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Gates M, Pillay J, Thériault G, Limburg H, Grad R, Klarenbach S, Korownyk C, Reynolds D, Riva JJ, Thombs BD, Kline GA, Leslie WD, Courage S, Vandermeer B, Featherstone R, Hartling L. Screening to prevent fragility fractures among adults 40 years and older in primary care: protocol for a systematic review. Syst Rev 2019; 8:216. [PMID: 31443711 PMCID: PMC6706906 DOI: 10.1186/s13643-019-1094-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 07/02/2019] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To inform recommendations by the Canadian Task Force on Preventive Health Care by systematically reviewing direct evidence on the effectiveness and acceptability of screening adults 40 years and older in primary care to reduce fragility fractures and related mortality and morbidity, and indirect evidence on the accuracy of fracture risk prediction tools. Evidence on the benefits and harms of pharmacological treatment will be reviewed, if needed to meaningfully influence the Task Force's decision-making. METHODS A modified update of an existing systematic review will evaluate screening effectiveness, the accuracy of screening tools, and treatment benefits. For treatment harms, we will integrate studies from existing systematic reviews. A de novo review on acceptability will be conducted. Peer-reviewed searches (Medline, Embase, Cochrane Library, PsycINFO [acceptability only]), grey literature, and hand searches of reviews and included studies will update the literature. Based on pre-specified criteria, we will screen studies for inclusion following a liberal-accelerated approach. Final inclusion will be based on consensus. Data extraction for study results will be performed independently by two reviewers while other data will be verified by a second reviewer; there may be some reliance on extracted data from the existing reviews. The risk of bias assessments reported in the existing reviews will be verified and for new studies will be performed independently. When appropriate, results will be pooled using either pairwise random effects meta-analysis (screening and treatment) or restricted maximum likelihood estimation with Hartun-Knapp-Sidnick-Jonkman correction (risk prediction model calibration). Subgroups of interest to explain heterogeneity are age, sex, and menopausal status. Two independent reviewers will rate the certainty of evidence using the GRADE approach, with consensus reached for each outcome rated as critical or important by the Task Force. DISCUSSION Since the publication of other guidance in Canada, new trials have been published that are likely to improve understanding of screening in primary care settings to prevent fragility fractures. A systematic review is required to inform updated recommendations that align with the current evidence base.
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Affiliation(s)
- Michelle Gates
- Alberta Research Centre for Health Evidence, University of Alberta, 11405 87 Avenue, Edmonton, Alberta T6G 1C9 Canada
| | - Jennifer Pillay
- Alberta Research Centre for Health Evidence, University of Alberta, 11405 87 Avenue, Edmonton, Alberta T6G 1C9 Canada
| | | | - Heather Limburg
- Global Health and Guidelines Division, Public Health Agency of Canada, Ottawa, Canada
| | - Roland Grad
- Department of Family Medicine, McGill University, Montreal, Canada
| | | | | | - Donna Reynolds
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - John J. Riva
- Department of Family Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Brett D. Thombs
- Faculty of Medicine, McGill University and Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada
| | | | - William D. Leslie
- Department of Medicine (Endocrinology), University of Manitoba, Winnipeg, Canada
- Department of Radiology (Nuclear Medicine), University of Manitoba, Winnipeg, Canada
| | - Susan Courage
- Global Health and Guidelines Division, Public Health Agency of Canada, Ottawa, Canada
| | - Ben Vandermeer
- Alberta Research Centre for Health Evidence, University of Alberta, 11405 87 Avenue, Edmonton, Alberta T6G 1C9 Canada
| | - Robin Featherstone
- Alberta Research Centre for Health Evidence, University of Alberta, 11405 87 Avenue, Edmonton, Alberta T6G 1C9 Canada
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence, University of Alberta, 11405 87 Avenue, Edmonton, Alberta T6G 1C9 Canada
