Intrinsic capacity and risk of death: Focus on the impact of using different diagnostic criteria for the nutritional domain.

OBJECTIVE: We aimed to estimate the ability of intrinsic capacity (IC) to predict death in community-dwelling older people using different diagnostic criteria to define the nutritional domain. METHODS: Participants from the Belgian SarcoPhAge cohort were followed from 2013 to the present. Four IC domains were assessed at baseline (data on the sensorial domain were not collected), and considered unsatisfactory below some specific thresholds. The nutritional domain was considered unsatisfactory if baseline malnutrition was present, defined by: 1) MNA-SF ≤11 points; 2) seven versions of the GLIM criteria, varying by the technique used to identify a reduced muscle mass; or 3) the combination of MNA-SF ≤11 points + GLIM criteria. The association between baseline unsatisfactory IC and 9-year mortality was calculated using the odds ratio (OR) adjusted for cofounders. RESULTS: Among the 534 participants (73.5 ± 6.2 years old; 60.3 % women at baseline), 157 (29.4 %) were dead after 9.3 ± 0.3 years of follow-up. Patients with baseline unsatisfactory IC in the locomotor domain (adjusted OR = 2.31 [95%CI 1.38-3.86]) or psychological domain (adjusted OR = 1.78 [1.12-2.83]) were at higher mortality risk. Regarding malnutrition, unsatisfactory IC in the nutrition domain was strongly associated with a higher mortality risk, whatever the criteria used to identify a reduced muscle mass. The highest association with mortality was found in participants with a baseline unsatisfactory nutritional domain defined by the combination of MNA-SF + GLIM criteria (adjusted OR = 3.27 [95%CI 1.72-6.23]). CONCLUSIONS: Presenting any unsatisfactory IC at baseline was associated with a higher 9-year mortality risk in community-dwelling older people. The sequential incorporation of MNA-SF and GLIM criteria as the IC nutritional domain would be helpful to guide public health actions towards healthy ageing.

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.

[Physical activity in nursing homes: contributions of the SENIOR cohort]. / L'activité physique en maison de repos : contributions de la cohorte SENIOR.

The SENIOR ("Sample of Elderly Nursing homes Individuals: an Observational Research") study is a prospective follow-up of a cohort of more than 600 people living in nursing homes in Belgium. One of the objectives of this study is to investigate ways of managing frailty in order to prevent the occurrence of adverse health events. Thanks to the numerous demographic, clinical and anamnestic data collected annually, this study has shown the importance of promoting qualitative physical activity in nursing homes in order to improve the quality of life of residents. Specifically, our research showed the positive effect of physical activity programmes on weekly energy expenditure and improvement of functional abilities, motivation to engage in physical activity and quality of life. Furthermore, the possibilities to improve the motivational context of group physical activity sessions and the feasibility of innovative physical activity programmes, based on the development of a giant play mat or the organisation of competitions in nursing homes, were highlighted.

L'étude SENIOR («Sample of Elderly Nursing homes Individuals : an Observational Research¼) est un suivi prospectif d'une cohorte de plus de 600 personnes résidant en maison de repos, en Belgique. Un des objectifs de celle-ci est l'étude des pistes de prise en charge de la fragilité afin de prévenir la survenue d'événements indésirables de santé. Grâce aux nombreuses données démographiques, cliniques et anamnestiques récoltées annuellement, cette étude a permis de montrer l'importance de promouvoir l'activité physique qualitative en maison de repos afin d'améliorer la qualité de vie des résidents. Plus précisément, nos recherches ont montré l'effet positif des programmes d'activité physique sur les dépenses énergétiques hebdomadaires et l'amélioration des capacités fonctionnelles, de la motivation à pratiquer l'activité physique et de la qualité de vie. Par ailleurs, les possibilités d'améliorer le contexte motivationnel des séances d'activité physique de groupe et la faisabilité de programmes d'activité physique innovants basés sur l'élaboration d'un tapis de jeu géant ou l'organisation de compétitions en maisons de retraite, ont été mises en évidence.

