Self-perception of fracture risk: what can it tell us?

In this study, we report that self-perception of fracture risk captures some aspect of fracture risk not currently measured using conventional fracture prediction tools and is associated with improved medication uptake. It suggests that adequate appreciation of fracture risk may be beneficial and lead to greater healthcare engagement and treatment. INTRODUCTION: This study aimed to assess how well self-perception of fracture risk, and fracture risk as estimated by the fracture prediction tool FRAX, related to fracture incidence and uptake and persistence of anti-osteoporosis medication among women participating in the Global Longitudinal study of Osteoporosis in Women (GLOW). METHODS: GLOW is an international cohort study involving 723 physician practices across 10 countries in Europe, North America and Australia. Aged ≥ 55 years, 60,393 women completed baseline questionnaires detailing medical history, including co-morbidities, fractures and self-perceived fracture risk (SPR). Annual follow-up included self-reported incident fractures and anti-osteoporosis medication (AOM) use. We calculated FRAX risk without bone mineral density measurement. RESULTS: Of the 39,241 women with at least 1 year of follow-up data, 2132 (5.4%) sustained an incident major osteoporotic fracture over 5 years of follow-up. Within each SPR category, risk of fracture increased as the FRAX categorisation of risk increased. In GLOW, only 11% of women with a lower baseline SPR were taking AOM at baseline, compared with 46% of women with a higher SPR. AOM use tended to increase in the years after a reported fracture. However, women with a lower SPR who were fractured still reported lower AOM rates than women with or without a fracture but had a higher SPR. CONCLUSIONS: These results suggest that SPR captures some aspect of fracture risk not currently measured using conventional fracture prediction tools and is also associated with improved medication uptake.

Use of pharmacologic agents for the primary prevention of osteoporosis among older women with low bone mass.

UNLABELLED: We examined the use of pharmacologic agents for the primary prevention of osteoporosis among older women with osteopenia. We found that these individuals were not managed in concordance with the National Osteoporosis Foundation (NOF) guidelines and that self-perceived osteoporosis risk and lower bone density were strongly associated with receipt of treatment. INTRODUCTION: Although osteoporosis medications are used for the primary prevention of osteoporosis among persons with low bone mass (osteopenia), their use may be discordant with clinical practice guidelines. METHODS: We studied women 55 years and older participating in the Global Longitudinal Study of Osteoporosis in Women (GLOW). Eligible participants had a dual energy x-ray absorptiometry (DXA) test performed at the University of Alabama at Birmingham hospital and had an osteopenia diagnosis based on their DXA test results. Participants' demographics, fracture risk factors, and exposure to osteoporosis medications were determined from the GLOW survey. We examined the proportions of women managed in concordance with the National Osteoporosis Foundation 2008 guidelines, and we assessed factors independently associated with osteoporosis treatment decisions. Women with a prior spine or hip fracture were excluded. RESULTS: Among 597 eligible women from GLOW, the mean age ± standard deviation (SD) was 70 ± 7 years. Among all subjects, 309 (52%) were treated in concordance with the NOF 2008 guidelines. Greater self-perceived osteoporosis risk and lower bone mineral density were significantly and consistently associated with receipt of osteoporosis treatment, both for those considered appropriate and for those considered inappropriate for treatment based on the NOF guidelines. CONCLUSIONS: We found significant discordance between NOF 2008 guidelines and pharmacologic management of women with osteopenia. A person's self-perceived osteoporosis risk and bone mineral density were most strongly associated with receipt of osteoporosis medication use among women with low bone mass.

Non-hip, non-spine fractures drive healthcare utilization following a fracture: the Global Longitudinal Study of Osteoporosis in Women (GLOW).

