Distribution of vertebral fractures varies among patients according to hip fracture type.

UNLABELLED: This study explored the distribution of vertebral fractures in hip fracture patients. Unlike patients with intertrochanteric fractures, those with subcapital fractures were less likely to have vertebral fractures in the T4-T10 region of the spine. The dissimilar distribution of vertebral fractures among patients with intertrochanteric and subcapital fractures may indicate different underlying etiologies. INTRODUCTION: There are two main types of hip fractures: intertrochanteric and subcapital. Both types can have associated vertebral fractures. In this study, we explored the distribution of vertebral fractures in the two hip fracture populations. METHODS: This was a retrospective analysis of a convenience sample of 120 patients: 40 with subcapital fractures and vertebral fractures, 40 with intertrochanteric fractures and vertebral fractures, and 40 with vertebral fractures only. Based on Genant's semiquantitative assessment method of radiographic images, the distribution and severity of each patient's vertebral fractures were explored [1]. RESULTS: Patients with subcapital fractures had significantly fewer total vertebral fractures (93 vs. 144, p = 0.005; 93 vs. 127, p = 0.019), vertebral fractures from T4 to T10 (41 vs. 81, p = 0.005; 41 vs. 64, p = 0.042), and vertebral fractures at the T7-T8 peak (11 vs. 31, p = 0.002; 11 vs. 30, p = 0.003) than patients with intertrochanteric fractures and those with vertebral fractures alone, respectively, and they were more likely to have only one vertebral fracture (15 vs. 3, p < 0.001; 15 vs. 2, p < 0.001). The number of vertebral fractures from T11 to L4 and at the T12-L1 peak did not differ among the groups. The numbers of fractures at each vertebral level was significantly correlated only between those with intertrochanteric fractures and those with vertebral fractures alone (r = 0.65, p = 0.009). CONCLUSION: The distribution of vertebral fractures among patients with subcapital fractures differed from the other fracture groups, which may indicate that subcapital fractures and some lumbar fractures have a different underlying etiology than intertrochanteric fractures and thoracic (T4-T10) fractures.

Comparison of hip fracture and osteoporosis medication prescription rates across Canadian provinces.

UNLABELLED: The study explores osteoporosis medication prescribing across Canadian provinces and any impact on hip fracture rates. Despite a marked variation in the prescribing of such medication, there is no effect on the hip fracture rate in either gender or any age group, suggesting either poor targeting or lack of efficacy. INTRODUCTION: Hip fractures are the most disabling and costly of osteoporotic fractures, and a reduction in the risk of hip fracture is an expectation of osteoporosis medications. In this study, we have compared the use of osteoporosis medication across Canadian provinces with the rate of hip fractures in the same regions. METHODS: Three years of hip fracture data (2007-2009 inclusive) were obtained from the Canadian Institute for Health Information for all Canadian provinces excluding Quebec. Population information was obtained from Statistics Canada and medication information from the Brogan Inc. database. Because osteoporosis medication is available daily, weekly, monthly, and yearly, medication prescriptions were converted to "units" of prescribing, so that a once a year infusion represented 365 units, a monthly prescription 30 units, and so forth. RESULTS: There is a fourfold difference in prescribing across provinces but no corresponding variation in hip fracture rate. No significant correlation exists between prescribing load and hip fracture rate. This was true for all age groups, both genders, and for both intertrochanteric and subcapital hip fracture. CONCLUSIONS: We find no association between osteoporosis medication prescribing and hip fracture rate. Possible explanations include insufficient numbers of at-risk patients on treatment, inappropriate targeting, and either lack of efficacy or efficacy limited to only certain subgroups of patients such as those with demonstrable trabecular osteoporosis.

Hypophosphatemic osteomalacia complicating von Recklinghausen's neurofibromatosis: increase in spinal density on treatment.

A 62-year-old white male with neurofibromatosis presented with multiple fractures and bone pain. He was found to have hypophosphatemic osteomalacia secondary to a renal tubular phosphate leak and was treated with phosphate, 1,25-dihydroxycholecalciferol and calcium. With treatment, his dual photon vertebral bone density increased markedly over 12 months. Repeat iliac crest bone biopsies showed that improvement in bone histology was predominantly cortical. This suggests that dual photon absorptiometry of the spine may be markedly influenced by changes in cortical bone status.

