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Lewandowski DA, Badurudeen A, Matthews T. The Impact of Concomitant Neck of Femur Fractures and Upper Limb Fractures on Length of Stay and Key Performance Indicators: A Single-Centre Study. Cureus 2024; 16:e60862. [PMID: 38910742 PMCID: PMC11192213 DOI: 10.7759/cureus.60862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2024] [Indexed: 06/25/2024] Open
Abstract
Background Hip fractures are one of the most common serious injuries seen today and constitute one of the most serious healthcare problems affecting the elderly worldwide. Due to the elderly population, associated falls and osteoporosis increase the incidence of hip fractures. Patients may remain hospitalized for several weeks, leading to one and a half million hospital bed days used each year. The reported incidence of a concurrent upper limb and a lower limb fracture is between 3% and 5%. It has been shown in the literature that patients who sustain both a hip fracture and an upper limb fracture have difficulties with rehabilitation which causes prolonged stays. The available literature on concomitant hip fracture and upper extremity fracture is limited. This study aimed to review patients with concurrent upper limb injury and hip fractures and to analyse the pattern of associated upper limb fractures, management of these fractures, length of hospital stay, mortality rates, and complications. Methodology We performed a retrospective data collection of all patients with a concomitant upper limb fracture and hip fracture from January 2017 to December 2020 at the University Hospital of Wales, Cardiff, United Kingdom. Patients were identified from the registers maintained in the ward. All patients aged over 60 years with a fragility hip fracture (managed operatively) and a concurrent upper limb fracture were included in the study. Patients aged less than 60 years were excluded. The local research department registered and approved this study as a service evaluation and therefore did not need ethical committee approval. The anatomical location of the upper limb and hip fractures was confirmed using the imaging database (Synapse). Results Of the 760 patients admitted with neck of femur fractures during this period, 39 (5.1%) patients had concomitant upper limb fractures. Only one upper limb fracture was managed with fixation, and for this study, that patient was excluded. Our retrospective search identified 38 patients, of whom 11 were men and 27 were women. Distal radius fractures were the most commonly associated upper limb fractures (55%). There was a significant increase in length of stay (43.6 days vs. 16.6 days) and delay in mobilization (58.9% vs. 81%) compared to an isolated hip fracture. There was no difference in the 30-day mortality rates. We were unable to collect the data for the Key Performance Indicator (KPI) of the National Institute for Health and Care Excellence compliant surgery, and this KPI was excluded from our study. Of the remaining five KPIs, our group of patients displayed better averages in three of the five categories, including prompt orthogeriatric review (92%), not delirious postoperatively (87%), and return to original residence (79%). Conclusions Due to the ageing population, hip fractures are increasing, and within one year of operation, have shown higher mortality rates. Annually, reports show that the worldwide incidence of fractures in the adult population ranges between 9.0 and 22.8 per 1,000. These fractures are more frequent in osteoporotic patients with weak bone quality. Following hip fractures, upper extremity fractures are the second most common among the osteoporotic, elderly population, with distal radius fractures being the most common. With the length of stay almost tripled (from 16.6 to 44.4 days), one can see this has a very big effect on costs in the National Health Service system.
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Affiliation(s)
| | - Abdul Badurudeen
- Trauma and Orthopaedics, University Hospital of Wales, Cardiff, GBR
| | - Tim Matthews
- Trauma and Orthopaedics, University Hospital of Wales, Cardiff, GBR
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Kelly M. Implementing findings from (hip) fracture registries. Injury 2023; 54 Suppl 5:110961. [PMID: 37563044 DOI: 10.1016/j.injury.2023.110961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 08/12/2023]
Abstract
The National Health Service in England has successfully used learning from its National Hip Fracture Database to drive improvements in care of the most frail orthopaedic trauma patients. While this could simply be viewed as achieving its primary function, the learning with regard to meaningful change that resulted has been applied across the other aspects of trauma to achieve improvements including multiply injured patients within trauma systems (Trauma Audit and Research Network (TARN)) and community level trauma. This work looks at the lessons that can be learned through the inception and running of a national database, in particular how it can be used as a template to achieve improved care in other aspects of orthopaedic trauma. It explains the UK system and the navigation of this to gain political and administrative traction in the creation of a national network and how this momentum was used to achieve a complete overhaul of the trauma system. There are lessons that are applicable across all healthcare systems.
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Affiliation(s)
- Michael Kelly
- North Bristol NHS Trust, Southmead Road, Bristol, BS10 5NB, UK.
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Fluck D, Lisk R, Yeong K, Mahmood R, Robin J, Fry CH, Han TS. Sex differences in clinical outcomes amongst 1105 patients admitted with hip fractures. Intern Emerg Med 2023; 18:1561-1568. [PMID: 37101056 DOI: 10.1007/s11739-023-03264-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 03/31/2023] [Indexed: 04/28/2023]
Abstract
Amongst hip fracture admissions, mortality is higher in men than in women. However, sex differences in other care-quality measures have not been well-documented. We aimed to examine sex differences in mortality as well as a wide range of underlying health indicators and clinical outcomes in adults ≥ 60 year of age admitted with hip fractures from their own homes to a single NHS hospital between April-2009 and June-2019. Sex differences in delirium, length of stay (LOS) and mortality in hospital, readmission, and discharge destination, were examined by logistic regression. There were 787 women and 318 men of similar mean age (± SD): 83.1 year (± 8.6) and 82.5 year (± 9.0), respectively (P = 0.269). There were no sex differences in history of dementia or diabetes, anticholinergic burden, pre-fracture physical function, American Society of Anesthesiologists grades, or surgical and medical management. Stroke and ischaemic heart disease, polypharmacy, and alcohol consumption were more common in men. After adjustment for these differences and age, men had greater risk of delirium (with or without cognitive impairment) within one day of surgery: OR = 1.75 (95%CI 1.14-2.68), LOS ≥ 3 weeks in hospital: OR = 1.52 (1.07-2.16), mortality in hospital: OR = 2.04 (1.14-3.64), and readmission once or more after 30 days of a discharge: OR = 1.53 (1.03-2.31). Men had a lower risk of a new discharge to residential/nursing care: OR = 0.46 (0.23-0.93). The present study revealed that, in addition to a greater risk of mortality than women, men also had many other adverse health outcomes. These findings, which have not been well-documented, serve to stimulate future targeted preventive strategies and research.
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Affiliation(s)
- David Fluck
- Department of Cardiology, Ashford and St Peter's NHS Foundation Trust, Guildford Road, Chertsey, KT16 0PZ, Surrey, UK
| | - Radcliffe Lisk
- Department of Orthopaedic Trauma, Ashford and St Peter's NHS Foundation Trust, Guildford Road, Chertsey, KT16 0PZ, Surrey, UK
| | - Keefai Yeong
- Department of Orthopaedic Trauma, Ashford and St Peter's NHS Foundation Trust, Guildford Road, Chertsey, KT16 0PZ, Surrey, UK
| | - Rashid Mahmood
- Department of Orthopaedic Trauma, Ashford and St Peter's NHS Foundation Trust, Guildford Road, Chertsey, KT16 0PZ, Surrey, UK
| | - Jonathan Robin
- Department of Acute Medicine, Ashford and St Peter's NHS Foundation Trust, Guildford Road, Chertsey, KT16 0PZ, Surrey, UK
| | - Christopher Henry Fry
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, BS8 1TD, UK
| | - Thang Sieu Han
- Department of Endocrinology, Ashford and St Peter's NHS Foundation Trust, Guildford Road, Chertsey, KT16 0PZ, Surrey, UK.
