Fracture Risk Following an Atypical Femoral Fracture.

Atypical femoral fractures (AFFs) occurring during the course of osteoporosis treatment usually lead to discontinuation of anti-resorptive (AR) drugs. However, the risk of fracture after an AFF is unknown. We conducted a follow-up study of patients with AFF matched 1:3 for age and gender with patients with a peripheral major osteoporotic fracture (pMOF), in the setting of a fracture liaison service, to investigate the incidence of subsequent low-trauma fractures. Fifty-five patients with AFF (95% women, age [mean ± standard deviation] 75 ± 10 years, 89% exposed to AR drugs), followed for 6.2 ± 3.7 years, were compared to 165 matched controls with a pMOF (hip 85%) followed for 4.3 ± 2.6 years. During the follow-up, 38% of patients in the AFF group and 16% in the pMOF group received AR therapies. Continuation of AR drugs after an AFF was associated with contralateral AFF in 27% of subjects. The risks of new low-trauma, major osteoporotic and imminent (within 2 years) fractures, were similar between the two groups: incidence rate ratio (95% confidence interval [CI]) of subsequent fracture following AFF relative to pMOF, 1.30 (95% CI, 0.82-2.04), 1.28 (95% CI, 0.74-2.15), and 1.11 (95% CI, 0.54-2.15), respectively. Moreover, the risk of sustaining multiple fractures per participant was significantly increased among patients with AFF compared to pMOF (hazard ratio 1.48 [95% CI, 1.00-2.19]; p = 0.049). When taking mortality into account, the risk of subsequent fractures tended to be higher in the AFF group (sub-hazard ratio 1.42 [95% CI, 0.95-2.12]). In conclusion, patients who sustained an AFF are at high risk of subsequent fragility fractures, at least equal or even greater to the risk observed after a pMOF. However, continuation of AR drugs increases the risk of contralateral AFF. Therefore, optimal modalities for secondary fracture prevention after AFF require further evaluation. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

[Development and evaluation of Fracture Liaison Service in Switzerland]. / Développement et évaluation des filières de l'ostéoporose en Suisse.

Osteoporosis is a major public health problem linked to fractures and more particularly to those of the hip, which is the major complication in terms of morbidity, mortality and costs. As the risk of a new fragility fracture is greatly increased after a first fracture episode, the concept of the « Osteoporosis pathway ¼ or « Fracture Liaison Service ¼, led by an interdisciplinary team with a coordinator, was developed for the secondary prevention of fractures. Osteoporosis pathways for which key performance indicators have recently been described, have demonstrated their ability to reduce the incidence of new fractures with a favorable cost-effectiveness ratio. Over the past two years, the development of the osteoporosis pathways network in Switzerland has been the main initiative led by the Swiss Association against Osteoporosis.

L'ostéoporose est un problème majeur de santé publique en lien avec les fractures, et plus particulièrement avec la fracture de la hanche qui est la complication principale en termes de morbidité, de mortalité et de coûts. Le risque de nouvelle fracture de fragilité étant fortement augmenté après une première fracture, le concept de « Filière ostéoporose ¼ ou « Fracture Liaison Service ¼, animée par une équipe interdisciplinaire avec un coordinateur, a été développé pour la prévention secondaire des fractures. Les filières ostéoporose, pour lesquelles des indicateurs clés de performance ont été récemment décrits, ont démontré leur capacité à réduire l'incidence de nouvelles fractures avec un rapport coût-efficacité favorable. Au cours de ces deux dernières années, le développement du réseau de filières ostéoporose en Suisse a été la principale initiative menée par l'Association suisse contre l'ostéoporose.

A randomized controlled trial of the safety and efficacy of a topical gentamicin-collagen sponge in diabetic patients with a mild foot ulcer infection.

OBJECTIVES: The initial phase of infection of a foot ulcer in a person with diabetes is often categorized as mild. Clinicians usually treat these infections with antimicrobial therapy, often applied topically. Some experts, however, believe that mild diabetic foot ulcer infections will usually heal with local wound care alone, without antimicrobial therapy or dressings. METHODS: To evaluate the potential benefit of treatment with a topical antibiotic, we performed a single-center, investigator-blinded pilot study, randomizing (1:1) adult patients with a mild diabetic foot ulcer infection to treatment with a gentamicin-collagen sponge with local care versus local care alone. Systemic antibiotic agents were prohibited. RESULTS: We enrolled a total of 22 patients, 11 in the gentamicin-collagen sponge arm and 11 in the control arm. Overall, at end of therapy, 20 (91%) patients were categorized as achieving clinical cure of infection, and 2 (9%) as significant improvement. At the final study visit, only 12 (56%) of all patients achieved microbiological eradication of all pathogens. There was no difference in either clinical or microbiological outcomes in those who did or did not receive the gentamicin-collagen sponge, which was very well tolerated. CONCLUSION: The results of this pilot trial suggest that topical antibiotic therapy with gentamicin-collagen sponge, although very well tolerated, does not appear to improve outcomes in mild diabetic foot ulcer infection.

