Castilla-La Mancha. Six AA. CC. had patients below the average, including Canary Islands and Galicia. In AA. CC. with highest and lowest adjusted hip fracture rate/100,000/year, the difference was 44% lower in women (Canary vs. Castilla-La Mancha) and 50% lower in men (Galicia vs. Catalonia). CONCLUSIONS: The analysis of the incidence of hip fracture in Spain in people≥65 year old shows a significant variability between AA. CC. Except in Canary Islands, this variability is difficult to explain only by factors such as population age, sun exposure or north-south gradient. Additional studies are needed to analyse the causes of these important differences between Spanish AA. CC.

[FRAX® thresholds to identify people with high or low risk of osteoporotic fracture in Spanish female population]. / Umbrales de FRAX(®) para identificar personas con alto o bajo riesgo de fractura osteoporótica en población femenina española.

BACKGROUND AND OBJECTIVE: To detect FRAX(®) threshold levels that identify groups of the population that are at high/low risk of osteoporotic fracture in the Spanish female population using a cost-effective assessment. PATIENTS AND METHODS: This is a cohort study. Eight hundred and sixteen women 40-90 years old selected from the FRIDEX cohort with densitometry and risk factors for fracture at baseline who received no treatment for osteoporosis during the 10 year follow-up period and were stratified into 3 groups/levels of fracture risk (low<10%, 10-20% intermediate and high>20%) according to the real fracture incidence. RESULTS: The thresholds of FRAX(®) baseline for major osteoporotic fracture were: low risk<5; intermediate ≥ 5 to <7.5 and high ≥ 7.5. The incidence of fracture with these values was: low risk (3.6%; 95% CI 2.2-5.9), intermediate risk (13.7%; 95% CI 7.1-24.2) and high risk (21.4%; 95% CI12.9-33.2). The most cost-effective option was to refer to dual energy X-ray absorptiometry (DXA-scan) for FRAX(®)≥ 5 (Intermediate and high risk) to reclassify by FRAX(®) with DXA-scan at high/low risk. These thresholds select 17.5% of women for DXA-scan and 10% for treatment. With these thresholds of FRAX(®), compared with the strategy of opportunistic case finding isolated risk factors, would improve the predictive parameters and reduce 82.5% the DXA-scan, 35.4% osteoporosis prescriptions and 28.7% cost to detect the same number of women who suffer fractures. CONCLUSIONS: The use of FRAX ® thresholds identified as high/low risk of osteoporotic fracture in this calibration (FRIDEX model) improve predictive parameters in Spanish women and in a more cost-effective than the traditional model based on the T-score ≤ -2.5 of DXA scan.

An increased rate of falling leads to a rise in fracture risk in postmenopausal women with self-reported osteoarthritis: a prospective multinational cohort study (GLOW).

OBJECTIVES: Patients with osteoarthritis have increased bone mass but no decrease in fractures. The association between self-reported osteoarthritis and incident falls and fractures was studied in postmenopausal women. METHODS: The Global Longitudinal Study of Osteoporosis in Women is a prospective multinational cohort of 60,393 non-institutionalised women aged ≥55 years who had visited primary care practices within the previous 2 years. Questionnaires were mailed at yearly intervals. Patients were classified as having osteoarthritis if they answered yes to the question, 'Has a doctor or other health provider ever said that you had osteoarthritis or degenerative joint disease?', and this was validated against primary care records in a subsample. Information on incident falls, fractures and covariates was self-reported. Cox and Poisson models were used for incident fractures and number of falls, respectively, to compute hazard ratios (HRs) and rate ratios (RRs) for baseline osteoarthritis status. RESULTS: Of 51 386 women followed for a median of 2.9 years (interquartile range 2.1-3.0), 20 409 (40%) reported osteoarthritis. The adjusted HR for osteoarthritis predicting fracture was 1.21 (95% CI 1.13 to 1.30; p<0.0001) and the adjusted RR for falls was 1.24 (95% CI 1.22 to 1.26; p<0.0001). However, the association between osteoarthritis and fracture was not significant after adjustment for incident falls (HR 1.06 (95% CI 0.98 to 1.15; p=0.13)). CONCLUSIONS: Postmenopausal women with self-reported osteoarthritis have a 20% increased risk of fracture and experience 25% more falls than those without osteoarthritis. These data suggest that increased falls are the causal pathway of the association between osteoarthritis and fractures.

[Analysis of demand for family medical care in Brazil using the International Classification of Primary Care]. / Análise de demanda em Medicina de Família no Brasil utilizando a Classificação Internacional de Atenção Primária.

In various countries, motives for contact of patients with Primary Health Care (PHC) is classified by the International Classification of Primary Care (ICPC-2). This instrument enables the assessment of why people seek care, thereby assisting in planning strategies to attend the population's health needs. The scope of this study was to identify the main reasons for same-day appointments in PHC units of a medium-sized Brazilian city. The methodology used was to examine all records of a typical month of three family practice residents. Data were extracted from a secondary database of same-day appointments during the spring of 2010, classified with ICPC and then statistically analyzed. 1222 records were considered; 32 motives accounted for 50% of contacts. Most common motives were related to the General and Unspecific chapter of the ICPC. About 20% of visits occurred for administrative reasons. Female sex and greater age were determinants of greater motives for consultation. Knowing the motives for appointments by gender and age may help PHC teams in tackling health problems at the critical point of access to PHC.

Análise de demanda em Medicina de Família no Brasil utilizando a Classificação Internacional de Atenção Primária / Analysis of demand for family medical care in Brazil using the International Classification of Primary Care

Em vários países, motivos de contatos entre pacientes e a Atenção Primária (APS) são codificados pela Classificação Internacional da Atenção Primária (CIAP-2). Tal instrumento permite avaliar as razões que levam pessoas a buscarem cuidados, sendo útil no planejamento de estratégias para contemplar as necessidades de saúde da população. Objetivo: estudar os principais motivos de consulta na demanda espontânea da atenção primária em município de médio porte brasileiro. Metodologia: considerou-se todos os registros de acolhimento num mês típico de trabalho de três médicos residentes de medicina de família e comunidade. Os dados foram extraídos de banco de dados secundário, classificados com a CIAP-2 e analisados estatisticamente. Resultados: avaliou-se 1222 registros de consultas; 32 motivos representaram 50% dos contatos. As razões mais frequentes de busca por cuidados relacionavam-se ao capítulo Geral e inespecífico. Quase 20% das consultas ocorreram por motivos administrativos. Sexo feminino e aumento da idade determinaram maior número de motivos para consultar. Conclusão: conhecer os motivos de consulta por gênero e idade pode ajudar as equipes no enfrentamento dos problemas de saúde apresentados no acolhimento - ponto crítico do acesso à APS.

In various countries, motives for contact of patients with Primary Health Care (PHC) is classified by the International Classification of Primary Care (ICPC-2). This instrument enables the assessment of why people seek care, thereby assisting in planning strategies to attend the population's health needs. The scope of this study was to identify the main reasons for same-day appointments in PHC units of a medium-sized Brazilian city. The methodology used was to examine all records of a typical month of three family practice residents. Data were extracted from a secondary database of same-day appointments during the spring of 2010, classified with ICPC and then statistically analyzed. 1222 records were considered; 32 motives accounted for 50% of contacts. Most common motives were related to the General and Unspecific chapter of the ICPC. About 20% of visits occurred for administrative reasons. Female sex and greater age were determinants of greater motives for consultation. Knowing the motives for appointments by gender and age may help PHC teams in tackling health problems at the critical point of access to PHC.