Previous fracture and subsequent fracture risk: a meta-analysis to update FRAX.

A large international meta-analysis using primary data from 64 cohorts has quantified the increased risk of fracture associated with a previous history of fracture for future use in FRAX. INTRODUCTION: The aim of this study was to quantify the fracture risk associated with a prior fracture on an international basis and to explore the relationship of this risk with age, sex, time since baseline and bone mineral density (BMD). METHODS: We studied 665,971 men and 1,438,535 women from 64 cohorts in 32 countries followed for a total of 19.5 million person-years. The effect of a prior history of fracture on the risk of any clinical fracture, any osteoporotic fracture, major osteoporotic fracture, and hip fracture alone was examined using an extended Poisson model in each cohort. Covariates examined were age, sex, BMD, and duration of follow-up. The results of the different studies were merged by using the weighted ß-coefficients. RESULTS: A previous fracture history, compared with individuals without a prior fracture, was associated with a significantly increased risk of any clinical fracture (hazard ratio, HR = 1.88; 95% CI = 1.72-2.07). The risk ratio was similar for the outcome of osteoporotic fracture (HR = 1.87; 95% CI = 1.69-2.07), major osteoporotic fracture (HR = 1.83; 95% CI = 1.63-2.06), or for hip fracture (HR = 1.82; 95% CI = 1.62-2.06). There was no significant difference in risk ratio between men and women. Subsequent fracture risk was marginally downward adjusted when account was taken of BMD. Low BMD explained a minority of the risk for any clinical fracture (14%), osteoporotic fracture (17%), and for hip fracture (33%). The risk ratio for all fracture outcomes related to prior fracture decreased significantly with adjustment for age and time since baseline examination. CONCLUSION: A previous history of fracture confers an increased risk of fracture of substantial importance beyond that explained by BMD. The effect is similar in men and women. Its quantitation on an international basis permits the more accurate use of this risk factor in case finding strategies.

Update of the fracture risk prediction tool FRAX: a systematic review of potential cohorts and analysis plan.

We describe the collection of cohorts together with the analysis plan for an update of the fracture risk prediction tool FRAX with respect to current and novel risk factors. The resource comprises 2,138,428 participants with a follow-up of approximately 20 million person-years and 116,117 documented incident major osteoporotic fractures. INTRODUCTION: The availability of the fracture risk assessment tool FRAX® has substantially enhanced the targeting of treatment to those at high risk of fracture with FRAX now incorporated into more than 100 clinical osteoporosis guidelines worldwide. The aim of this study is to determine whether the current algorithms can be further optimised with respect to current and novel risk factors. METHODS: A computerised literature search was performed in PubMed from inception until May 17, 2019, to identify eligible cohorts for updating the FRAX coefficients. Additionally, we searched the abstracts of conference proceedings of the American Society for Bone and Mineral Research, European Calcified Tissue Society and World Congress of Osteoporosis. Prospective cohort studies with data on baseline clinical risk factors and incident fractures were eligible. RESULTS: Of the 836 records retrieved, 53 were selected for full-text assessment after screening on title and abstract. Twelve cohorts were deemed eligible and of these, 4 novel cohorts were identified. These cohorts, together with 60 previously identified cohorts, will provide the resource for constructing an updated version of FRAX comprising 2,138,428 participants with a follow-up of approximately 20 million person-years and 116,117 documented incident major osteoporotic fractures. For each known and candidate risk factor, multivariate hazard functions for hip fracture, major osteoporotic fracture and death will be tested using extended Poisson regression. Sex- and/or ethnicity-specific differences in the weights of the risk factors will be investigated. After meta-analyses of the cohort-specific beta coefficients for each risk factor, models comprising 10-year probability of hip and major osteoporotic fracture, with or without femoral neck bone mineral density, will be computed. CONCLUSIONS: These assembled cohorts and described models will provide the framework for an updated FRAX tool enabling enhanced assessment of fracture risk (PROSPERO (CRD42021227266)).

Fracture experience among participants from the FROCAT study: what thresholding is appropriate using the FRAX tool?