Copy task performance and urinary incontinence in Alzheimer's disease.

The relationship between behavioral symptoms and cognitive impairment in Alzheimer's Disease (AD) is only poorly understood. The aim of the present study was to examine cognitive correlates of urinary incontinence in AD. Although incontinence is generally accepted as an accompaniment of AD, it was our clinical impression that it correlated poorly with global measures of cognitive impairment. A retrospective pilot study of 17 incontinent demented patients and 17 continent patients, matched for age, sex, and total score on the Folstein Mini-Mental Status Exam (MMSE), revealed a striking association between an inability to do a copy task and urinary incontinence. A prospective study confirmed this finding in a sample of 45 patients meeting DSMIII-R diagnostic criteria for dementia, probable Alzheimer's disease. The 17 incontinent patients did not differ from the 28 continent patients in age, sex distribution, or total score on the MMSE. However, the incontinent subjects scored significantly lower on a cube copying task. Qualitative analysis revealed that the drawings by incontinent patients showed features comparable with those observed in the drawings by patients with right-sided parietal lesions, in particular, poor representation of perspective and spatial orientation. Further investigation of the relationship between copying performance and incontinence may have implications for understanding the cortical mechanisms of urinary continence. The present results also underscore the limitations of the MMSE as a measure of dementia severity and suggest there are areas of cognitive ability which are inadequately assessed by MMSE but which may be of major important in understanding the loss of functional skills in the dementing patient.

Acute effects of exercise on neuropsychological function in elderly subjects.

Fit elderly score higher on tests of fluid intelligence than aged-matched sedentary controls. Elderly patients who have taken part in exercise programs have shown improvement in mental function. We compared the effects of 45 minutes of exercise on memory, mood, and cognitive function in elderly subjects to a control intervention using a randomized control study design. Neuropsychological tests employed where the color slide test, digit symbol test, digit span test, logical memory test, word fluency test, and the Mini-Mental State Examination. We measured mood using a mood test and geriatric depression scale. Each subject was tested before, and immediately after, control and exercise sessions. Fifteen elderly subjects [ten men and five women; mean age, 66 years, (range, 60 to 85 years)] completed the study. There was a greater improvement in six of the eight scores of cognitive function following exercise, compared to control. These differences were significantly greater following exercise for the logical memory test score (P less than or equal to 0.02) and Mini-Mental State Examination (P less than or equal to 0.025) compared with the control intervention.

A questionnaire to evaluate disability in osteoporotic patients with vertebral compression fractures.

BACKGROUND: Few studies have reported on the functional disability due to vertebral compression factors in osteoporosis. The Osteoporosis Functional Disability Questionnaire (OFDQ) was developed to assess disability in patients with osteoporosis and back pain due to vertebral fractures. The domains of the OFDQ include: quantitative indices of pain, a standard 20-item depression scale, 26 items relating to functional abilities, a scale of social activities, and confidence in the ability of prescribed osteoporosis treatment to reverse disability. METHODS: Reliability of the OFDQ was assessed using test-retest and internal consistency methods. Criterion validity was demonstrated by correlating disability against radiographic evidence of vertebral fractures. Construct validity was demonstrated through comparisons of 81 patients with osteoporosis and fractures to 37 healthy age-matched controls. Additional evidence was found in comparing 45 of the 81 cases who were actively engaged in an exercise program with 36 cases who were sedentary. RESULTS: The test-retest reliabilities ranged from .76 to .93, with internal consistencies from .57 to .96. The OFDQ correlated significantly with relevant spinal pathology, and showed significant improvements in activities of daily living and socialization when active exercisers were compared to inactive patients with osteoporosis. CONCLUSIONS: The OFDQ is a reliable instrument which correlates well with objective measures of osteoporotic spinal damage. It is also sensitive to changes in disability brought about by participation in our aerobic exercise program. The OFDQ may be a useful adjunct to measuring outcomes in other osteoporotic treatment protocols.

The vitamin D metabolites in the pathogenesis and management of osteoporosis.