- Institute of Cardiovascular Research, Royal Holloway, University of London, Egham, TW20 0EX, Surrey, UK.
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Alonso N, Albagha OME, Azfer A, Larraz-Prieto B, Berg K, Riches PL, Ostanek B, Kocjan T, Marc J, Langdahl BL, Ralston SH. Genome-wide association study identifies genetic variants which predict the response of bone mineral density to teriparatide therapy. Ann Rheum Dis 2023:ard-2022-223618. [PMID: 36941031 DOI: 10.1136/ard-2022-223618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 02/15/2023] [Indexed: 03/23/2023]
Abstract
OBJECTIVES Teriparatide (TPTD) is an effective treatment for osteoporosis but the individual response to therapy is variable for reasons that are unclear. This study aimed to determine whether the response to TPTD might be influenced by genetic factors. METHODS We searched for predictors of the response of bone mineral density (BMD) to TPTD using a two-stage genome-wide association study in 437 patients with osteoporosis from three referral centres. Demographic and clinical data including the response of BMD to treatment at the lumbar spine and hip were extracted from the medical records of each participant. RESULTS Allelic variation at rs6430612 on chromosome 2, close to the CXCR4 gene was associated with the response of spine BMD to TPTD at a genome wide significant level (p=9.2×10-9 beta=-0.35 (-0.47 to -0.23)). The increase in BMD was almost twice as great in AA homozygotes at rs6430612 as compared with GG homozygotes with intermediate values in heterozygotes. The same variant was also associated with response of femoral neck and total hip BMD (p=0.007). An additional locus on chromosome 19 tagged by rs73056959 was associated with the response of femoral neck BMD to TPTD (p=3.5×10-9, beta=-1.61 (-2.14 to -1.07)). CONCLUSIONS Genetic factors influence the response to TPTD at the lumbar spine and hip with a magnitude of effect that is clinically relevant. Further studies are required to identify the causal genetic variants and underlying mechanisms as well as to explore how genetic testing for these variants might be implemented in clinical practice.
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Affiliation(s)
- Nerea Alonso
- Centre for Genomic and Experimental Medicine, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Omar M E Albagha
- Centre for Genomic and Experimental Medicine, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
- College of Health and Life Sciences, Hamad Bin Khalifa University, Doha, Qatar
| | - Asim Azfer
- Centre for Genomic and Experimental Medicine, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
| | - Beatriz Larraz-Prieto
- Centre for Genomic and Experimental Medicine, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
| | - Kathryn Berg
- Centre for Genomic and Experimental Medicine, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
| | - Philip L Riches
- Centre for Genomic and Experimental Medicine, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
- Rheumatic Diseases Unit, Western General Hospital, Edinburgh, UK
| | - Barbara Ostanek
- Department of Clinical Biochemistry, Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
| | - Tomaz Kocjan
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Department of Internal Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Janja Marc
- Department of Clinical Biochemistry, Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
| | - Bente L Langdahl
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Stuart H Ralston
- Centre for Genomic and Experimental Medicine, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
- Rheumatic Diseases Unit, Western General Hospital, Edinburgh, UK
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Yawar B, Salmon J, McSorley A, Meehan S, Auld C, Abdulrahman H, Khan MN, Qureshi AI, Flynn R, Neely I, Yawar A, Asim A, Mustafa S, McAdam A, Sapumohotti A, Duffy E, Sandhu H, Hanratty B. Impact of COVID-19 Pandemic on the Length of Hospital Stay in Hip Fracture Patients: A Single Centre Study. Cureus 2022; 14:e27328. [PMID: 35949731 PMCID: PMC9357390 DOI: 10.7759/cureus.27328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2022] [Indexed: 11/05/2022] Open
Abstract
Background Hip fracture is a debilitating injury, especially in older individuals, which is associated with significant morbidity and mortality. In recent decades, there has been a great focus on early rehabilitation and discharge after hip fractures. The aim of such efforts is to minimize the financial and clinical burden of this condition. We conducted our study during the COVID-19 pandemic and compared the length of hospital stay (LOS) in 2020 to the LOS in 2019. Additionally, we studied the factors which may impact the LOS, such as premorbid status according to established scoring systems, the type of fracture, an operation performed, and time to surgery. Methods We collected the data regarding the length of stay (in days) for all hip fracture patients admitted to our unit from 1st January 2019 until 31st December 2020. We then compared the mean LOS for both years using the t-test. We calculated the Nottingham Hip Fracture Score (NHFS) and American Society of Anaesthesiologists (ASA) scores for patients admitted in 2020 and calculated the correlation between increasing values of these scores and the LOS. We also compared the mean LOS for patients admitted in 2020 based on the type of fracture and type of management. We studied the correlation between the time to surgery and the LOS for patients admitted in 2020. Results Three hundred and eighty-eight patients were admitted with hip fractures in 2020, and 452 were admitted in 2019. LOS in 2020 was significantly lower (23.39 days) compared to 2019 (31.36 days) with p<0.01. While evaluating data from 2019, it was noted that there was a small positive correlation between LOS and NHFS (r=0.231, p<0.001) and LOS and ASA (r=0.18, p<0.001). The mean LOS for intracapsular fractures was noted to be lower than that of extracapsular fractures, but this was not statistically significant (p=0.17). An ANOVA test showed that the mean LOS for patients undergoing hemiarthroplasty, dynamic hip screws (DHS), and intramedullary nails (IMN) was significantly longer than for patients managed with total hip replacement or patients managed non-operatively (F=3.551, p<0.01). Conclusion Hip fracture patients admitted to our department were discharged quicker during the first year of the COVID-19 pandemic. The LOS for hip fractures increases with an increase in their NHFS or ASA scores. Extracapsular and intracapsular fractures lead to roughly the same periods of inpatient stay. Patients undergoing hemiarthroplasty, DHS, or IMN stay longer in the hospital compared to other treatment modalities.
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Sanders L, Johnson N, Dias JJ. Kirschner Wire Fixation in Dorsally Displaced Distal Radius Fractures: A Biomechanical Evaluation. J Wrist Surg 2022; 11:21-27. [PMID: 35127260 PMCID: PMC8807103 DOI: 10.1055/s-0041-1729761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/29/2021] [Indexed: 10/21/2022]
Abstract
Background There is currently no consensus for the optimum configuration and number of Kirschner wires (K-wires) to use for the stabilization of dorsally displaced distal radius fractures. In this biomechanical study, we compared the load to failure and stiffness of four common K-wire configurations to identify the strongest construct for use in extra-articular dorsally displaced distal radius fractures. Case Description We created a standard distal radius fracture model in turkey tarsometatarsi which was stabilized using two or three K-wires (1.6 mm) in four different configurations. Following a power calculation, 10 fracture models of each configuration underwent testing in cantilever bending and axial compression. Literature Review Recent randomized trials have shown no evidence that volar locking plates are superior to K-wires for the treatment of dorsally displaced distal radius fractures. This has led to an increase in the popularity of much cheaper K-wires. Several different K-wire techniques have been described but there is no strong evidence to determine which is the optimal configuration and number of wires. Clinical Relevance The three-wire interfragmentary configuration was stiffer than the three-wire Kapandji in axial compression and cantilever bending. There was no difference in load to failure in cantilever bending or axial compression. The three-wire interfragmentary technique is the stiffest configuration of K-wires for dorsally displaced distal radius fractures. The two-wire Kapandji technique was significantly weaker than the other configurations, especially in cantilever bending. Conclusion The authors recommend to always use three wires for percutaneous pinning and never to use two intrafocal wires alone.