Is it time to consider population screening for fracture risk in postmenopausal women? A position paper from the International Osteoporosis Foundation Epidemiology/Quality of Life Working Group.

The IOF Epidemiology and Quality of Life Working Group has reviewed the potential role of population screening for high hip fracture risk against well-established criteria. The report concludes that such an approach should strongly be considered in many health care systems to reduce the burden of hip fractures. INTRODUCTION: The burden of long-term osteoporosis management falls on primary care in most healthcare systems. However, a wide and stable treatment gap exists in many such settings; most of which appears to be secondary to a lack of awareness of fracture risk. Screening is a public health measure for the purpose of identifying individuals who are likely to benefit from further investigations and/or treatment to reduce the risk of a disease or its complications. The purpose of this report was to review the evidence for a potential screening programme to identify postmenopausal women at increased risk of hip fracture. METHODS: The approach took well-established criteria for the development of a screening program, adapted by the UK National Screening Committee, and sought the opinion of 20 members of the International Osteoporosis Foundation's Working Group on Epidemiology and Quality of Life as to whether each criterion was met (yes, partial or no). For each criterion, the evidence base was then reviewed and summarized. RESULTS AND CONCLUSION: The report concludes that evidence supports the proposal that screening for high fracture risk in primary care should strongly be considered for incorporation into many health care systems to reduce the burden of fractures, particularly hip fractures. The key remaining hurdles to overcome are engagement with primary care healthcare professionals, and the implementation of systems that facilitate and maintain the screening program.

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)).

Intrinsic Capacity Defined Using Four Domains and Mortality Risk: A 5-Year Follow-Up of the SarcoPhAge Cohort.

OBJECTIVES: The concept of 'intrinsic capacity' (IC) offers a new way to approach another concept, that of 'healthy aging'. The first objective of the present study was to assess the ability of the construct of 'intrinsic capacity' to predict death. The second objective was to assess whether deteriorations in intrinsic capacity, measured over 1 and 2 years, are predictive of death. DESIGN: The present analysis was based on a prospective cohort study. SETTING: Community-dwelling participants. PARTICIPANTS: The study recruited older adults aged 65 years and older. MEASUREMENTS: Intrinsic capacity (IC) encompasses five domains: sensorial (not evaluated here), cognition (Mini-Mental State Examination), nutrition (Mini-Nutritional Assessment), mobility (Short Physical Performance Battery), and psychological (Geriatric Depression Scale). Each domain was considered satisfactory when its assessment, for an individual, was above the threshold defined by the initial validation of the domain assessment tool. To explore the relationship between IC and mortality risk, a Cox model was applied. The predictive value of the dynamic aspects (i.e., changes over 1 year and 2 years) was investigated using the following categorization of IC: stable, deteriorated, improved. RESULTS: The sample was composed of 481 volunteers aged 73.4±6.12 years (60.1% women). Two satisfactory IC domains appeared to be significantly associated with reduced mortality risk: the satisfactory mobility domain (adjusted HR=0.45 [0.26-0.79]) and the satisfactory psychological domain (adjusted HR = 0.56 [1.04-3.09]). When considering intrinsic capacity as a whole construct, using a composite Z-score, we noticed that the risk of death was decreased by 49% for an increase of 1 standard deviation in IC. Changes in intrinsic capacity in the mobility and psychological domains led to an increased risk of death (from 2.74 to 4.18-fold). CONCLUSION: The concept of intrinsic capacity seems highly relevant in order to assess older adults' health and well-being. This concept should be considered for integration into clinical practice.

The global approach to rehabilitation following an osteoporotic fragility fracture: A review of the rehabilitation working group of the International Osteoporosis Foundation (IOF) committee of scientific advisors.