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Prieto-Alhambra D, Reyes C, Sainz MS, González-Macías J, Delgado LG, Bouzón CA, Gañan SM, Miedes DM, Vaquero-Cervino E, Bardaji MFB, Herrando LE, Baztán FB, Ferrer BL, Perez-Coto I, Bueno GA, Mora-Fernandez J, Doñate TE, Blasco JMI, Aguado-Maestro I, Sáez-López P, Doménech MS, Climent-Peris V, Rodríguez ÁD, Sardiñas HK, Gómez ÓT, Serra JT, Caeiro-Rey JR, Cano IA, Carsi MB, Etxebarria-Foronda I, Hernández JDA, Solis JR, Suau OT, Nogués X, Herrera A, Díez-Perez A. In-hospital care, complications, and 4-month mortality following a hip or proximal femur fracture: the Spanish registry of osteoporotic femur fractures prospective cohort study. Arch Osteoporos 2018; 13:96. [PMID: 30218380 PMCID: PMC6153683 DOI: 10.1007/s11657-018-0515-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 08/31/2018] [Indexed: 02/03/2023]
Abstract
UNLABELLED We have characterised 997 hip fracture patients from a representative 45 Spanish hospitals, and followed them up prospectively for up to 4 months. Despite suboptimal surgical delays (average 59.1 hours), in-hospital mortality was lower than in Northern European cohorts. The secondary fracture prevention gap is unacceptably high at 85%. PURPOSE To characterise inpatient care, complications, and 4-month mortality following a hip or proximal femur fracture in Spain. METHODS Design: prospective cohort study. Consecutive sample of patients ≥ 50 years old admitted in a representative 45 hospitals for a hip or proximal femur fragility fracture, from June 2014 to June 2016 and followed up for 4 months post-fracture. Patient characteristics, site of fracture, in-patient care (including secondary fracture prevention) and complications, and 4-month mortality are described. RESULTS A total of 997 subjects (765 women) of mean (standard deviation) age 83.6 (8.4) years were included. Previous history of fracture/s (36.9%) and falls (43%) were common, and 10-year FRAX-estimated major and hip fracture risks were 15.2% (9.0%) and 8.5% (7.6%) respectively. Inter-trochanteric (44.6%) and displaced intra-capsular (28.0%) were the most common fracture sites, and fixation with short intramedullary nail (38.6%) with spinal anaesthesia (75.5%) the most common procedures. Surgery and rehabilitation were initiated within a mean 59.1 (56.7) and 61.9 (55.1) hours respectively, and average length of stay was 11.5 (9.3) days. Antithrombotic and antibiotic prophylaxis were given to 99.8% and 98.2% respectively, whilst only 12.4% received secondary fracture prevention at discharge. Common complications included delirium (36.1 %) and kidney failure (14.1%), with in-hospital and 4-month mortality of 2.1% and 11% respectively. CONCLUSIONS Despite suboptimal surgical delay, post-hip fracture mortality is low in Spanish hospitals. The secondary fracture prevention gap is unacceptably high at > 85%, in spite of virtually universal anti-thrombotic and antibiotic prophylaxis.
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Affiliation(s)
- Daniel Prieto-Alhambra
- GREMPAL (Grup de Recerca en Epidemiologia de les Malalties Prevalents de l’Aparell Locomotor) Research Group, CIBERFES, IDIAP Jordi Gol (Universitat Autònoma de Barcelona) and Instituto de Salud Carlos III, Av Gran Via de les Corts Catalanes, 587, Atic, 08007 Barcelona, Spain ,Musculoskeletal Pharmaco and Device Epidemiology – Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Windmill Road, Oxford, OX3 7LD UK ,Musculoskeletal Research Unit, IMIM-Parc Salut Mar, CIBERFES, Universitat Autònoma de Barcelona, Doctor Aiguader 88, 08003 Barcelona, Spain
| | - Carlen Reyes
- GREMPAL (Grup de Recerca en Epidemiologia de les Malalties Prevalents de l’Aparell Locomotor) Research Group, CIBERFES, IDIAP Jordi Gol (Universitat Autònoma de Barcelona) and Instituto de Salud Carlos III, Av Gran Via de les Corts Catalanes, 587, Atic, 08007 Barcelona, Spain
| | - Miguel Sanz Sainz
- IIS Aragón (Instituto de Investigación Sanitaria de Aragón), Hospital Universitario Miguel Servet, Padre Arrupe, s/n, 50009 Zaragoza, Spain
| | - Jesús González-Macías
- IDIVAL (Instituto de Investigación Marqués de Valdecilla), HUMV (Hospital Universitario Marqués de Valdecilla), UC (Universidad de Cantabria), Av de Valdecilla sn, 39011 Santander, Cantabria Spain
| | - Luis Gracia Delgado
- Hospital Universitario Reina Sofía de Cordoba, Av Menendez Pidal, 14004 Córdoba, Spain
| | - Cristina Alonso Bouzón
- Geriatric Unit, Hospital Universitario de Getafe, Carr. De Madrid – Toledo, Km 12,500, 28905 Getafe, Madrid Spain
| | - Sarah Mills Gañan
- Traumatology and Orthopaedics Unit, Hospital Universitario La Paz, Paseo de la Castellana, 261, 28046 Madrid, Spain
| | | | | | | | - Laura Ezquerra Herrando