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Affiliation(s)
- Liam Sanders
- Department of Trauma and Orthopaedics, Academic Team of Musculoskeletal Surgery, University Hospitals of Leicester, Leicester General Hospital, Leicester, United Kingdom
| | - Nick Johnson
- Department of Trauma and Orthopaedics, Academic Team of Musculoskeletal Surgery, University Hospitals of Leicester, Leicester General Hospital, Leicester, United Kingdom
| | - Joseph J. Dias
- Department of Trauma and Orthopaedics, Academic Team of Musculoskeletal Surgery, University Hospitals of Leicester, Leicester General Hospital, Leicester, United Kingdom
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Middleton R, Poveda JL, Orfila Pernas F, Martinez Laguna D, Diez Perez A, Nogués X, Carbonell Abella C, Reyes C, Prieto-Alhambra D. Mortality, Falls, and Fracture Risk Are Positively Associated With Frailty: A SIDIAP Cohort Study of 890 000 Patients. J Gerontol A Biol Sci Med Sci 2022; 77:148-154. [PMID: 33885746 PMCID: PMC8751782 DOI: 10.1093/gerona/glab102] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Frail subjects are at increased risk of adverse outcomes. We aimed to assess their risk of falls, all-cause mortality, and fractures. METHOD We used a retrospective cohort study using the Sistema d'Informació per al Desenvolupament de l'Investigació en Atenció Primària database (>6 million residents). Subjects aged 75 years and older with ≥1 year of valid data (2007-2015) were included. Follow-up was carried out from (the latest of) the date of cohort entry up to migration, end of the study period or outcome (whichever came first). The eFRAGICAP classified subjects as fit, mild, moderate, or severely frail. Outcomes (10th revision of the International Classification of Diseases) were incident falls, fractures (overall/hip/vertebral), and all-cause mortality during the study period. Statistics: hazard ratios (HRs), 95% CI adjusted (per age, sex, and socioeconomic status), and unadjusted cause-specific Cox models, accounting for competing risk of death (fit group as the reference). RESULTS A total of 893 211 subjects were analyzed; 54.4% were classified as fit, 34.0% as mild, 9.9% as moderate, and 1.6% as severely frail. Compared with the fit, frail had an increased risk of falls (adjusted HR [95% CI] of 1.55 [1.52-1.58], 2.74 [2.66-2.84], and 5.94 [5.52-6.40]), all-cause mortality (adjusted HR [95% CI] of 1.36 [1.35-1.37], 2.19 [2.16-2.23], and 4.29 [4.13-4.45]), and fractures (adjusted HR [95% CI] of 1.21 [1.20-1.23], 1.51 [1.47-1.55], and 2.36 [2.20-2.53]) for mild, moderate, and severe frailty, respectively. Severely frail had a high risk of vertebral (HR of 2.49 [1.99-3.11]) and hip fracture (HR [95% CI] of 1.85 [1.50-2.28]). Accounting for competing risk of death did not change results. CONCLUSION Frail subjects are at increased risk of death, fractures, and falls. The eFRAGICAP tool can easily assess frailty in electronic primary care databases in Spain.
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Affiliation(s)
- Robert Middleton
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, UK
| | | | - Francesc Orfila Pernas
- Gerència Territorial de Barcelona, Institut Català de la Salut, Spain
- Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Daniel Martinez Laguna
- CIBERFes, Instituto Carlos III, Madrid, Spain
- Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Adolfo Diez Perez
- CIBERFes, Instituto Carlos III, Madrid, Spain
- Musculoskeletal Research Unit, IMIM-Hospital del Mar, Barcelona, Spain
| | - Xavier Nogués
- CIBERFes, Instituto Carlos III, Madrid, Spain
- Internal Medicine Department, IMIM-Hospital del Mar, Barcelona, Spain
| | - Cristina Carbonell Abella
- Gerència Territorial de Barcelona, Institut Català de la Salut, Spain
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | - Carlen Reyes
- CIBERFes, Instituto Carlos III, Madrid, Spain
- Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Daniel Prieto-Alhambra
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, UK
- CIBERFes, Instituto Carlos III, Madrid, Spain
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Wek C, Reichert I, Gee M, Foley R, Ahluwalia R. Have advances in surgical implants and techniques in hemiarthroplasty for intracapsular hip fractures improved patient outcomes compared to THA? A systematic review and meta-analysis of the evidence. Surgeon 2022; 20:e344-e354. [DOI: 10.1016/j.surge.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 11/09/2021] [Accepted: 12/04/2021] [Indexed: 10/19/2022]
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Gokhale S, D'sa P, Agarwal R, Clutton J, Roy K, Carpenter EC, Mohanty K, Hodgson P. Results From an All Wales Trainee Led Collaborative Prospective Audit on Management of Ankle Fractures. Cureus 2021; 13:e19269. [PMID: 34900463 PMCID: PMC8648132 DOI: 10.7759/cureus.19269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2021] [Indexed: 11/05/2022] Open
Abstract
Aim The purpose of this all Wales national audit was to compare compliance against British Orthopedic Association Standards for Trauma (BOAST) guidelines on the management of ankle fractures. Methods A multi-center prospective audit of the management of adult ankle fractures was conducted between February 2, 2020, and February 17, 2020, via the Welsh Orthopedic Research Collaborative (WORC). Regional leads were recruited in nine NHS hospitals across six university health boards, and recruited collaborators in their respective hospitals. Questionnaires for the data collection on both surgical and conservative management were made available via a password-protected website (walesortho.co.uk). We defined early weight-bearing (EWB) as unrestricted weight-bearing on the affected leg within three weeks of injury or surgery and delayed weight-bearing (DWB) as unrestricted weight-bearing after three weeks of injury or surgery. Results A total of 28 collaborators contributed data for 238 ankle fractures. Poor documentation at the time of injury was noted. Less than 50% of patients with posterior malleolus fracture had a CT scan for further evaluation. Eighty-four percent of the non-operatively treated patients did not have a weight-bearing X-ray (WBXR). Patients who had a WBXR were more likely to be allowed EWB but this was not statistically significant. EWB was allowed in 59.43% and 10% of the non-operatively and operatively treated patients, respectively. DWB was higher in patients who had fixation of the posterior malleolus or syndesmosis. Conclusion There is poor compliance with BOAST guidelines on the management of ankle fractures across Wales. We need to improve documentation and also consider performing a CT scan when the posterior malleolus is fractured. A weight-bearing X-ray should be performed more often to ascertain the stability of an ankle fracture, and those that are deemed stable should be treated with early weight-bearing. The guidelines need to be clearer regarding weight-bearing after fixation especially when posterior malleolus and/or syndesmosis are fixed.