Studies on post-menopausal osteoporotic patients indicate that 1,25-(OH)2 D3 concentrations are no different from those in age-matched normal subjects and the data suggest that the malabsorption of calcium found in many osteoporotic patients cannot generally be attributed to low plasma 1,25-(OH)2 D3 levels. The effects are discussed of three different therapies - sex hormones alone, vitamin D metabolites alone and a combination of both - on calcium balance and peripheral bone loss in treated compared with untreated osteoporotic patients. The results indicate that combined therapy with a vitamin D metabolite and an oestrogen is more effective in inhibiting the rate of bone resorption in post-menopausal osteoporosis than treatment with either agent used alone, and should be regarded as the treatment of choice at the present time. It is suggested that, using this regimen which is suitable for patients up to about 65 years of age, calcium supplementation is not required, provided daily calcium intake is reasonably adequate, and may even be undesirable by increasing the risk of hypercalcaemia.

Dose-dependent response of FSH, flushes and urinary calcium to oestrogen.

The reduction of gonadotrophin levels, urinary calcium and hot flushes in post-menopausal patients by ethinyl oestradiol is shown to be dose dependent, near maximum response being achieved by a dose of 15 micrograms daily. Equivalent ethinyl oestradiol doses to a number of other gonadal hormone preparations have been assessed using the derived dose-response curve of the reduction in urinary calcium.

A placebo-controlled trial of ethinyl oestradiol and norethisterone in climacteric women.

A placebo-controlled trial has shown that 15 microgram of ethinyl oestradiol is as effective as 25 microgram daily in reducing both menopausal symptoms and the urinary excretion of calcium and hydroxyproline. Norethisterone 5 mg daily also showed a significant reduction in the climacteric symptoms but was less effective than either of the ethinyl oestradiol doses.

PIP: A small placebo-controlled double-blind study was conducted to assess the efficacy of hormone replacement therapy in relieving climacteric symptoms. Women in the study received 1 of the following treatments: 1) 15 ug ethiny l estradiol daily; 2) 25 ug ethinyl estradiol daily; 3) 5mg norethisterone daily; or 4) a placebo. There was a significant cumulative fall in climacteric symptoms for the women on the 3 active therapies but no significant change in the placebo-treated group. The 15 ug-dose of ethinyl estradiol achieved the greatest reduction in symptoms, the 25 ug-dose achieved the next best effects, and the norethisterone treatment the least change. Differences among the 3 treatments were not statistically significant. Most of the improvement was due to a reduction in hot flushes. Bone resorption was also controlled with the treatment. It is concluded that hormone replacement therapy is effective in controlling menopause-related symptoms. Since norethisterone was almost as effective as the estrogens and since it is considered by many to be a safer compound, it is concluded that progestogen replacement therapy might be the recommended mode of treatment for menopausal symptoms.

Improving a system of care for elderly persons in rural areas.

This article describes a community initiative to improve the care of elders in largely rural areas. An organization development framework guided pilot projects in two communities, with support from a regional geriatric program. Two interdisciplinary teams, representing primary service agencies in the communities, have been trained to serve as local resources in geriatric assessment and intervention. Through the resource teams, the communities are developing a more integrated and coordinated approach to care for the elderly population. The process has yielded valuable insights into the implementation of system change.

An apoptotic response to photodynamic therapy with endogenous protoporphyrin in vivo.

CDF1 mice bearing the colon-26 tumor were treated with aminolevulinic acid (200 mg kg-1) by tail-vein injection, with tumor sites irradiated 4 h later at 633 nm (75-120 J cm-2). 10 h after irradiation, samples of tumors were removed for histology studies and analysis of DNA fragmentation by static gel electrophoresis. The resulting patterns indicate an apoptotic response to photodynamic therapy with endogenously formed protoporphyrin.

Home care after hip fracture in a health planning region.

Health-care restructuring has increased the focus on integrating health care. Therefore the study purpose was to quantify patient movement from hospital to home care before restructuring occurred in a health planning district. Hospital discharge abstracts and home care records identified patients with a hip fracture who used home care (n = 353). Patients from acute care were more likely than rehabilitation or convalescent inpatients to wait > 3 days for home care after hospital discharge (RR 1.54, 95% CI 1.18, 2.00). Institution-dwellers were more likely than community-dwellers to wait > 3 days for home care (RR 2.35, 95% CI 1.86, 2.97). Home care rehabilitation clients were more likely than non-rehabilitation users to wait > 3 days for home care (RR 2.10, 95% CI 1.42, 3.09). Waiting time for home care is associated with hospital care setting and the home care service utilized. Evaluations of restructuring efforts should consider accounting for these relationships.