- F.E.A of the Traumatology and Orthopaedics Unit, Hospital Clínico Universitario Lozano Blesa, Av. San Juan Bosco, 15, 50009 Zaragoza, Spain
| | - Fátima Brañas Baztán
- Geriatric Unit, Hospital Universitario Infanta Leonor, Gran Vía del Este, 80, 28031 Madrid, Spain
| | - Bartolomé Lladó Ferrer
- Hospital Son Llàtzer, Carretera de Manacor, PQ 4 (Son Ferriol), 07198 Palma de Mallorca, Spain
| | - Ivan Perez-Coto
- Hospital Universitario San Agustín, Camino de Heros, 6, 33401 Avilés, Asturias Spain
| | - Gaspar Adrados Bueno
- Internal Medicine Unit, Hospital Infanta Cristina, Av. de Elvas, s/n, 06080 Badajoz, Spain
| | - Jesús Mora-Fernandez
- Geriatric Unit, Hospital Clínico San Carlos, calle Prof. Martín Lagos s/n, 28040 Madrid, Spain
| | | | | | | | - Pilar Sáez-López
- Hospital Universitario Fundación Jiménez Díaz, IdiPAZ (Instituto de Investigación del Hospital La Paz), Madrid, Spain
| | - Monica Salomó Doménech
- Corporación sanitaria Universitaria Parc Tauli, Parc Taulí, 1, 08208 Sabadell, Barcelona Spain
| | - Vicente Climent-Peris
- Traumatology and Orthopaedics Unit, Hospital Públic Lluis Alcanyis de Xàtiva, Carretera Xátiva-Silla, Km 2, 46800 Xàtiva, Valencia Spain
| | - Ángel Díez Rodríguez
- Traumatology and Orthopaedics Unit, Hospital Virgen del Puerto, Paraje Valcorchero, 10600 Plasencia, Cáceres Spain
| | - Humberto Kessel Sardiñas
- Geriatric Care Unit, Complejo Hospitalario Torrecárdenas, Calle Hermandad de Donantes de Sangre, 04009 Almería, Spain
| | - Óscar Tendero Gómez
- Hospital Universitari Son Espases, Carr. de Valldemossa, 79, 07120 Palma, Islas Baleares Spain
| | - Jordi Teixidor Serra
- Hospital Universitari Vall de Hebron, Passeig de la Vall d’Hebron, 119-129, 08035 Barcelona, Spain
| | - José Ramón Caeiro-Rey
- Traumatology and Orthopaedics Unit, Complejo Hospitalario Universitario de Santiago de Compostela, Rúa da Choupana, s/n, 15706 Santiago de Compostela, A Coruña Spain
| | | | - Mariano Barrés Carsi
- Hospital Universitari i Politècnic La Fe, Av de Fernando Abril Martorell, 106, 46026 València, Spain
| | | | - Juan Dionisio Avilés Hernández
- Orthogeriatric Unit, Hospital Clínico Universitario Virgen de Arrixaca, Ctra. Madrid-Cartagena, s/n, 30120 El Palmar, Murcia Spain
| | - Juan Rodriguez Solis
- Geriatric Unit, Hospital Universitario de Guadalajara, Calle Donante de Sangre, s/n, 19002 Guadalajara, Spain
| | - Oscar Torregrosa Suau
- Bone Metabolism Unit, Internal Medicine Unit, Hospital General Universitari d’Elx, Carrer Almazara, 11, 03203 Elche, Alicante Spain
| | - Xavier Nogués
- Internal Medicine Department IMIM (Hospital del Mar Medical Research), CIBER FES ISCIII, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Antonio Herrera
- Department of Surgery, Aragón Health Research Institute, University of Zaragoza, Zaragoza, Spain
| | - Adolfo Díez-Perez
- Musculoskeletal Research Unit, IMIM-Parc Salut Mar, CIBERFES, Universitat Autònoma de Barcelona, Doctor Aiguader 88, 08003 Barcelona, Spain
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Kanis JA, Harvey NC, Cooper C, Johansson H, Odén A, McCloskey EV. A systematic review of intervention thresholds based on FRAX : A report prepared for the National Osteoporosis Guideline Group and the International Osteoporosis Foundation. Arch Osteoporos 2016; 11:25. [PMID: 27465509 PMCID: PMC4978487 DOI: 10.1007/s11657-016-0278-z] [Citation(s) in RCA: 269] [Impact Index Per Article: 33.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 06/16/2016] [Indexed: 02/03/2023]
Abstract
UNLABELLED This systematic review identified assessment guidelines for osteoporosis that incorporate FRAX. The rationale for intervention thresholds is given in a minority of papers. Intervention thresholds (fixed or age-dependent) need to be country-specific. INTRODUCTION In most assessment guidelines, treatment for osteoporosis is recommended in individuals with prior fragility fractures, especially fractures at spine and hip. However, for those without prior fractures, the intervention thresholds can be derived using different methods. The aim of this report was to undertake a systematic review of the available information on the use of FRAX® in assessment guidelines, in particular the setting of thresholds and their validation. METHODS We identified 120 guidelines or academic papers that incorporated FRAX of which 38 provided no clear statement on how the fracture probabilities derived are to be used in decision-making in clinical practice. The remainder recommended a fixed intervention threshold (n = 58), most commonly as a component of more complex guidance (e.g. bone mineral density (BMD) thresholds) or an age-dependent threshold (n = 22). Two guidelines have adopted both age-dependent and fixed thresholds. RESULTS Fixed probability thresholds have ranged from 4 to 20 % for a major fracture and 1.3-5 % for hip fracture. More than one half (39) of the 58 publications identified utilised a threshold probability of 20 % for a major osteoporotic fracture, many of which also mention a hip fracture probability of 3 % as an alternative intervention threshold. In nearly all instances, no rationale is provided other than that this was the threshold used by the National Osteoporosis Foundation of the USA. Where undertaken, fixed probability thresholds have been determined from tests of discrimination (Hong Kong), health economic assessment (USA, Switzerland), to match the prevalence of osteoporosis (China) or to align with pre-existing guidelines or reimbursement criteria (Japan, Poland). Age-dependent intervention thresholds, first developed by the National Osteoporosis Guideline Group (NOGG), are based on the rationale that if a woman with a prior fragility fracture is eligible for treatment, then, at any given age, a man or woman with the same fracture probability but in the absence of a previous fracture (i.e. at the 'fracture threshold') should also be eligible. Under current NOGG guidelines, based on age-dependent probability thresholds, inequalities in access to therapy arise especially at older ages (≥70 years) depending on the presence or absence of a prior fracture. An alternative threshold using a hybrid model reduces this disparity. CONCLUSION The use of FRAX (fixed or age-dependent thresholds) as the gateway to assessment identifies individuals at high risk more effectively than the use of BMD. However, the setting of intervention thresholds needs to be country-specific.
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Affiliation(s)
- John A Kanis
- Centre for Metabolic Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK.
- Institute of Health and Ageing, Australian Catholic University, Melbourne, Australia.
| | - Nicholas C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Helena Johansson
- Centre for Metabolic Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK
| | - Anders Odén
- Centre for Metabolic Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK
| | - Eugene V McCloskey
- Centre for Metabolic Diseases, University of Sheffield Medical School, Beech Hill Road, Sheffield, S10 2RX, UK
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5
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Etxebarria-Foronda I, Carpintero P. An atypical fracture in male patient with osteogenesis imperfecta. CLINICAL CASES IN MINERAL AND BONE METABOLISM 2015; 12:278-81. [PMID: 26811713 DOI: 10.11138/ccmbm/2015.12.3.278] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Abstract
So-called atypical fractures have been related to prolonged treatment with bisphosphonates. Although there remain unanswered questions with respect to their etiology and physiopathology, it does appear to be a causal relationship. There are many references in the literature about this problem in patients in whom these drugs have been used to treat osteoporosis, but few reports in patients who have received this therapy for the management of osteogenesis imperfecta. The Authors describe a case of a young male patient with osteogenesis imperfecta with a number of historical fractures, and who received treatment with these drugs, initially parenterally and subsequently orally, presenting as a complication of the treatment, an atypical diaphyseal femoral fracture. The characteristics of the fracture are consistent with the updated diagnostic criteria of the American Society for Bone and Mineral Research. The clinical case, its treatment, both surgically and metabolically with teriparatide, and its development over a year, are analysed. The case is notable for, on the one hand, the significance of the presence of this type of fracture in a young patient with this disease, and on the other, because of the administration of teriparatide outside its established clinical indications, with twin objectives: to improve the bone structure of the patient's underlying disease, and to counteract the harmful effects which bisphosphonates may have on this bone.
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Affiliation(s)
| | - Pedro Carpintero
- Orthopaedic Surgery and Traumatology Department, Reina Sofia University Hospital, Córdoba, Spain
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