OBJECTIVE: To perform an external validation of FRAX algorithm thresholds for reporting level of risk of fracture in Spanish women (low < 5%; intermediate ≥ 5% and < 7.5%; high ≥ 7.5%) taken from a prospective cohort "FRIDEX". METHODS: A retrospective study of 1090 women aged ≥ 40 and ≤ 90 years old obtained from the general population (FROCAT cohort). FRAX was calculated with data registered in 2002. All fractures were validated in 2012. Sensitivity analysis was performed. RESULTS: When analyzing the cohort (884) excluding current or past anti osteoporotic medication (AOM), using our nominated thresholds, among the 621 (70.2%) women at low risk of fracture, 5.2% [CI95%: 3.4-7.6] sustained a fragility fracture; among the 99 at intermediate risk, 12.1% [6.4-20.2]; and among the 164 defined as high risk, 15.9% [10.6-24.2]. Sensitivity analysis against model risk stratification FRIDEX of FRAX Spain shows no significant difference. By including 206 women with AOM, the sensitivity analysis shows no difference in the group of intermediate and high risk and minimal differences in the low risk group. CONCLUSIONS: Our findings support and validate the use of FRIDEX thresholds of FRAX when discussing the risk of fracture and the initiation of therapy with patients.

Changing trends in the epidemiology of hip fracture in Spain.

UNLABELLED: Temporal trends in hip fracture incidence have recently been reported in some developed countries. Such data in Spain has previously been incomplete; this study reports the stratified incidence of hip fractures in people over 65 in Spain during the last 14 years. INTRODUCTION: The main objective is to establish whether temporal trends in hip fracture incidence in Spain exist. METHODS: Ecological study with data from hospital discharges nationwide. The study includes patients aged ≥ 65 years during a 14-year period (1997-2010). The analysis compares two periods of four years: 1997-2000 (P1) and 2007-2010 (P2). RESULTS: There were 119,857 fractures in men and 415,421 in women. Comparing periods (P1 vs P2) over 10 years, the crude incidence rate/100,000 inhabitant/year increased an average of 2.3%/year in men and 1.4% in women. After adjustment, the rate increased an average of 0.4%/year in men (p < 0.0001), but decreased 0.2%/year in women (p < 0.0001). In men, younger than 85, the decrease was not significant except in 70-74 years, and from 80 years, the adjusted rate increases significantly (p < 0.0001). In women under 80 years of age, the decrease in adjusted rate was significant; there was no change in 80-84 years, and the adjusted rate increased significantly in individuals 85 years and older (p < 0.0001). Mortality rates declined by 22% in both sexes, and the index of overaging population rises 30.1 % in men and 25.2% in women. CONCLUSIONS: This study supports other international studies by showing changes in the incidence of hip fractures after age-population adjustment, which denotes a decrease in the younger age groups and among women and shows an increase in both groups over 85 years. The increase in the crude incidence rate of hip fracture in Spain reflects changes in population structure.

Respuesta a los autores: La resolución de enfermería en las consultas urgentes de atención primaria / No disponible

No disponible

Is lung function associated with bone mineral density? Results from the Hertfordshire Cohort Study.

UNLABELLED: Given limited information available regarding associations between lung function and bone mineral density among healthy subjects, we undertook these analyses in the Hertfordshire Cohort Study. Forced expiratory volume in 1 s (FEV(1)), forced vital capacity (FVC) and FEV(1)/FVC were not associated with bone mineral density at any site; associations with bone mineral content were removed by adjustment for body size. PURPOSE: There is limited information available regarding the association between lung function and bone mineral density among healthy elderly subjects. We addressed this issue in the Hertfordshire Cohort Study. METHODS: From the above cohort, 985 subjects (496 men and 489 women) aged 60-72 years were recruited. All subjects underwent bone density measurements using dual energy X-ray absorptiometry and lung function tests using standardised spirometry. Chronic obstructive pulmonary disease (COPD) was defined as a FEV(1)/FVC ratio

Evaluación de la eficacia de enfermería en la resoluciónde las consultas urgentes en atención primaria / Efficacy of nurse practitioner management of primary care emergency visits