UNLABELLED: We evaluated healthcare utilization associated with treating fracture types in >51,000 women aged ≥55 years. Over the course of 1 year, there were five times more non-hip, non-spine fractures than hip or spine fractures, resulting in twice as many days of hospitalization and rehabilitation/nursing home care for non-hip, non-spine fractures. INTRODUCTION: The purpose of this study is to evaluate medical healthcare utilization associated with treating several types of fractures in women ≥55 years from various geographic regions. METHODS: Information from the Global Longitudinal Study of Osteoporosis in Women (GLOW) was collected via self-administered patient questionnaires at baseline and year 1 (n = 51,491). Self-reported clinically recognized low-trauma fractures at year 1 were classified as incident spine, hip, wrist/hand, arm/shoulder, pelvis, rib, leg, and other fractures. Healthcare utilization data were self-reported and included whether the fracture was treated at a doctor's office/clinic or at a hospital. Patients were asked if they had undergone surgery or been treated at a rehabilitation center or nursing home. RESULTS: During 1-year follow-up, there were 195 spine, 134 hip, and 1,654 non-hip, non-spine fractures. Clinical vertebral fractures resulted in 617 days of hospitalization and 512 days of rehabilitation/nursing home care; hip fractures accounted for 1,306 days of hospitalization and 1,650 days of rehabilitation/nursing home care. Non-hip, non-spine fractures resulted in 3,805 days in hospital and 5,186 days of rehabilitation/nursing home care. CONCLUSIONS: While hip and vertebral fractures are well recognized for their associated increase in health resource utilization, non-hip, non-spine fractures, by virtue of their 5-fold greater number, require significantly more healthcare resources.

Burden of non-hip, non-vertebral fractures on quality of life in postmenopausal women: the Global Longitudinal study of Osteoporosis in Women (GLOW).

UNLABELLED: Among 50,461 postmenopausal women, 1,822 fractures occurred (57% minor non-hip, non-vertebral [NHNV], 26% major NHNV, 10% spine, 7% hip) over 1 year. Spine fractures had the greatest detrimental effect on EQ-5D, followed by major NHNV and hip fractures. Decreases in physical function and health status were greatest for spine or hip fractures. INTRODUCTION: There is growing evidence that NHNV fractures result in substantial morbidity and healthcare costs. The aim of this prospective study was to assess the effect of these NHNV fractures on quality of life. METHODS: We analyzed the 1-year incidences of hip, spine, major NHNV (pelvis/leg, shoulder/arm) and minor NHNV (wrist/hand, ankle/foot, rib/clavicle) fractures among women from the Global Longitudinal study of Osteoporosis in Women (GLOW). Health-related quality of life (HRQL) was analyzed using the EuroQol EQ-5D tool and the SF-36 health survey. RESULTS: Among 50,461 women analyzed, there were 1,822 fractures (57% minor NHNV, 26% major NHNV, 10% spine, 7% hip) over 1 year. Spine fractures had the greatest detrimental effect on EQ-5D summary scores, followed by major NHNV and hip fractures. The number of women with mobility problems increased most for those with major NHNV and spine fractures (both +8%); spine fractures were associated with the largest increases in problems with self care (+11%), activities (+14%), and pain/discomfort (+12%). Decreases in physical function and health status were greatest for those with spine or hip fractures. Multivariable modeling found that EQ-5D reduction was greatest for spine fractures, followed by hip and major/minor NHNV. Statistically significant reductions in SF-36 physical function were found for spine fractures, and were borderline significant for major NHNV fractures. CONCLUSION: This prospective study shows that NHNV fractures have a detrimental effect on HRQL. Efforts to optimize the care of osteoporosis patients should include the prevention of NHNV fractures.

Are existing measures of overall diet quality associated with peak bone mass in young premenopausal women?