PURPOSE: To conduct a review of the current state of the evidence for rehabilitation strategies post-fragility fracture. METHODS: Narrative review conducted by the Rehabilitation Working Group of the International Osteoporosis Foundation Committee of Scientific Advisors characterizing the range of rehabilitation modalities instrumental for the management of fragility fractures. RESULTS: Multi-modal exercise post-fragility fracture to the spine and hip is strongly recommended to reduce pain, improve physical function, and improve quality of life. Outpatient physiotherapy post-hip fracture has a stronger evidence base than outpatient physiotherapy post-vertebral fracture. Appropriate nutritional care after fragility fracture provides a large range of improvement in morbidity and mortality. Education increases understanding of osteoporosis which in turn increases utilization of other rehabilitation services. Education may improve other health outcomes such as pain and increase a patient's ability for self-advocacy. CONCLUSION: Rehabilitation interventions are inter-reliant, and research investigating the interaction of exercise, nutrition, and other multi-modal therapies may increase the relevance of rehabilitation research to clinical care.

Should We Worry About Nutrition Of Adults With Minor Burns? An Audit Of Their Intakes.

Small burn injuries are managed in an outpatient setting by surgeons and/or nurses. Nutrition in minor burn patients is rarely investigated. This observational study aimed to quantify their nutritional intakes, and o compare them to theoretical adequate values. Their average daily food intakes since injury were evaluated by a dietician using a ten-point visual assessment of consumed portions during the last meal (SEFI tool) and a food anamnesis. Macro- and micronutrient intakes were compared to national recommended dietary allowances (RDA) for healthy subjects: intakes <66% RDA were considered inadequate. Forty-two patients with a median age of 45 (34-56) years, BMI of 25.9 (23.5-28.9) kg/m2, and burn surface area (BSA) of 2 (1-3) % were included. Energy and protein RDA were reached in 28.6 and 71.4% of the patients, respectively. Intakes of n-3 fatty acids were inadequate in 80.9% of the patients. A SEFI <7 was associated with insufficient intakes regards both energy and proteins. Inadequate intakes of different micronutrients were frequently observed, but no risk factors could be detected. Vitamin A and C were the most impacted: 71.4% of the patients had inadequate intakes. Vitamin D intake was low: 225 (56-431) UI/d. In contrast, intakes of iron, selenium and zinc were adequate in at least 61.9% of the patients. In conclusion, this audit highlighted that a majority of macronutrient and micronutrient intakes did not reach the levels recommended by the RDA. Such data should help in designing further studies aimed at assessing the impact of optimized nutrition on outcomes.

Certains patients, souffrant de brûlures mineures, sont suivis en externe par des chirurgiens et/ou des infirmières. La nutrition de tels patients est rarement étudiée. Cette étude observationnelle a pour but de quantifier leurs apports nutritionnels et de les comparer aux apports théoriques nécessaires. Leurs apports moyens depuis la brûlure ont été évalués par une diététicienne en utilisant une échelle visuelle (0 à 10) d'évaluation des portions consommées lors du dernier repas (échelle SEFI) et un historique de leurs repas. Les apports macro- et micronutritionnels réels ont été comparés aux apports recommandés aux sujets sains, un apport <66 % étant considéré comme insuffisant. Quarante deux patients d'âge médian de 45 ans (34- 56), à l'IMC de 25,9 (23,5- 28,9) kg/m² et brûlés sur 2 % (1- 3) SCT ont été inclus. Les apports en énergie et protéines étaient suffisants dans 28,6 et 71,4 % des cas. Ceux en acides gras 3 étaient insuffisants dans 80,9 % des cas. Un SEFI < 7 était associé à des apports insuffisants aussi bien en calories qu'en protéines. Des apports insuffisants en micronutriments étaient fréquemment observés, sans facteur de risque particulier, les apports en vitamines A et C étant ceux ayant été le plus souvent considérés comme insuffisants (dans 71,4 % des cas). Les apports de vitamine D (225- 56/431) UI/j étaient faibles eux aussi. À l'opposé, les apports en Fe, Se et Zn étaient considérés comme satisfaisants chez au moins 61,9 % des patients. En conclusion, cette étude montre que les patients, dans leurs majorité, n'ingèrent pas les quantités de macro- et micronutriments recommandés. Elle peut servir de point de départ à des études évaluant l'impact d'une optimisation nutritionnelle dans cette situation.