SU-E-J-27: Effects of Metal Artifacts of KV and MV CT Images on Structure Delineation and Tissue Electron/Mass Density Calculation.

PURPOSE: To quantitatively evaluate effects of image artifacts of hip prostheses on the accuracy of structure delineation and tissue density calculation on kV and MV CT images. METHODS: Five hip prostheses made of stainless steel, titanium and cobalt chrome alloys were positioned inside a water tank and scanned respectively on a Philips CT and a Tomotherapy Hi-Art unit. Prostheses were positioned to mimic single and bilateral implantations. Rods of tissue materials of lung, water and bone were placed at locations next and distal to metal implants near femoral head, neck and stem of prostheses. kV and MV CT scans were repeated for each placement. On CT images, cross-sectional outlines of metal implants and tissue rods were delineated. Densities of rod materials were determined and compared to the true values. RESULTS: Metal artifacts were severe on kV CTs and minimal on MV CTs. Cross-sectional outlines of metal implants and tissue rods on kV CTs were severely distorted by artifacts while those on MV CTs remained clearly identifiable. For kV CTs, deviations of measured tissue density from true value were up to 51.3%, 30.6% and 40.9% respectively for lung, bone and solid water. The magnitude of deviation was generally larger at locations closer to metal implants and greater with bilateral implants than single implant. For MV CTs, deviations of measured density from true value were less than 6% for all three tissue materials either with single or bilateral implants. Magnitude of deviation appeared to be uniform and independent of locations relative to metal implants. CONCLUSIONS: High Z metal artifacts on kV CTs can have severe impact on the accuracy of structure delineation and tissue density calculation, while on MV CTs, the impact is substantially less and insignificant. MV CTs should be considered for treatment planning on patients with high Z metal implants.

Current bone mass and body weight changes in alcoholic males.

The relationships between current bone mass and changes in body weight were studied in 45 male veterans whose weights and heights at the time of enlistment into the Armed Forces over 40 years ago were obtained, and who were, or had been, chronic alcohol abusers. Those who lost and those who gained weight did not appear to differ in severity of alcoholism but differed in femoral neck cortical thickness, iliac crest trabecular bone volume, and lumbar bone mineral density, the former being significantly lower. Subjects with a hip fracture and those with spinal fractures are significantly lighter now, but were initially of similar weight to those without fractures. We conclude that maintenance of body weight protects against bone loss and fracture even in the presence of chronic alcoholism.

Osteoporosis management in long-term care. Survey of Ontario physicians.

OBJECTIVE: To survey physicians in Ontario regarding their approach to diagnosis and treatment of osteoporosis among residents of long-term care facilities. DESIGN: Mailed questionnaire covering physician demographics; current clinical practice relating to osteoporosis; and perceived barriers to prevention, diagnosis, and treatment of the disease. SETTING: Long-term care facilities in Ontario. PARTICIPANTS: Medical directors of long-term care facilities. MAIN OUTCOME MEASURES: Demographic variables; physician attitudes; and practices concerning awareness, diagnosis, and treatment of osteoporosis. RESULTS: Respondents returned 275 of 490 questionnaires, for a response rate of 56.1%. Most respondents (92.4%) were family physicians; 28.7% were caring for more than 100 patients in long-term care. Most (85.8%) saw from one to 10 hip fractures yearly in their practices. Although 49.6% of respondents estimated the prevalence of osteoporosis to be 40% to 80% among their long-term care patients, 45.5% said that they did not routinely assess their patients for the disease, and 26.8% do not routinely treat it. Half (50.9%) of physicians would treat patients at high risk based on clinical history; 47.9% if patients had a vertebral compression fracture on plain x-ray examination; 43.8% if patients were highly functional; 42.0% if osteoporosis were confirmed with bone mineral densitometry; and 30.0% if patients had a recent fracture. Perceived barriers to initiating treatment included cost of therapy, patient or family reluctance to accept therapy, and time or cost of diagnosis. CONCLUSION: Although physicians are aware that patients in long-term care facilities are at high risk for osteoporosis and hip fractures, the disease remains underdiagnosed and undertreated.