BACKGROUND: Low peak bone mass in young adulthood is associated with an increased risk of osteoporosis and fracture after menopause, and an understanding of the modifiable factors that contribute to low peak bone mass is important for fracture prevention. Diet is an important modifiable factor linked to bone health and, although studies have examined the role of individual dietary components in bone health, bone growth and maintenance are complex processes, and such studies may not adequately represent the role of diet in these processes. METHODS: To address this issue, a cross-sectional analysis of 226 healthy, premenopausal women aged 18-30 years was conducted to determine whether existing indices of overall diet quality are associated with bone density in premenopausal women nearing peak bone mass. Bone density was measured using dual-energy X-ray absorptiometry and diet quality was measured using two overall diet scores based on current dietary guidelines: the Recommended Food Score and the Alternate Healthy Eating Index (AHEI). RESULTS: In the multiple linear regression, bone density did not increase across quartiles of either diet quality score and was not associated with continuous diet quality variables. Furthermore, none of the individual AHEI components (e.g. fruit intake, vegetable intake) were associated with bone density. CONCLUSIONS: These findings suggest that existing diet quality scores are not appropriate for studies of peak bone mass, most likely because they do not give sufficient weight to foods and nutrients important to bone health. We recommend the development of a diet pattern index that better predicts bone mass measures.

Caregivers and elderly relatives. The prevalence of caregiving in a family practice.

Persons 65 years and older are the most rapidly growing age group in the United States. As age increases, functional ability deteriorates and the need for help from another person escalates. Caring for elderly persons experiencing functional deterioration is stressful, creating hidden patients among caregivers. This study surveyed randomly selected active family practice patients 40 years and older to determine the prevalence and extent of the caregiving role and functional disability among elderly relatives. One in five patients (126/602) surveyed had caregiving responsibilities for noninstitutionalized relatives (total, 153 patients). One third of caregivers lived with the relative; most of the remaining two thirds visited their relative at least twice weekly. Caregivers reported some functional impairment in 60% of their relatives, and substantial impairment in 40%. The caregiving experience is common, and the potential for stress from managing an elderly relative's disability is substantial. Further research is needed to elaborate on the burden of the caregiver.

Early termination of breast-feeding: identifying those at risk.

In a private pediatric practice, 94 infants who were breast-feeding were followed for the first 2 months of life in order to define the frequency of cessation of breast-feeding and to identify factors that would predict mothers and infants at risk for early cessation. At 8 weeks, 30% of the mothers had stopped nursing. Factors associated with cessation were: maternal lack of confidence in breast-feeding (P less than .001); anticipated duration of nursing less than 6 months (P = .002); ratings by the nursery staff of infant's excessive crying (P = .007), infant's demanding personality (P = .007), trouble with feeding (P = .001), and future trouble with feeding (P = .004). Together, these factors predicted 77% of the mothers who terminated breast-feeding. Supplementing with formula before the 2-week office visit also led to termination of breast-feeding by 8 weeks (P = .006). This decision was frequently made without medical advice. Nearly 64% (14/22) of the mothers who added formula within the first 2 weeks did so without contacting the pediatric practice.

Recurrence of skin disease in a nursery: ineffectuality of hexachlorophene bathing.

An outbreak of streptococcal and staphylococcal skin disease was discovered in a full-term nursery after the discontinuation of bathing infants with hexachlorophene. The epidemic was only temporarily controlled by conventional means and recurred despite reinstitution of hexachlorophene bathing. Measures that decreased infants' exposure to visitors and hospital personnel and enforced aseptic techniques in the nursery were more important than use of hexachlorophene soap in achieving and maintaining control.

Epidemiology for medical students: a course relevant to clinical practice.

A new course was designed to make epidemiology clinically relevant to medical undergraduates. The objectives were that students should (1) know the epidemiology of common diseases, (2) understand epidemiological concepts useful in diagnosis and treatment, and (3) be able to critically assess published medical evidence. Results of a written examination showed that objectives 1 and 2 had been 'easily' achieved by 80% and 68% of students respectively. Student opinion of the course, assessed by an anonymous questionnaire, showed that the majority of students considered the course to be an important part of medical education. Before the course 19% felt 'reasonably able' or 'very able' to achieve nine specific objectives related to epidemiological concepts in diagnosis and treatment. By the end of the course this had risen to 78%.

Epidemiology for medical students: a controlled trial of three teaching methods.