An Assessment of the Toulouse Saint Louis University Mini Falls Assessment Tool to Predict Incident Falls among Older Adults Residing in Nursing Homes: A 6-Month Prospective Study.

OBJECTIVES: Toulouse Saint Louis University Mini Falls Assessment (TSLUMFA) tool has been designed to predict falls. It was initially validated in a geriatric clinic in 2018. The primary objective was to evaluate the predictive capacity of the TSLUMFA for incident falls in older adults residing in nursing homes. The secondary objective was to determine the TSLUMFA optimal cut-off value identifying those older adults with a high-risk of falling. SETTINGS: A longitudinal study was carried out over a period of six months. PARTICIPANTS: 93 older adults residing in nursing homes were evaluated for the present study. MEASUREMENTS: The TSLUMFA (made up of 7 criteria) was administered at baseline, and incident falls were recorded based on a registry of falls. Comparisons of TSLUMFA scores between fallers and non-fallers were performed using the U Mann-Whitney test or Chi². Correlation between the total TSLUMFA score (/30 points) and incident fall(s) was explored using the Cox proportional hazard model. ROC analysis enabled an optimal cut-off value to be established to identify those adults at the highest-risk of falling. RESULTS: In the study, 93 older adults (61.3% women) with a median age of 80 (69-87) years were included. The median total TSLUMFA score was 21 (19-24.5) points. During the 6-month study period, 38 subjects (40.9%) experienced at least one fall. The total TSLUMFA score in older adults with incident fall(s) was significantly lower than in those who did not fall (20 (15.75-22.25) points versus 23 (20-25) points and a p-value of <0.001). For each 1-point higher score at the total TSLUMFA a 9% less chance of falling was observed during the study period (p-value = 0.006). The AUC was 0.736 (95%CI: 0.617-0.822) and p-value <0.001, clearly demonstrating its interesting performance as a screening tool. A score of ≤ 21 points was identified as the optimal cut-off to identify those older adults at a higher-risk of falling. CONCLUSION: The TSLUMFA performed well and successfully identified older adults with a high risk of falling in a nursing home setting. Further comparisons with existing tools are warranted.

Development and validation of a short version of the Sarcopenia Quality of Life questionnaire: the SF-SarQoL.

PURPOSE: To facilitate the measurement of quality of life in sarcopenia, we set out to reduce the number of items in the previously validated Sarcopenia Quality of Life (SarQoL®) questionnaire, and to evaluate the clinimetric properties of this new short form. METHODS: The item reduction process was carried out in two phases. First, information was gathered through item-impact scores from older people (n = 1950), a Delphi method with sarcopenia experts, and previously published clinimetric data. In the second phase, this information was presented to an expert panel that decided which of the items to include in the short form. The newly created SFSarQoL was then administered to older, community-dwelling participants who previously participated in the SarcoPhAge study. We examined discriminative power, internal consistency, construct validity, test-retest reliability, structural validity and examined item parameters with a graded response model (IRT). RESULTS: The questionnaire was reduced from 55 to 14 items, a 75% reduction. A total of 214 older, community-dwelling people were recruited for the validation study. The clinimetric evaluation showed that the SF-SarQoL® can discriminate on sarcopenia status [EWGSOP2 criteria; 34.52 (18.59-43.45) vs. 42.86 (26.56-63.69); p = 0.043], is internally consistent (α = 0.915, ω = 0.917) and reliable [ICC = 0.912 (0.847-0.942)]. A unidimensional model was fitted (CFI = 0.978; TLI = 0.975; RMSEA = 0.108, 90% CI 0.094-0.123; SRMR = 0.055) with no misfitting items and good response category separation. CONCLUSIONS: A new, 14-item, short form version of the Sarcopenia Quality of Life questionnaire has been developed and shows good clinimetric properties.