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Affiliation(s)
- Sandeep Gokhale
- Trauma and Orthopedics, University Hospital of Wales, Cardiff, GBR
| | - Prashanth D'sa
- Trauma and Orthopedics, University Hospital of Wales, Cardiff, GBR
| | - Rishi Agarwal
- Trauma and Orthopedics, University Hospital of Wales, Cardiff, GBR
| | - Juliet Clutton
- Trauma and Orthopedics, University Hospital of Wales, Cardiff, GBR
| | - Kunal Roy
- Trauma and Orthopedics, Wrexham Maelor Hospital, Wrexham, GBR
| | | | - Khitish Mohanty
- Trauma and Orthopedics, University Hospital of Wales, Cardiff, GBR
| | - Paul Hodgson
- Trauma and Orthopedics, University Hospital of Wales, Cardiff, GBR
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Hara T, Hijikata Y, Matsubara Y, Watanabe N. Pharmacological interventions versus placebo, no treatment or usual care for osteoporosis in people with chronic kidney disease stages 3-5D. Cochrane Database Syst Rev 2021; 7:CD013424. [PMID: 34231877 PMCID: PMC8262129 DOI: 10.1002/14651858.cd013424.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) is an independent risk factor for osteoporosis and is more prevalent among people with CKD than among people who do not have CKD. Although several drugs have been used to effectively treat osteoporosis in the general population, it is unclear whether they are also effective and safe for people with CKD, who have altered systemic mineral and bone metabolism. OBJECTIVES To assess the efficacy and safety of pharmacological interventions for osteoporosis in patients with CKD stages 3-5, and those undergoing dialysis (5D). SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 25 January 2021 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials comparing any anti-osteoporotic drugs with a placebo, no treatment or usual care in patients with osteoporosis and CKD stages 3 to 5D were included. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, assessed their quality using the risk of bias tool, and extracted data. The main outcomes were the incidence of fracture at any sites; mean change in the bone mineral density (BMD; measured using dual-energy radiographic absorptiometry (DXA)) of the femoral neck, total hip, lumbar spine, and distal radius; death from all causes; incidence of adverse events; and quality of life (QoL). Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS Seven studies involving 9164 randomised participants with osteoporosis and CKD stages 3 to 5D met the inclusion criteria; all participants were postmenopausal women. Five studies included patients with CKD stages 3-4, and two studies included patients with CKD stages 5 or 5D. Five pharmacological interventions were identified (abaloparatide, alendronate, denosumab, raloxifene, and teriparatide). All studies were judged to be at an overall high risk of bias. Among patients with CKD stages 3-4, anti-osteoporotic drugs may reduce the risk of vertebral fracture (RR 0.52, 95% CI 0.39 to 0.69; low certainty evidence). Anti-osteoporotic drugs probably makes little or no difference to the risk of clinical fracture (RR 0.91, 95% CI 0.79 to 1.05; moderate certainty evidence) and adverse events (RR 0.99, 95% CI 0.98 to 1.00; moderate certainty evidence). We were unable to incorporate studies into the meta-analyses for BMD at the femoral neck, lumbar spine and total hip as they only reported the percentage change in the BMD in the intervention group. Among patients with severe CKD stages 5 or 5D, it is uncertain whether anti-osteoporotic drug reduces the risk of clinical fracture (RR 0.33, 95% CI 0.01 to 7.87; very low certainty evidence). It is uncertain whether anti-osteoporotic drug improves the BMD at the femoral neck because the certainty of this evidence is very low (MD 0.01, 95% CI 0.00 to 0.02). Anti-osteoporotic drug may slightly improve the BMD at the lumbar spine (MD 0.03, 95% CI 0.03 to 0.04, low certainty evidence). No adverse events were reported in the included studies. It is uncertain whether anti-osteoporotic drug reduces the risk of death (RR 1.00, 95% CI 0.22 to 4.56; very low certainty evidence). AUTHORS' CONCLUSIONS Among patients with CKD stages 3-4, anti-osteoporotic drugs may reduce the risk of vertebral fracture in low certainty evidence. Anti-osteoporotic drugs make little or no difference to the risk of clinical fracture and adverse events in moderate certainty evidence. Among patients with CKD stages 5 and 5D, it is uncertain whether anti-osteoporotic drug reduces the risk of clinical fracture and death because the certainty of this evidence is very low. Anti-osteoporotic drug may slightly improve the BMD at the lumbar spine in low certainty evidence. It is uncertain whether anti-osteoporotic drug improves the BMD at the femoral neck because the certainty of this evidence is very low. Larger studies including men, paediatric patients or individuals with unstable CKD-mineral and bone disorder are required to assess the effect of each anti-osteoporotic drug at each stage of CKD.
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Affiliation(s)
- Takashi Hara
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Yasukazu Hijikata
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Yukiko Matsubara
- Department of Nephrology, Hiroshima University Hospital, Hiroshima, Japan
| | - Norio Watanabe
- Department of Psychiatry, Soseikai General Hospital, Kyoto, Japan
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Stephens A, Rudd H, Stephens E, Ward J. Secondary Prevention of Hip Fragility Fractures During the COVID-19 Pandemic: Service Evaluation of "MRS BAD BONES". JMIR Aging 2020; 3:e25607. [PMID: 33326412 PMCID: PMC7772051 DOI: 10.2196/25607] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/09/2020] [Accepted: 12/14/2020] [Indexed: 11/22/2022] Open
Abstract
Background Management of osteoporosis is an important consideration for patients with femoral neck fractures due to the morbidity and mortality it poses. The input of orthogeriatric teams is invaluable in coordinating secondary fragility fracture prevention. The COVID-19 pandemic resulted in the rapid restructuring of health care teams and led to the redeployment of orthogeriatricians. Objective This study aimed to determine the impact COVID-19 had on the secondary prevention of fragility fractures among patients with femoral neck fractures, and to optimize management in this population. Methods A retrospective audit was conducted of patients with femoral neck fractures before and after the lockdown in response to the COVID-19 pandemic in the United Kingdom. A reaudit was conducted following the development of our new mnemonic, “MRS BAD BONES,” which addressed key factors in the assessment and management of osteoporosis: medication review, rheumatology/renal advice, smoking cessation; blood tests, alcohol limits, DEXA (dual energy X-ray absorptiometry) scan; bone-sparing medications, orthogeriatric review, nutrition, exercise, supplements. The Fisher exact test was used for comparison analyses between each phase. Results Data for 50 patients were available in each phase. The orthogeriatric team reviewed 88% (n=44) of patients prelockdown, which fell to 0% due to redeployment, before recovering to 38% (n=19) in the postintervention period. The lockdown brought a significant drop in the prescription of vitamin D/calcium supplements from 81.6% (n=40) to 58.0% (n=29) (P=.02); of bone-sparing medications from 60.7% (n=17) to 18.2% (n=4) (P=.004), and DEXA scan requests from 40.1% (n=9) to 3.6% (n=1) (P=.003). Following the implementation of our mnemonic, there was a significant increase in the prescription of vitamin D/calcium supplements to 85.7% (n=42) (P=.003), bone-sparing medications to 72.4% (n=21) (P<.001), and DEXA scan requests to 60% (n=12) (P<.001). Conclusions The redeployment of the orthogeriatric team, due to the COVID-19 pandemic, impacted the secondary prevention of fragility fractures in the study population. The “MRS BAD BONES” mnemonic significantly improved management and could be used in a wider setting.