Objetivo: Evaluar la eficacia de enfermería en la resolución de las consultas urgentes en atención primaria (AP) mediante la aplicación de los protocolos incorporados a la historia clínica informatizada (e-CAP).Método: Estudio descriptivo, transversal y retrospectivo. Se incluyeron de forma consecutiva todos los pacientes que solicitaron una consulta urgente para el mismo día en una área básica de salud (ABS) semiurbana de la provincia de Girona, entre el 15 de marzo al 15 de abril de 2010. Se valoró la aplicación por parte de enfermería de los protocolos de actuación consensuados para la atención de los motivos de consulta urgentes protocolizados en el e-CAP. Se analizaron las variables sociodemográficas (edad, sexo, país de origen), asistenciales (motivo de consulta) y de enfermería (antigüedad, lugar de trabajo). La eficacia de enfermería se valoró mediante el análisis de las re-consultas en menos de 48 horas y por las derivaciones a otro profesional. Resultados: Se analizaron 296 consultas. La edad media fue de 34,4 ± 25,5 años,53,3% fueron mujeres y 25,3% inmigrantes. El principal motivo de consulta fueron las heridas (12,5%). El 77,4% no reconsultó en las primeras 48 horas (80,5% motivos de consulta protocolizados vs 73,2% no protocolizados, p = 0,14). Los motivos protocolizados (57,1% de las consultas) tuvieron un menor porcentaje de derivación a otro profesional (33,1% protocolizados vs 64,6% no protocolizados p < 0,001). La reconsulta en los motivos protocolizados fue menor en inmigrantes (12,1% vs 29,4% p = 0,04) y en los pacientes más jóvenes (31,6 ± 24 años vs 41,1 ± 25,4 años p = 0,04).Conclusión: Enfermería tiene una alta capacidad de resolución de las consultas urgentes en AP. La eficacia de enfermería aumenta cuando atiende las consultas urgentes con un motivo de consulta protocolizado en el e-CAP (AU)

Objective: To assess the efficacy of nurse practitioner management of emergency visits by means of consensus protocols integrated into the computerized medical record system of a primary health care center. Methods: Descriptive, cross-sectional, retrospective study. All patients seeking appointments for same-day care within a semiurban health care district in the province of Girona, Spain, were included consecutively between March 15 and April15, 2010. We evaluated the nurses’ application of the appropriate computerized practice protocols in the system. Sociodemographic variables (age, sex, country of origin), care variables (reason for the visit), and nurse variables(seniority, place of work) were analyzed. The nurses’ efficacy was evaluated on the basis of revisits within 48 hours or the need for referral to another care provider. Results: A total of 296 visits were included. The mean (SD) patient age was 34.4 (25.5) years; 53.3% were women and25.3% were immigrants. Open wounds (12.5%) were the main reason for seeking care. No revisits within 48 hours were needed in 77.4% of the cases (80.5% of those treated by protocol did not revisit vs 73.2% of those whose care was not protocol-guided, P=.14). Conditions treated by protocol (57.1% of the visits) generated fewer referrals to another professional (33.1% of protocol-guided visits were referred vs 64.6% of non protocol-guided visits, P<.001). Immigrants made fewer revisits for problems treated by protocol (12.1% revisited vs 29.4% when no protocol was used, P=.04).Younger patients revisited less often (mean age of 31.5 [24] years for patients not revisiting vs 41.1 [25] years for revisitors, P=.04).Conclusions: The ability of the nursing staff to manage primary care emergency visits is high. Nurse practitioner efficacy increases when a computerized protocol is available to assist in managing a case (AU)

Triple vs. quadruple therapy for treating Helicobacter pylori infection: a meta-analysis.