Relationship between smoking and the incidence of sarcopenia: The SarcoPhAge cohort.

INTRODUCTION: The association of tobacco use and incidence of muscle impairments has not been extensively explored in research. In this study, the relationship between smoking and the incidence of sarcopenia is investigated. METHODS: The present longitudinal study used data from the Sarcopenia and Physical Impairment with advancing Age (SarcoPhAge) cohort, which includes older adults aged ≥65 years. All individuals with follow-up data on muscle health were included in this post hoc analysis. A diagnosis of sarcopenia was established, at each year of follow-up, according to the European Working Group on Sarcopenia in older People 2 (EWGSOP2) criteria. A sensitivity analysis was performed using other diagnostic criteria for sarcopenia. The smoking status and the number of cigarettes smoked per day were self-reported. The relationship between smoking status or the number of cigarettes smoked per day and the incidence of sarcopenia/severe sarcopenia throughout the 5 years of follow-up was evaluated using the Cox proportional hazards model. RESULTS: In total, the study population included 420 participants, with a median age of 71.7 years (P25-P75 = 67.7-76.9 years) and 59.8% were female. Over the 5 years of follow-up, 78 participants (18.6%) became sarcopenic as per the EWGSOP2 criteria and 41 individuals (9.8%) developed severe sarcopenia. There were significantly more smokers than non-smokers who developed sarcopenia (35.9% vs 16.8%, P-value = 0.003). A fully adjusted Cox model confirmed this observation, yielding a hazard ratio of 2.36 (95% confidence interval [CI]: 1.31-4.26), meaning that smokers have a 2.36-fold higher risk of developing sarcopenia. Furthermore, individuals who smoked had a 2.68 times increased risk of developing severe sarcopenia (95% CI: 1.21-5.93) than those who did not smoke. Sensitivity analyses globally confirmed these findings when applying other diagnostic criteria for sarcopenia. DISCUSSION: Smoking seems to be an important predictor for the onset of sarcopenia, highlighting, once again, that tobacco use is a major public health problem.

Determining individual trajectories of joint space loss: improved statistical methods for monitoring knee osteoarthritis disease progression.

OBJECTIVES: Knee osteoarthritis (KOA) progression is frequently monitored by calculating the change in knee joint space width (JSW) measurements. Such differences are small and sensitive to measurement error. We aimed to assess the utility of two alternative statistical modelling methods for monitoring KOA. MATERIAL AND METHODS: We used JSW on radiographs from both the control arm of the Strontium Ranelate Efficacy in Knee Osteoarthritis trial (SEKOIA), a 3-year multicentre, double-blind, placebo-controlled phase three trial, and the Osteoarthritis Initiative (OAI), an open-access longitudinal dataset from the USA comprising participants followed over 8 years. Individual estimates of annualised change obtained from frequentist linear mixed effect (LME) and Bayesian hierarchical modelling, were compared with annualised crude change, and the association of these parameters with change in WOMAC pain was examined. RESULTS: Mean annualised JSW changes were comparable for all estimates, a reduction of around 0.14 mm/y in SEKOIA and 0.08 mm/y in OAI. The standard deviation (SD) of change estimates was lower with LME and Bayesian modelling than crude change (SEKOIA SD = 0.12, 0.12 and 0.21 respectively; OAI SD = 0.08, 0.08 and 0.11 respectively). Estimates from LME and Bayesian modelling were statistically significant predictors of change in pain in SEKOIA (LME P-value = 0.04, Bayes P-value = 0.04), while crude change did not predict change in pain (P-value = 0.10). CONCLUSIONS: Implementation of LME or Bayesian modelling in clinical trials and epidemiological studies, would reduce sample sizes by enabling all study participants to be included in analysis regardless of incomplete follow up, and precision of change estimates would improve. They provide increased power to detect associations with other measures.

Clinical Impact of Nutritional Status and Energy Balance in Elderly Hospitalized Patients.