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Affiliation(s)
- Alastair Stephens
- Trauma and Orthopaedic Department, University Hospital Coventry and Warwickshire, Coventry, United Kingdom
| | - Hannah Rudd
- Trauma and Orthopaedic Department, University Hospital Coventry and Warwickshire, Coventry, United Kingdom
| | - Emilia Stephens
- Trauma and Orthopaedic Department, University Hospital Coventry and Warwickshire, Coventry, United Kingdom
| | - Jayne Ward
- Trauma and Orthopaedic Department, University Hospital Coventry and Warwickshire, Coventry, United Kingdom
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12
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Patel B, Aqil A, Riaz O, Jeffers R, Dickson D. The 2nd Metacarpal Cortical Index as a Simple Screening Tool for Osteopenia. J Bone Metab 2020; 27:261-266. [PMID: 33317229 PMCID: PMC7746479 DOI: 10.11005/jbm.2020.27.4.261] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 11/01/2020] [Indexed: 11/11/2022] Open
Abstract
Background Osteopenia is a known risk factor for sustaining skeletal fractures. Prevention of fragility fractures has obvious clinical and economic advantages, however screening all patients using a dual energy X-ray absorptiometry (DXA) is controversial not only because of the cost implications but also because it would potentially involve exposing a percentage of normal patients to unnecessary radiation. We wished to assess whether a simple hand X-ray measuring the 2nd metacarpal cortical index (2MCI) could be used as a simple screening tool for identifying patients with osteopenia. Methods We retrospectively collected the radiographic data of 206 patients who had a simple radiograph of the hand and a DXA scan within one year of each other from our picture archiving and communication system database. The 2MCI was calculated for all patients. As data was parametric, a Pearson’s correlation was performed to assess association between T-scores and 2MCI. Further analysis involved the construction of receiver operating characteristic (ROC) curves to identify a 2MCI index, which would give the most appropriate sensitivity and specificity values for identifying the presence of osteopenia. Results A statistically significant and moderate correlation between DXA T-scores and 2MCI values was found (r=0.54, n=206, P<0.001). Further ROC curve analysis of normal and osteopenic subjects identified that a 2MCI of 41.5 had a sensitivity of 100% and specificity of 53% for detecting osteopenia. Conclusions Our results support the use of the 2MCI as a simple screening tool for identifying patients with osteopenia.
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Affiliation(s)
- Bhavika Patel
- Bradford Teaching Hospitals NHS Foundation Trust, Duckworth Lane, Bradford, United Kingdom
| | - Adeel Aqil
- Bradford Teaching Hospitals NHS Foundation Trust, Duckworth Lane, Bradford, United Kingdom
| | - Osman Riaz
- Bradford Teaching Hospitals NHS Foundation Trust, Duckworth Lane, Bradford, United Kingdom
| | - Russ Jeffers
- Bradford Teaching Hospitals NHS Foundation Trust, Duckworth Lane, Bradford, United Kingdom
| | - David Dickson
- Bradford Teaching Hospitals NHS Foundation Trust, Duckworth Lane, Bradford, United Kingdom
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13
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Manetti S, Turchetti G, Fusco F. Determining the cost-effectiveness requirements of an exoskeleton preventing second hip fractures using value of information. BMC Health Serv Res 2020; 20:955. [PMID: 33059683 PMCID: PMC7565816 DOI: 10.1186/s12913-020-05768-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 09/28/2020] [Indexed: 11/20/2022] Open
Abstract
Background Falls may lead to hip fractures, which have a detrimental effect on the prognosis of patients as well as a considerable impact on healthcare expenditures. Since a secondary hip fracture (SHF) may lead to even higher costs than primary fractures, the development of innovative services is crucial to limit falls and curb costs in high-risk patients. An early economic evaluation assessed which patients with a second hip fracture could benefit most from an exoskeleton preventing falls and whether its development is feasible. Methods The life-course of hip fractured patients presenting with dementia or cardiovascular diseases was simulated using a Markov model relying on the United Kingdom administrative data and complemented by published literature. A group of experts provided the exoskeleton parameters. Secondary analyses included a threshold analysis to identify the exoskeleton requirements (e.g. minimum impact of the exoskeleton on patients’ quality of life) leading to a reimbursable incremental cost-effectiveness ratio. Similarly, the uncertainty around these requirements was modelled by varying their standard errors and represented alongside population Expected Value of Perfect Information (EVPI). Results Our base-case found the exoskeleton cost-effective when providing a statistically significant reduction in SHF risk. The secondary analyses identified 286 cost-effective combinations of the exoskeleton requirements. The uncertainty around these requirements was explored producing further 22,880 scenarios, which showed that this significant reduction in SHF risk was not necessary to support the exoskeleton adoption in clinical practice. Conversely, a significant improvement in women quality of life was crucial to obtain an acceptable population EVPI regardless of the cost of the exoskeleton. Conclusions Our study identified the exoskeleton requisites to be cost-effective and the value of future research. Decision-makers could use our analyses to assess not only whether the exoskeleton could be cost-effective but also how much further research and development of the exoskeleton is worth to be pursued.
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Affiliation(s)
- Stefania Manetti
- Institute of Management, Scuola Superiore Sant'Anna, Pisa, Italy.,Department of Surgery and Cancer, St Mary's Hospital, Imperial College London, London, UK
| | | | - Francesco Fusco
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, UK. .,Centre for Health Economics, University of York, Heslington, York, UK. .,Department of Public Health & Primary Care, University of Cambridge, Institute of Public Health, Forvie Site, Robinson Way, Cambridge, CB2 0SR, UK.
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14
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Abstract
With increasing longevity of the population globally, the prevalence of osteoporosis will rise, associated with significant morbidity, disability and increased mortality. Adequate intake of calcium, vitamin D, increasing physical activity, a strategy of avoiding falls, cessation of smoking and avoiding excessive alcohol intake are pivotal in maintaining healthy bones in all age groups. Oral bisphosphonates remain the most cost-effective first line of treatment. Better methods of identifying patients with high fracture risk is needed as there is adequate effective treatment for osteoporosis.
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15
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Keene DJ, Forde C, Sugavanam T, Williams MA, Lamb SE. Exercise for people with a fragility fracture of the pelvis or lower limb: a systematic review of interventions evaluated in clinical trials and reporting quality. BMC Musculoskelet Disord 2020; 21:435. [PMID: 32622352 PMCID: PMC7335435 DOI: 10.1186/s12891-020-03361-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 05/25/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To aid design of exercise trials for people with pelvic and lower limb fragility fractures a systematic review was conducted to identify what types of exercise interventions and mobility outcomes have been assessed, investigate intervention reporting quality, and evaluate risk of bias in published trials. METHODS Systematic searches of electronic databases (CENTRAL, MEDLINE, EMBASE, PEDro) 1996-2019 were conducted to identify randomised controlled trials of exercise for pelvic or lower limb fragility fractures. Two reviewers independently screened titles and abstracts. One reviewer extracted data, a second verified. Two reviewers independently assessed risk of bias. Intervention reporting quality was based on TIDieR, assessed by one reviewer and verified by a second. Narrative synthesis was undertaken. Registration: PROSPERO CRD42017060905. RESULTS Searches identified 37 trials including 3564 participants, median sample size 81 (IQR 48-124), participants aged 81 years (IQR 79-82) and 76% (2536/3356) female. All trials focussed on people with hip fracture except one on ankle fracture. Exercise types focussed on resistance exercise in 14 trials, weight bearing exercise in 5 trials, 13 varied dose of sessions with health professionals, and 2 trials each focussed on treadmill gait training, timing of weight bearing or aerobic exercise. 30/37 (81%) of trials reported adequate sequence generation, 25/37 (68%) sufficient allocation concealment. 10/37 (27%) trials lacked outcome assessor blinding. Of 65 exercise interventions, reporting was clear for 33 (51%) in terms of when started, 61 (94%) for where delivered, 49 (75%) for who delivered, 47 (72%) for group or individual, 29 (45%) for duration, 46 (71%) for session frequency, 8 (12%) for full prescription details to enable the exercises to be reproduced, 32 (49%) clearly reported tailoring or modification, and 23 (35%) reported exercise adherence. Subjectively assessed mobility was assessed in 22/37 (59%) studies and 29/37 (78%) used an objective measure. CONCLUSIONS All trials focussed on hip fracture, apart from one ankle fracture trial. Research into pelvic and other lower limb fragility fractures is indicated. A range of exercise types were investigated but to date deficiencies in intervention reporting hamper reproducibility. Adoption of TIDieR and CERT guidelines should improve intervention reporting as use increases. Trials would be improved by consistent blinded outcome assessor use and with consensus on which mobility outcomes should be assessed.