BACKGROUND: Triple therapy (proton pump inhibitor, clarithromycin and amoxicillin or an imidazole) is the first-line treatment for Helicobacter pylori infection. However, the effectiveness of triple therapy is decreasing due to the increase in antibiotic resistance. Quadruple therapy (proton pump inhibitor, tetracycline, metronidazole and a bismuth salt) is a very effective regimen even in areas of high prevalence of antibiotic resistance, and may be an alternative first-line treatment. AIM: To compare triple vs. quadruple therapy for the first-line treatment of H. pylori infection. METHODS: An extensive literature search was performed to identify randomized trials comparing triple vs. quadruple therapy. Selected trials were included in a meta-analysis using Review Manager 4.1. RESULTS: Four studies met the inclusion criteria. Eradication rates with quadruple therapy were slightly higher in both the intention-to-treat (81% vs. 78%; odds ratio, 0.83; 95% confidence interval, 0.61-1.14) and per protocol (88% vs. 85%; odds ratio, 0.81; 95% confidence interval, 0.55-1.20) analysis, although the differences were not statistically significant. Nor were there significant differences in compliance or adverse effects between the therapies. CONCLUSION: Triple and quadruple therapies seem to be roughly equivalent in terms of effectiveness, compliance and side-effects profile when administered as first-line treatment for H. pylori infection.

[Management of dyspepsia, gastroduodenal ulcer and Helicobacter pylori infection in primary care]. / Manejo de la dispepsia, la enfermedad ulcerosa y la infección por Helicobacter pylori en atención primaria.

OBJECTIVE: To evaluate management of dyspepsia, gastroduodenal ulcer and Helicobacter pylori infection in the setting of family practice. DESIGN: An observational transversal study was performed. An anonymous questionnaire was send by mail between January and October 2000. SETTING: Primary care. PARTICIPANTS: Physicians of 17 Primary Care centers. RESULTS: Sixty-four per cent of the physicians returned the answered questionnaire (107/165). Primary care doctors reported they had indicated eradication therapy at least once during last year in 94.3%; 89.7% usually indicate H. pylori eradication for duodenal ulcer and 70.1% for gastric ulcer. The main method for the study of dyspepsia was endoscopy associated with antral histology or rapid urease test for determination of H. pylori status. Omeprazole, clarithromycin and amoxicillin twice daily for seven days was the preferred eradication therapy (77.6%). Forty-five percent of physicians systematically tested patients to confirm cure of the infection; 36.4% tested patients only if symptoms relapsed. Breath test (72.7%) was the preferred method to confirm eradication. Physicians with postgraduate specialty in Family Care and Community Medicine (MFyC) demand less often gastroenterologist evaluation, indicate less frequently upper tract radiology, use more often C13 urea breath test for diagnosis and indicate more often eradication treatment for erosive duodenitis than unspecialised family doctors. CONCLUSIONS: Management of dyspepsia and H. pylori infection in Primary Care in our area is reasonably adapted to current consensus recommendations. Many differences in management were observed between MFyC and non-specialised primary care physicians.

Manejo de la dispepsia, la enfermedad ulcerosa y la infección por helicobacter pylori en atención primaria / Management of dyspepsia, gastroduodenal ulcer and helicobacter pylori infection in primary care

Objetivo. Analizar el manejo de la dispepsia, la úlcera péptica y la infección por Helicobacter pylori (Hp) en atención primaria. Diseño. Estudio observacional, transversal, realizado mediante cuestionario anónimo entre enero y octubre de 2000.Emplazamiento. Atención primaria. Participantes. Médicos de 17 centros de atención primaria (CAP).Mediciones. Encuesta de 19 preguntas remitida por correo. Resultados principales. Respondieron un 64,8 por ciento de los médicos (107/165). El 94,3 por ciento había realizado uno o más tratamientos erradicadores en el último año. El 89,7 por ciento indica erradicación de forma habitual en la úlcera duodenal y el 70,1 por ciento en la úlcera gástrica. El 79,4 por ciento no ha indicado nunca tratamiento erradicador sin documentar la infección por Hp. La endoscopia asociada a histología y/o ureasa es la técnica más utilizada para el diagnóstico. La pauta terapéutica más utilizada (77,6 por ciento) es omeprazol, claritromicina y amoxicilina durante 7 días, cada 12 h. El 44,9 por ciento comprueba siempre la erradicación después del tratamiento, mientras que el 36,4 por ciento sólo lo hace si recidiva la sintomatología. El test del aliento (72,7 por ciento) es la prueba más utilizada para comprobar la erradicación. No se observaron diferencias en las respuestas en función de la antigüedad ni la titularidad de la plaza. Por el contrario, los especialistas en medicina familiar y comunitaria (MFyC) remiten menos a menudo pacientes al digestólogo, utilizan menos el tránsito gastroesofágico, utilizan más el test del aliento y realizan más tratamientos en duodenitis erosiva en comparación con el resto de facultativos de atención primaria. Conclusiones. Las actitudes observadas se adecuan razonablemente a lo establecido en las reuniones de consenso y varían entre los médicos MFyC y el resto de facultativos de atención primaria. (AU)