Medical students taking a course in epidemiology for clinical practice were taught by either lectures, small group seminars or self-learning packages. Examination performances were no different for the three groups, but self-perceived mastery of learning objectives, and satisfaction with the course were higher for students who received self-learning packages. Sixty per cent of self instruction students found the teaching method was successful compared with 37% of the seminar students and only 19% who received lectures. A combination of self-instructional package and seminar would seem to hold most promise for a workable and effective course.

Evaluating worksite health programs.

Worksite health enhancement programs utilize screening and early disease detection or risk reduction as health promotion activities. Objectives for these include improving the health and productivity of employees and reducing health care costs. However, critical questions about the effectiveness of programs should be answered before managers initiate these activities. Issues include accuracy of measurement and subject classification, adequate use of comparisons and follow-up in evaluation studies, and evidence of cost effectiveness.

Changes in the use of diagnostic technologies among Medicare patients, 1985 and 1990.

This paper examines changes in the use of selected diagnostic technologies for Medicare patients in 1985 and 1990. The analysis compares patients across five common, medical tracer conditions: acute myocardial infarction (AMI), congestive heart failure (CHF), stroke, pneumonia, and gastrointestinal (GI) hemorrhage. The relationship of hospital characteristics to patterns of technology use was assessed by grouping hospitals by a composite measure of "costliness." The overall use of 21 diagnostic tests rose by 27% over the 5-year period. Increases were most marked among the three cardiovascular tracers and for related technologies, such as cardiac angiography and cardiac ultrasound. There was evidence that newer technologies partially replaced older diagnostic tests that were used for similar indications: rates of noninvasive cerebrovascular imaging rose while rates of cerebral angiography declined. However, for several common, long-established tests, such as electrocardiogram and chest radiograph, there were consistent increases that are unexplained. High-cost hospitals performed diagnostic tests at much higher rates than lower-cost hospitals in both 1985 and 1990, but the rate of increase in test use across the two study years was generally greater for the lower-cost hospitals.

Bacterial diseases of the colon.

Acute diarrhea of bacterial origin is discussed for seven enteric pathogens, and specific antimicrobial therapy based on positive identification is stressed. Selection of patients with self-limited disease not requiring antimicrobial therapy is emphasized in order to avoid costly laboratory tests. The role of daycare facilities in the spread of enteric pathogens in this country is discussed. This article includes a review of newer methods for treating infants and children with oral rehydration and rapid refeeding.

Pesticide containers: their contribution to poisoning.

Pesticide containers play an important role in the epidemiology of pesticide poisonings. Investigations of short-term exposures have shown that difficulty in disposal of used containers, inappropriate pesticide paskaging, and lack of safety containers for household products contribute to morbidity. Remedies for some of the container-associated hazards could be achieved under existing laws.

Protective clothing as a means of reducing nicotine absorption in tobacco harvesters.

Green tobacco sickness is an occupational illness of tobacco illness of tobacco harvesters that is thought to be caused by dermal absorption of nicotine from contact with green tobacco leaf. Wearing of rubberized nylon rainsuits effectively prevented nicotine absorption in volunteers who picked wet tobacco. Nicotine absorption was demonstrated in workers who wore clothing that was not waterproof.

Heavy metal exposure in populations living around zinc and copper smelters.

Arsenic, cadmium, and lead levels were determined simultaneously in multiple environmental media and human tissues in two zinc smelter (Bartlesville, Oklahoma and Palmerton, Pennsylvania) and two copper smelter (Ajo, Arizona and Anaconda, Montana) communities. Environmental media sampled included air, soil, household dust, and tap water; human samples included hair, blood, and urine. Between 200 and 300 residents from various age groups (1-5, 6-18, 20-40, and 60 + yr) were sampled in 1978 and 1979 and completed questionnaires in each of the four communities. Samples for all media were selected under a probability sampling framework at various distances from the smelters. Results of this investigation indicated that increased environmental levels and body burdens were exhibited at distances closest to the smelters. Of the three tissues sampled, hair was the most useful in determining relationships between environmental metal levels, distance, and body burden. Furthermore, while there was evidence that all ages had hair metal levels that were related to environmental levels and distance from the smelter, these relationships were much more pronounced for the 1- to 5-yr-old age group. The 1 to 5 yr olds also had the highest tissue metal levels across age groups. Higher hair metal levels were also found for males; smokers; children who ate paint, dirt, or clay; and for individuals who spent more time out of doors.