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Affiliation(s)
- David J Keene
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
| | - Colin Forde
- Physiotherapy Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Thavapriya Sugavanam
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Mark A Williams
- Department of Sport, Health Sciences and Social Work, Oxford Brookes University, Oxford, UK
| | - Sarah E Lamb
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- College of Medicine and Health, University of Exeter, Exeter, UK
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16
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Sacks B, Mughal HN, Ahluwalia A, Rudran B, Parmar KR. The BOAST recommendations for care of the older or frail orthopaedic trauma patient. Br J Hosp Med (Lond) 2020; 81:1-8. [PMID: 32730158 DOI: 10.12968/hmed.2020.0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Safe and effective care for the elderly or physiologically frail patient in cases of trauma requires a multidisciplinary perioperative approach. This article expands upon the British Orthopaedic Association Standards for Trauma and Orthopaedics guidelines for the management of the older or frail orthopaedic trauma patient. Optimisation of the patient is key to a successful surgical outcome, because these patients often have significant comorbidities involving bone health, nutrition, cognitive function and cardiovascular stability. This article discusses the evidence base for tailoring the management of these patients and the importance of doing so in an ageing population. It considers the requisite preoperative procedures and investigations, guidelines for specific cases such as comatose patients or those with complex fractures, and ceiling of care discussions, and then focuses on the postoperative period, including physiotherapy, rehabilitation goals and medical management.
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Affiliation(s)
- Ben Sacks
- Department of Colorectal Surgery, University College London Hospital, London, UK
| | | | - Aashish Ahluwalia
- Department of Trauma and Orthopaedics, Hillingdon Hospital, London, UK
| | - Branavan Rudran
- Department of Trauma and Orthopaedics, Hillingdon Hospital, London, UK
| | - Kishan R Parmar
- Department of Trauma and Orthopaedics, Hillingdon Hospital, London, UK
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17
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Gupta A, Jayes LR, Holmes S, Sahota O, Canavan M, Elkin SL, Lim K, Murphy AC, Singh S, Towlson EA, Ward H, Scullion J, McKeever TM, Bolton CE. Management of Fracture Risk in Patients with Chronic Obstructive Pulmonary Disease (COPD): Building a UK Consensus Through Healthcare Professional and Patient Engagement. Int J Chron Obstruct Pulmon Dis 2020; 15:1377-1390. [PMID: 32606647 PMCID: PMC7311204 DOI: 10.2147/copd.s233398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 03/23/2020] [Indexed: 12/21/2022] Open
Abstract
Introduction Osteoporosis and bone fractures are common in chronic obstructive pulmonary disease (COPD) and contribute significantly to morbidity and mortality. Current national guidance on COPD management recommends addressing bone health in patients, however, does not detail how. This consensus outlines key elements of a structured approach to managing bone health and fracture risk in patients with COPD. Methods A systematic approach incorporating multifaceted methodologies included detailed patient and healthcare professional (HCP) surveys followed by a roundtable meeting to reach a consensus on what a pathway would look like. Results The surveys revealed that fracture risk was not always assessed despite being recognised as an important aspect of COPD management by HCPs. The majority of the patients also stated they would be receptive to discussing treatment options if found to be at risk of osteoporotic fractures. Limited time and resource allocation were identified as barriers to addressing bone health during consultations. The consensus from the roundtable meeting was that a proactive systematic approach to assessing bone health should be adopted. This should involve using fracture risk assessment tools to identify individuals at risk, investigating secondary causes of osteoporosis if a diagnosis is made and reinforcing non-pharmacological and preventative measures such as smoking cessation, keeping active and pharmacological management of osteoporosis and medicines management of corticosteroid use. Practically, prioritising patients with important additional risk factors, such as previous fragility fractures, older age and long-term oral corticosteroid use for an assessment, was felt required. Conclusion There is a need for integrating fracture risk assessment into the COPD pathway. Developing a systematic and holistic approach to addressing bone health is key to achieving this. In tandem, opportunities to disseminate the information and educational resources are also required.
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Affiliation(s)
- Ayushman Gupta
- NIHR Nottingham BRC Respiratory Theme, School of Medicine, University of Nottingham, City Hospital Campus, Nottingham, UK
| | - Leah R Jayes
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, City Hospital Campus, Nottingham, UK
| | - Steve Holmes
- General Practitioner, Park Medical Partnership, Shepton Mallet, UK
| | - Opinder Sahota
- Department of Geriatric Medicine, Nottingham University Hospitals Trust, Nottingham, UK
| | - Melissa Canavan
- Department of Respiratory, Respiratory Care Solutions, Leeds, UK
| | - Sarah L Elkin
- Department of Respiratory Medicine, Imperial College Healthcare Trust, London W2 1NY, UK; Airways Section, National Heart and Lung Institute, Imperial College, London, UK
| | - Kelvin Lim
- Eastwood Primary Care Centre, Eastwood, Nottingham, UK
| | - Anna C Murphy
- Department of Pharmacy, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Sally Singh
- Department of Respiratory Science, University Hospitals of Leicester NHS Trust, Leicester, UK.,Department of Respiratory Science, University of Leicester, Leicester, UK
| | | | - Helen Ward
- Faculty of Medicine, The Royal Wolverhampton NHS Trust, West Midlands, UK
| | - Jane Scullion
- Department of Respiratory Science, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Tricia M McKeever
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, City Hospital Campus, Nottingham, UK
| | - Charlotte E Bolton
- NIHR Nottingham BRC Respiratory Theme, School of Medicine, University of Nottingham, City Hospital Campus, Nottingham, UK
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18
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Eleni A, Panagiotis P. A systematic review and meta-analysis of vitamin D and calcium in preventing osteoporotic fractures. Clin Rheumatol 2020; 39:3571-3579. [PMID: 32447604 DOI: 10.1007/s10067-020-05122-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/11/2020] [Accepted: 04/21/2020] [Indexed: 01/31/2023]
Abstract
To assess and update the effect of the combination of vitamin D and calcium in the reduction of osteoporotic fractures, a systematic review across Cochrane Database, NIHR HTA database, PubMed and Google Scholar was performed using mesh terms : Cohort studies OR Prospective Studies OR Longitudinal Studies OR Follow-Up Studies OR Incidence OR Risk OR Rate and Osteoporotic Fractures OR Fractures, Bone OR Fractures, Spontaneous OR Spinal Fractures OR Humeral Fractures OR Hip Fractures OR Femoral Neck Fractures AND Vitamin D AND Calcium and key words: vitamin D, fractures, osteoporosis, calcium, dietary supplements. Statistical analysis was performed with Review Manager (RevMan 5.3) using relative risk and confidence interval 95%. The combination reduced total fractures and hip fractures while no effect was observed in wrist fractures. The combination was also well tolerated. Only minor side effects were reported. This systematic review suggests that the combination of vitamin D and calcium can exert a beneficial effect towards osteoporotic fracture reduction.