OBJECTIVES: This study aimed 1) to assess the nutritional status of patients hospitalized in a geriatric ward using the recent Global Leadership Initiative on Malnutrition (GLIM) criteria, 2) to determine the balance between the energy intake (EI) with an enriched diet and the energy requirement (ER) using indirect calorimetry, and 3) to assess whether undernutrition is associated with 1-year outcome. DESIGN: This is a prospective cross-sectional study. SETTING: This study was performed in a geriatric unit. PARTICIPANTS: Patients of this geriatric unit were eligible for the study if they agreed to participate and if they did not meet the exclusion criteria (presence of malignant tumour, uncontrolled heart or renal failure, thyroidal disease, uncontrolled sepsis, oedema of the lower limbs, wearing of a pacemaker, biological thyroid dysfunction and inability to perform walking tests). MEASUREMENTS: Rest energy expenditure (REE) was measured by indirect calorimetry within the week of hospitalization. Total energy expenditure (TEE) was obtained by multiplying REE by a physical activity level coefficient and energy expenditure that was related to thermogenesis (i.e., 10% of the total amount of energy ingested over 24 h) was added. Food intake was measured over a 3-day period. Undernutrition was defined using MNA and the criteria of the GLIM leadership. Clinical outcomes included 1-year institutionalisation and mortality. RESULTS: Seventy-nine patients (84.9 ± 5.3 years) were included. A total of 21 (26.6 %) patients were found undernourished. REE was 1088 ± 181kcal/day (17.8 ± 2.9 kcal/kg/day) and TEE was 1556 ± 258 kcal/day (25.4 ± 4.2 kcal/kg/day). Weight-adjusted REE and TEE were higher in undernourished patients compared to those well-nourished (19.8 ± 3.1 vs. 17.1 ± 2.6 kcal/day and 28.4±4.5 vs. 24.4±3.7 kcal/day) (p<0.05). The lower was the Body Mass Index (BMI), the higher was the energy needs (p<0.01). EI was significantly greater than energy requirements (difference requirements - intake with enriched diet = -354 ± 491 kcal/day; p<0.0001). This difference did not depend on BMI (p=0.82), appendicular skeletal mass index (ASMI) (p=0.63), or the presence of undernutrition (p=0.33). At 1-year follow-up, 15 (19%) patients died and 20 (25.6%) were institutionalized. On multivariable analysis, male gender (OR=5.63; p=0.015) and undernutrition (OR=7.29; p=0.0043) emerged as independently associated with death. On multivariable analysis, only ASMI (OR 0.59 (0.35-0.99), p=0.044) and activities of daily living (ADL) (OR 1.14 (1.00-1.30), p=0.043) were significantly associated with institutionalization. CONCLUSIONS: Undernutrition as assessed by the GLIM criteria remains common in elderly patients hospitalized in a geriatric unit and is associated with increased 1-year mortality but not with institutionalization. Energy requirements are higher in undernourished patients and in patients with a low BMI. Enriched energy intakes could sufficiently cover the energy needs of this population.

Symptomatic Efficacy of Pharmacological Treatments for Knee Osteoarthritis: A Systematic Review and a Network Meta-Analysis with a 6-Month Time Horizon.