Diagnosis of Helicobacter pylori after triple therapy in uncomplicated duodenal ulcers--a cost-effectiveness analysis.

BACKGROUND: The cost-effectiveness of determining Helicobacter pylori status after treatment remains to be established. AIM: To determine the benefit of post-treatment assessment of H. pylori eradication in patients with uncomplicated duodenal ulcer. MATERIALS AND METHODS: A decision analysis was performed in patients with uncomplicated duodenal ulcer who were H. pylori-positive and had received eradication therapy. A decision tree was devised to compare the costs per patient of two different strategies: (a) systematic performance of post-treatment urea breath test and new treatment if positive; and (b) clinical follow-up, 13C-urea breath test if dyspeptic symptoms recurred and eradication treatment if the test was positive. RESULTS: Post-eradication 13C-urea breath test was notably more expensive than clinical follow-up, both in a low-cost per care setting (197 vs. 132 Euros) and in a high-cost per care (614 vs. 340 US $) scenario. This conclusion remained stable for a wide range of variations of the variables included in the decision tree (e.g. cure rates of eradication treatment, cost of the urea breath test or sensitivity, and specificity of urea breath test to detect eradication). CONCLUSION: In patients with uncomplicated duodenal ulcer, evaluation of eradication after H. pylori treatment markedly increases costs with no clear improvement in results and therefore should not be performed routinely.

[The attitude of primary health care physicians in the metropolitan area of Barcelona about the diagnosis and treatment of Helicobacter pylori infection in gastroduodenal diseases]. / Actitud de los médicos de atención primaria del área metropolitana de Barcelona frente al diagnóstico y tratamiento de la infección por Helicobacter pylori en enfermedades gastroduodenales.

AIM: To evaluate the attitude of primary health care physicians versus the diagnosis and treatment of infection by Helicobacter pylori in patients with dyspepsia and gastroduodenal ulcer. DESIGN: An observational, transversal study was performed by a self administered questionnaire from June to October, 1997. PARTICIPANTS: Primary health care physicians from 38 reformed Medical Centers in the metropolitan area of Barcelona were included in the study. RESULTS: Of the 359 doctors to whom the questionnaire was sent, 283 responded (78.8%). In a patient with dyspepsia 95.4% would first request endoscopy. If they knew of the presence of infection by Helicobacter pylori 96.1% would administer eradication treatment in patients with gastric and duodenal ulcer and 15% would also do so if the endoscopy were normal. If the presence of infection by Helicobacter pylori were unknown in a patient with gastroduodenal ulcer, 65.3% would treat with anti-H2 or proton pump inhibitors associated with a diagnostic test of infection by Helicobacter pylori. If the physician decided to carry out eradication treatment of Helicobacter pylori infection, 98.6% would use one of the regimes recommended by different scientific societies. If confirmation of eradication of Helicobacter pylori infection were requested, 89% would do so one and three months after completion of treatment. In patients with gastric ulcer, 69.3% would request endoscopy on completion of treatment. The percentage of physicians specialized in Family and Community Medicine who would carry out eradication treatment in patients with duodenal ulcer and Helicobacter pylori infection and who would request endoscopies in patients with dyspepsia was found to be statistically significant in comparison with physicians without this specialty. CONCLUSIONS: The attitude of primary care physicians in the metropolitan area of Barcelona with regard to the diagnosis and treatment of infection by Helicobacter pylori in gastroduodenal diseases largely reflects the recommendations recently made by several scientific societies. In general there are no significant differences with respect to this attitude in regard to the age and sex of the physician, although their training was found to influence in some of the responses analyzed.