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Affiliation(s)
- Albani Eleni
- Public Health Program, Department of Health Sciences, European University, Diogenis Str 6, 2404, Nicosia, Cyprus
| | - Petrou Panagiotis
- School of Sciences and Engineering, Pharmacy School, Pharmacoepidemiology-Pharmacovigilance, University of Nicosia, Makedonitissis 46, 2417, Nicosia, Cyprus.
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19
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Souza D, Barbalho M, Ramirez-Campillo R, Martins W, Gentil P. High and low-load resistance training produce similar effects on bone mineral density of middle-aged and older people: A systematic review with meta-analysis of randomized clinical trials. Exp Gerontol 2020; 138:110973. [PMID: 32454079 DOI: 10.1016/j.exger.2020.110973] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 05/15/2020] [Accepted: 05/19/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE To compare the effects of high-load (≥ 70 of 1RM) and low-load (< 70 of 1RM) resistance training (RT) on femoral neck and lumbar spine bone mineral density (BMD) in middle-aged and older people. DESIGN Systematic review with meta-analysis. DATA SOURCE English language searches of the electronic databases PubMed/Medline, Scopus and Web of Science. INCLUSION CRITERIA (i) older or middle-aged (≥ 45 years old) participants of both sexes with or without comorbidities, (ii) studies that compared high-load (≥70% 1 RM) versus low-load (<70% 1RM) RT, (iii) studies that examined femoral neck or lumbar spine BMD. RESULTS From 1052 studies found, six were included in qualitative and quantitative analysis. The meta-analysis revealed no difference between groups for femoral neck (weighted mean difference [MD] and 95% confidence interval (CI) = 0.00 g/cm2 [95% CI, -0.01 to 0.01]; P = 0.63) and lumbar spine (MD = 0.01 g/cm2 [95% CI, -0.00 to 0.02]; P = 0.12) BDM. There was a substantial heterogeneity for femoral neck (I2 = 47%; P = 0.07) and lumbar spine (I2 = 59%; P = 0.02). Subgroup analysis revealed a significant effect of high-load RT on femoral neck BMD when participants presented normal BMD values (MD = 0.01 g/cm2 [95% CI, -0.00 to 0.02]; P = 0.04) and on interventions lasting up to 6 months (MD = 0.01 g/cm2 [95% CI, -0.00 to 0.02]; P = 0.03). CONCLUSION Both high- and low-load RT have similar effects on femoral neck and lumbar spine BMD in aging people.
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Affiliation(s)
- Daniel Souza
- Faculdade de Educação Física e Dança, Universidade Federal de Goiás, Goiânia, Brazil.
| | - Matheus Barbalho
- Faculdade de Educação Física e Dança, Universidade Federal de Goiás, Goiânia, Brazil
| | - Rodrigo Ramirez-Campillo
- Laboratory of Human Performance, Quality of Life and Wellness Research Group, Department of Physical Activity Sciences, Universidad de Los Lagos, Osorno, Chile
| | - Wagner Martins
- University of Brasilia, Division of Physical Therapy, Ceilandia, Brazil
| | - Paulo Gentil
- Faculdade de Educação Física e Dança, Universidade Federal de Goiás, Goiânia, Brazil
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20
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Johnson NA, Stirling E, Alexander M, Dias JJ. The relationship between temperature and hip and wrist fracture incidence. Ann R Coll Surg Engl 2020; 102:348-354. [PMID: 32233845 DOI: 10.1308/rcsann.2020.0030] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Predicting when fracture incidence will rise assists in healthcare planning and delivery of preventative strategies. The aim of this study was to investigate the relationship between temperature and the incidence of hip and wrist fractures. METHODS Data for adults presenting to our unit with a hip or wrist fracture over a seven and eight-year period respectively were analysed. Incidence rates were calculated and compared with meteorological records. A Poisson regression model was used to quantify the relationship between temperature and fracture rate. RESULTS During the respective study periods, 8,380 patients presented with wrist fractures and 5,279 patients were admitted with hip fractures. All women (≥50 years: p<0.001; <50 years: p<0.001) and men aged ≥50 years (p=0.046) demonstrated an increased wrist fracture rate with reduced temperature. Men aged <50 years also had an increased wrist fracture rate with increased temperature (p<0.001).The hip fracture rate was highest in women aged ≥50 years but was not associated with temperature (p=0.22). In men aged ≥50 years, there was a significant relationship between reduced temperature and increased fracture rate (p<0.001). CONCLUSIONS Fragility fracture of the wrist is associated with temperature. Compared with an average summer, an additional 840 procedures are performed for wrist fractures during an average winter in our trust with an additional 798 bed days taken up at a cost of £3.2 million. The winter increase seen in male hip fracture incidence requires approximately 888 surgical procedures, with 18,026 bed days, and costs £7.1 million. Hip fracture incidence in older women is not related to temperature.
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Affiliation(s)
- N A Johnson
- University Hospitals of Leicester NHS Trust, UK
| | | | - M Alexander
- University Hospitals of Leicester NHS Trust, UK
| | - J J Dias
- University Hospitals of Leicester NHS Trust, UK
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Cehic M, Lerner RG, Achten J, Griffin XL, Prieto-Alhambra D, Costa ML. Prescribing and adherence to bone protection medications following hip fracture in the United Kingdom: results from the World Hip Trauma Evaluation (WHiTE) cohort study. Bone Joint J 2019; 101-B:1402-1407. [PMID: 31674239 DOI: 10.1302/0301-620x.101b11.bjj-2019-0387.r1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Bone health assessment and the prescription of medication for secondary fracture prevention have become an integral part of the acute management of patients with hip fracture. However, there is little evidence regarding compliance with prescription guidelines and subsequent adherence to medication in this patient group. PATIENTS AND METHODS The World Hip Trauma Evaluation (WHiTE) is a multicentre, prospective cohort of hip fracture patients in NHS hospitals in England and Wales. Patients aged 60 years and older who received operative treatment for a hip fracture were eligible for inclusion in WHiTE. The prescription of bone protection medications was recorded from participants' discharge summaries, and participant-reported use of bone protection medications was recorded at 120 days following surgery. RESULTS Of 5456 recruited patients with baseline data, 2853 patients (52%) were prescribed bone protection medication at discharge, of which oral bisphosphonates were the most common, 4109 patients (75%) were prescribed vitamin D or calcium, and 606 patients (11%) were not prescribed anything. Of those prescribed a bone protection medication, only 932 patients (33%) reported still taking their medication 120 days later. CONCLUSION These data provide a reference for current prescription and adherence rates. Adherence with oral medication remains poor in patients with hip fracture. Cite this article: Bone Joint J 2019;101-B:1402-1407.