Síndrome de Cushing con respuesta clínica al tratamiento con bloqueadores beta / Cushing syndrome with clinical response to beta-blockers

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Tratamiento de la hiperglucemia en el hospital. Impresiones y conocimientos del médico residente / Interns’ viewpoints and knowledge about management of hyperglycemia in the hospital setting

Antecedentes y objetivo En muchos hospitales se han instaurado nuevos protocolos de insulinoterapia, a pesar de lo cual, no se logra un adecuado control. Evaluamos mediante una encuesta, la percepción de los médicos residentes ante la hiperglucemia, determinamos las barreras para obtener un óptimo control, y el impacto en las mismas de un programa de insulinización. Material y métodos Se aplicó un cuestionario, que valoraba el grado de conocimiento y la práctica habitual ante la hiperglucemia, antes y a los 6 meses de la implantación de un protocolo de insulinoterapia intrahospitalario. Resultados Completaron el cuestionario 25 residentes. El control glucémico se consideró «muy importante» en todas las situaciones de ingreso; sin embargo, en la hospitalización convencional solo lo consideró el 36%. La mayor parte se sentían «cómodos» utilizando la pauta de «solo insulina rápida», que fue la más empleada, pero no con la pauta basal/bolo que era «poco/nada» utilizada. A los 6 meses, aumentó la percepción del número de pacientes bien controlados, el bienestar y utilización de las pautas basal/bolo, aunque el empleo de «solo insulina rápida» se mantuvo. La mayor dificultad referida para un adecuado manejo de la hiperglucemia fue la falta de conocimientos. Conclusiones Los facultativos residentes conocen la importancia de un adecuado control, pero la falta de conocimientos impide obtenerlo. El programa formativo y la protocolización conllevaron una mejoría en la percepción y aplicabilidad de las pautas intensificadas. Sin embargo, a pesar del esfuerzo, sigue siendo elevado el empleo de pautas basadas exclusivamente de insulina rápida. En el programa formativo de los residentes debería destacarse el majo de la hiperglucemia (AU)

Background and objective: In many hospitals, adequate glycemic control is not achieved despite implementation of new insulin therapy protocols. Our aim was to assess resident physician’ attitudes toward inpatient hyperglycemia, barriers to achieve optimum control, and impact on them of an insulin training program Material and methods: A questionnaire was used to assess understanding and standard management of hyperglycemia before and six months after implementation of an inpatient insulin treatment program. Results: Twenty-five interns completed the questionnaire. Glycemic control was considered ‘‘very important’’ in all admission situations, but was only considered ‘‘very important’’ inconventional hospitalization by 36% of interns. Most of these felt ‘‘comfortable’’ using sliding scales, but not with the basal/bolus regimen, which was the least commonly used. Perception of number of well-controlled patients and comfort and use of basal/bolus therapy increased at six months, but use of ‘‘sliding scales’’ remained high. The greatest difficulty reported for adequate management of hyperglycemia was the lack of knowledge. Conclusions: Most residents are aware of the importance of adequate glycemic control, but cannot achieve it because of inadequate knowledge. The insulin training program led to an improved perception and applicability of basal-bolus insulin regimens. However, despite all efforts, use of sliding scales remains high. Training programs should emphasize management of hyperglycemia (AU)

[Interns' viewpoints and knowledge about management of hyperglycemia in the hospital setting]. / Tratamiento de la hiperglucemia en el hospital. Impresiones y conocimientos del médico residente.

BACKGROUND AND OBJECTIVE: In many hospitals, adequate glycemic control is not achieved despite implementation of new insulin therapy protocols. Our aim was to assess resident physician' attitudes toward inpatient hyperglycemia, barriers to achieve optimum control, and impact on them of an insulin training program MATERIAL AND METHODS: A questionnaire was used to assess understanding and standard management of hyperglycemia before and six months after implementation of an inpatient insulin treatment program. RESULTS: Twenty-five interns completed the questionnaire. Glycemic control was considered "very important" in all admission situations, but was only considered "very important" in conventional hospitalization by 36% of interns. Most of these felt "comfortable" using sliding scales, but not with the basal/bolus regimen, which was the least commonly used. Perception of number of well-controlled patients and comfort and use of basal/bolus therapy increased at six months, but use of "sliding scales" remained high. The greatest difficulty reported for adequate management of hyperglycemia was the lack of knowledge. CONCLUSIONS: Most residents are aware of the importance of adequate glycemic control, but cannot achieve it because of inadequate knowledge. The insulin training program led to an improved perception and applicability of basal-bolus insulin regimens. However, despite all efforts, use of sliding scales remains high. Training programs should emphasize management of hyperglycemia.