INTRODUCTION: Several pharmacological treatments aiming at a better symptomatic control of osteoarthritis (OA) are used in daily practice but their efficacy is often disputed. The purpose of this network meta-analysis (NMA) is to assess the efficacy on pain and function of the drugs that are most widely prescribed against knee OA. METHODS: Medline, Scopus, and Cochrane database of systematic reviews were searched for randomized controlled trials published up to August 2019 and assessing the efficacy of knee OA treatments using a 6-month time horizon. Pain and function changes from baseline were the primary outcomes. A Bayesian network meta-analysis was run and standardized mean differences (SMDs) with 95% credibility intervals (95% CrIs) were calculated. RESULTS: 9697 references were identified and 80 RCTs were concordant with our inclusion criteria (79 studies involving 15,609 individuals reported pain outcomes and 55 studies involving 13,655 individuals reported function outcomes). A significant decrease in pain was observed for the intra-articular (IA) combination of hyaluronic acid (HA) and triamcinolone (SMD - 0.49, 95% CrI - 0.78; - 0.19), vitamin D (SMD - 0.31, 95% CrI - 0.56; - 0.06), IA HA (SMD - 0.29, 95% CrI - 0.40; - 0.17), prescription-grade crystalline glucosamine sulfate (pCGS) (SMD - 0.29, 95% CrI - 0.58; - 0.004), and prescription-grade chondroitin sulfate (pCS) (SMD - 0.26, 95% CrI - 0.44; - 0.08). Significant improvements in physical function were found with pCGS (SMD - 0.44, 95% CrI - 0.66; - 0.21), vitamin D (SMD - 0.30, 95% CrIs - 0.49; - 0.11) and IA HA (SMD - 0.21, 95% CrIs - 0.31; - 0.11). CONCLUSION: Six months of treatment with IA HA, pCGS, pCS, vitamin D and the combination of IA HA and triamcinolone improve pain and/or physical function in patients suffering from knee OA.

The Belgian Bone Club 2020 guidelines for the management of osteoporosis in postmenopausal women.

PURPOSE: To provide updated evidence-based guidelines for the management of osteoporosis in postmenopausal women in Belgium. METHODS: The Belgian Bone Club (BBC) gathered a guideline developer group. Nine "Population, Intervention, Comparator, Outcome" (PICO) questions covering screening, diagnosis, non-pharmacological and pharmacological treatments, and monitoring were formulated. A systematic search of MEDLINE, the Cochrane Database of Systematic Reviews, and Scopus was performed to find network meta-analyses, meta-analyses, systematic reviews, guidelines, and recommendations from scientific societies published in the last 10 years. Manual searches were also performed. Summaries of evidence were provided, and recommendations were further validated by the BBC board members and other national scientific societies' experts. RESULTS: Of the 3840 references in the search, 333 full texts were assessed for eligibility, and 129 met the inclusion criteria. Osteoporosis screening using clinical risk factors should be considered. Patients with a recent (<2 years) major osteoporotic fracture were considered at very high and imminent risk of future fracture. The combination of bone mineral density measured by dual-energy X-ray absorptiometry and 10-year fracture risk was used to categorize patients as low or high risk. Patient education, the combination of weight-bearing and resistance training, and optimal calcium intake and vitamin D status were recommended. Antiresorptive and anabolic osteoporosis treatment should be considered for patients at high and very high fracture risk, respectively. Follow-up should focus on compliance, and patient-tailored monitoring should be considered. CONCLUSION: BBC guidelines and 25 guideline recommendations bridge the gap between research and clinical practice for the screening, diagnosis, and management of osteoporosis.

Assessment of Cardiovascular Safety of Anti-Osteoporosis Drugs.

The incidence of osteoporosis and cardiovascular disease increases with age, and there are potentially shared mechanistic associations between the two conditions. It is therefore highly relevant to understand the cardiovascular implications of osteoporosis medications. These are presented in this narrative review. Calcium supplementation could theoretically cause atheroma formation via calcium deposition, and in one study was found to be associated with myocardial infarction, but this has not been replicated. Vitamin D supplementation has been extensively investigated for cardiac benefit, but no consistent effect has been found. Despite findings in the early 21st century that menopausal hormone therapy was associated with coronary artery disease and venous thromboembolism (VTE), this therapy is now thought to be potentially safe (from a cardiac perspective) if started within the first 10 years of the menopause. Selective estrogen receptor modulators (SERMs) are associated with increased risk of VTE and may be related to fatal strokes (a subset of total strokes). Bisphosphonates could theoretically provide protection against atheroma. However, data from randomised trials and observational studies have neither robustly supported this nor consistently demonstrated the potential association with atrial fibrillation. Denosumab does not appear to be associated with cardiovascular disease and, although parathyroid hormone analogues are associated with palpitations and dizziness, no association with a defined cardiovascular pathology has been demonstrated. Finally, romosozumab has been shown to have a possible cardiovascular signal, and therefore post-market surveillance of this therapy will be vital.