Fever in children younger than three months of age. A pooled analysis.

Concern that febrile infants younger than 3 months of age are at high risk of serious infection has prompted a management policy of routine hospitalization with antibiotic administration. Ten published studies of febrile infants younger than 3 months of age were reviewed, and data were statistically combined to develop estimates of the risk of bacteremia and serious infection. Factors that predicted increased risk were similarly evaluated. Mean and median risk estimates included, respectively, 3.0 and 3.4 percent for bacteremia, 1.3 and 1.0 percent for septic meningitis, and 5.0 and 7.0 percent for pneumonia. These were no higher than comparable estimates for older infants. Clinical appearance was 92 percent sensitive in predicting bacteremia in 500 infants (23 of 25 cases). Younger age, higher fever, and elevated white blood cell count were associated with increased risk of serious infection. Data from these studies do not support the belief that febrile infants younger than 3 months are uniformly at greater risk of serious infection than older infants. Judicious evaluation of younger infants could lead to more selective, cost-efficient management.

Effects of an educational feedback strategy on physician utilization of thyroid function panels.

Physician overutilization of clinical laboratory tests has been well documented, but previous attempts aimed at changing this behavior have met with limited success. An educational feedback strategy was used to try to change physician behavior in ordering thyroid function panels (TFPs) in the Duke-Watts Family Medicine group practice. The rate of TFP ordering significantly decreased for three months following the intervention but rose to the preintervention level within six months. Senior residents appeared to be more responsive to the educational feedback than junior residents. Results obtained in this and other studies suggest that other factors compete with educational approaches in motivating physician behavior, and these override rational decision making.

An evaluation of potassium usage in ambulatory hypertensive patients.

Controversies surround the practice of prescribing potassium for ambulatory hypertensive patients who are being treated with diuretics. A chart review was conducted in a family medicine group practice to examine habits of potassium monitoring and supplement prescribing for patients receiving diuretic therapy for control of hypertension. Eighty-four percent of the 134 patients studied were monitored for serum potassium. For those with values obtained both before and after institution of diuretic therapy, mean potassium fell from 4.1 mEq/liter to 3.8 mEq/liter and 29 percent of patients had potassium levels fall to 3.5 mEq/liter or less. Almost half of patients received some type of potassium therapy, with diet enrichment and pharmacologic supplementation being the most common. When mean serum potassium values and percentage of patients with hypokalemia were compared for patients who were prescribed potassium therapy and for those who were not, there was little evidence that patients benefited from potassium prescribing.

Sex of physician as a determinant of psychosocial problem recognition.

With increasing scrutiny of the role of women in the medical profession, there has been speculation that women physicians provide more sensitivity and empathy to their patients. To compare the psychosocial awareness of female and male physicians, medical records were reviewed for 909 patient visits to six women and seven men who were first year family practice residents. Charts were audited for evidence of acknowledgement of 21 categories of psychosocial or sexual problems. Women physicians saw more patients than their male counterparts and had a higher percentage of visits from women patients (73 percent compared to 65 percent): Types of medical problems seen were similar for men and women physicians with 42 percent of patients noted to have at least one psychosocial or sexual problem. Recognition of problems did not differ significantly between men and women physicians. Women physicians found 44 percent of their female patients had at least one psychosocial problem compared to a 40 percent rate for men physicians seeing either male or female patients, but this small difference could have occurred by chance. When three family medicine faculty members were asked to rank the residents, their ratings were better predictors of psychosocial awareness than was the sex of the resident physician.