How to manage osteoporosis before the age of 50.

This narrative review discusses several aspects of the management of osteoporosis in patients under 50 years of age. Peak bone mass is genetically determined but can also be affected by lifestyle factors. Puberty constitutes a vulnerable period. Idiopathic osteoporosis is a rare, heterogeneous condition in young adults due in part to decreased osteoblast function and deficient bone acquisition. There are no evidence-based treatment recommendations. Drugs use can be proposed to elderly patients at very high risk. Diagnosis and management of osteoporosis in the young can be challenging, in particular in the absence of a manifest secondary cause. Young adults with low bone mineral density (BMD) do not necessarily have osteoporosis and it is important to avoid unnecessary treatment. A determination of BMD is recommended for premenopausal women who have had a fragility fracture or who have secondary causes of osteoporosis: secondary causes of excessive bone loss need to be excluded and treatment should be targeted. Adequate calcium, vitamin D, and a healthy lifestyle should be recommended. In the absence of fractures, conservative management is generally sufficient, but in rare cases, such as chemotherapy-induced osteoporosis, antiresorptive medication can be used. Osteoporosis in young men is most often of secondary origin and hypogonadism is a major cause; testosterone replacement therapy will improve BMD in these patients. Diabetes is characterized by major alterations in bone quality, implying that medical therapy should be started sooner than for other causes of osteoporosis. Primary hyperparathyroidism, hyperthyroidism, Cushing's syndrome and growth hormone deficiency or excess affect cortical bone more often than trabecular bone.

Alternative and complementary therapies in osteoarthritis and cartilage repair.

Osteoarthritis (OA) is the most common joint condition and, with a burgeoning ageing population, is due to increase in prevalence. Beyond conventional medical and surgical interventions, there are an increasing number of 'alternative' therapies. These alternative therapies may have a limited evidence base and, for this reason, are often only afforded brief reference (or completely excluded) from current OA guidelines. Thus, the aim of this review was to synthesize the current evidence regarding autologous chondrocyte implantation (ACI), mesenchymal stem cell (MSC) therapy, platelet-rich plasma (PRP), vitamin D and other alternative therapies. The majority of studies were in knee OA or chondral defects. Matrix-assisted ACI has demonstrated exceedingly limited, symptomatic improvements in the treatment of cartilage defects of the knee and is not supported for the treatment of knee OA. There is some evidence to suggest symptomatic improvement with MSC injection in knee OA, with the suggestion of minimal structural improvement demonstrated on MRI and there are positive signals that PRP may also lead to symptomatic improvement, though variation in preparation makes inter-study comparison difficult. There is variability in findings with vitamin D supplementation in OA, and the only recommendation which can be made, at this time, is for replacement when vitamin D is deplete. Other alternative therapies reviewed have some evidence (though from small, poor-quality studies) to support improvement in symptoms and again there is often a wide variation in dosage and regimens. For all these therapeutic modalities, although controlled studies have been undertaken to evaluate effectiveness in OA, these have often been of small size, limited statistical power, uncertain blindness and using various methodologies. These deficiencies must leave the question as to whether they have been validated as effective therapies in OA (or chondral defects). The conclusions of this review are that all alternative interventions definitely require clinical trials with robust methodology, to assess their efficacy and safety in the treatment of OA beyond contextual and placebo effects.

Correction to: Algorithm for the management of patients at low, high and very high risk of osteoporotic fractures.

The article 'Algorithm for the management of patients at low, high and very high risk of osteoporotic fractures',written by J. A. Kanis, was originally published Online First without Open Access. After publication in volume [#], issue [#] and page [#-#], the author decided to opt for Open Choice and to make the article an Open Access publication.