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Affiliation(s)
- Matthew Cehic
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Kadoorie Centre, University of Oxford, Oxford, UK.,Oxford University Hospitals NHS Foundation Trust, Trauma Research, Kadoorie Centre, John Radcliffe Hospital, Oxford, UK.,Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Robin G Lerner
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Kadoorie Centre, University of Oxford, Oxford, UK
| | - Juul Achten
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Kadoorie Centre, University of Oxford, Oxford, UK
| | - Xavier L Griffin
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Kadoorie Centre, University of Oxford, Oxford, UK.,Oxford University Hospitals NHS Foundation Trust, Trauma Research, Kadoorie Centre, John Radcliffe Hospital, Oxford, UK
| | - Daniel Prieto-Alhambra
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Kadoorie Centre, University of Oxford, Oxford, UK
| | - Matthew L Costa
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Kadoorie Centre, University of Oxford, Oxford, UK.,Oxford University Hospitals NHS Foundation Trust, Trauma Research, Kadoorie Centre, John Radcliffe Hospital, Oxford, UK
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22
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Hara T, Hijikata Y, Matsubara Y, Watanabe N. Pharmacological interventions for osteoporosis in people with chronic kidney disease stages 3‐5D. Cochrane Database Syst Rev 2019; 2019:CD013424. [PMCID: PMC6734171 DOI: 10.1002/14651858.cd013424] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: This review aims to assess the effects of pharmacological interventions for osteoporosis in patients with CKD stages 3‐5D.
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Affiliation(s)
- Takashi Hara
- Kyoto University Graduate School of Medicine/School of Public HealthDepartment of Healthcare EpidemiologyYoshida Konoe‐cho, Sakyo‐kuKyotoJapan606‐8501
| | - Yasukazu Hijikata
- Kyoto University Graduate School of Medicine/School of Public HealthDepartment of Healthcare EpidemiologyYoshida Konoe‐cho, Sakyo‐kuKyotoJapan606‐8501
| | - Yukiko Matsubara
- Keiai HospitalDepartment of Nephrology3‐10‐23 Mukaihara, Itabashi‐kuTokyoJapan173‐0036
| | - Norio Watanabe
- Kyoto University Graduate School of Medicine/School of Public HealthDepartment of Health Promotion and Human BehaviorYoshida Konoe‐cho, Sakyo‐kuKyotoJapan606‐8501
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23
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Barker KL, Newman M, Stallard N, Leal J, Minns Lowe C, Javaid MK, Noufaily A, Adhikari A, Hughes T, Smith DJ, Gandhi V, Cooper C, Lamb SE. Exercise or manual physiotherapy compared with a single session of physiotherapy for osteoporotic vertebral fracture: three-arm PROVE RCT. Health Technol Assess 2019; 23:1-318. [PMID: 31456562 DOI: 10.3310/hta23440] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND A total of 25,000 people in the UK have osteoporotic vertebral fracture (OVF). Evidence suggests that physiotherapy may have an important treatment role. OBJECTIVE The objective was to investigate the clinical effectiveness and cost-effectiveness of two different physiotherapy programmes for people with OVF compared with a single physiotherapy session. DESIGN This was a prospective, adaptive, multicentre, assessor-blinded randomised controlled trial (RCT) with nested qualitative and health economic studies. SETTING This trial was based in 21 NHS physiotherapy departments. PARTICIPANTS The participants were people with symptomatic OVF. INTERVENTIONS Seven sessions of either manual outpatient physiotherapy or exercise outpatient physiotherapy compared with the best practice of a 1-hour single session of physiotherapy (SSPT). MAIN OUTCOME MEASURES Outcomes were measured at 4 and 12 months. The primary outcomes were quality of life and muscle endurance, which were measured by the disease-specific QUALEFFO-41 (Quality of Life Questionnaire of the European Foundation for Osteoporosis - 41 items) and timed loaded standing (TLS) test, respectively. Secondary outcomes were (1) thoracic kyphosis angle, (2) balance, evaluated via the functional reach test (FRT), and (3) physical function, assessed via the Short Physical Performance Battery (SPPB), 6-minute walk test (6MWT), Physical Activity Scale for the Elderly, a health resource use and falls diary, and the EuroQol-5 Dimensions, five-level version. RESULTS A total of 615 participants were enrolled, with 216, 203 and 196 randomised by a computer-generated program to exercise therapy, manual therapy and a SSPT, respectively. Baseline data were available for 613 participants, 531 (86.6%) of whom were women; the mean age of these participants was 72.14 years (standard deviation 9.09 years). Primary outcome data were obtained for 69% of participants (429/615) at 12 months: 175 in the exercise therapy arm, 181 in the manual therapy arm and 173 in the SSPT arm. Interim analysis met the criteria for all arms to remain in the study. For the primary outcomes at 12 months, there were no significant benefits over SSPT of exercise [QUALEFFO-41, difference -0.23 points, 95% confidence interval (CI) -3.20 to 1.59 points; p = 1.000; and TLS test, difference 5.77 seconds, 95% CI -4.85 to 20.46 seconds; p = 0.437] or of manual therapy (QUALEFFO-41, difference 1.35 points, 95% CI -1.76 to 2.93 points; p = 0.744; TLS test, difference 9.69 seconds (95% CI 0.09 to 24.86 seconds; p = 0.335). At 4 months, there were significant gains for both manual therapy and exercise therapy over SSPT in the TLS test in participants aged < 70 years. Exercise therapy was superior to a SSPT at 4 months in the SPPB, FRT and 6MWT and manual therapy was superior to a SSPT at 4 months in the TLS test and FRT. Neither manual therapy nor exercise therapy was cost-effective relative to a SSPT using the threshold of £20,000 per quality-adjusted life-year. There were no treatment-related serious adverse events. CONCLUSIONS This is the largest RCT to date assessing physiotherapy in participants with OVFs. At 1 year, neither treatment intervention conferred more benefit than a single 1-hour physiotherapy advice session. The focus of future work should be on the intensity and duration of interventions to determine if changes to these would demonstrate more sustained effects. TRIAL REGISTRATION Current Controlled Trials ISRCTN49117867. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 44. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Karen L Barker
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Meredith Newman
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nigel Stallard
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Jose Leal
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Catherine Minns Lowe
- Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Muhammad K Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Angela Noufaily
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Anish Adhikari
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Tamsin Hughes
- Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - David J Smith
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Varsha Gandhi
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Cyrus Cooper
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah E Lamb
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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24
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Metcalfe D, Zogg CK, Judge A, Perry DC, Gabbe B, Willett K, Costa ML. Pay for performance and hip fracture outcomes: an interrupted time series and difference-in-differences analysis in England and Scotland. Bone Joint J 2019; 101-B:1015-1023. [PMID: 31362544 PMCID: PMC6683232 DOI: 10.1302/0301-620x.101b8.bjj-2019-0173.r1] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Aims Hip fractures are associated with high morbidity, mortality, and costs. One strategy for improving outcomes is to incentivize hospitals to provide better quality of care. We aimed to determine whether a pay-for-performance initiative affected hip fracture outcomes in England by using Scotland, which did not participate in the scheme, as a control. Materials and Methods We undertook an interrupted time series study with data from all patients aged more than 60 years with a hip fracture in England (2000 to 2018) using the Hospital Episode Statistics Admitted Patient Care (HES APC) data set linked to national death registrations. Difference-in-differences (DID) analysis incorporating equivalent data from the Scottish Morbidity Record was used to control for secular trends. The outcomes were 30-day and 365-day mortality, 30-day re-admission, time to operation, and acute length of stay. Results There were 1 037 860 patients with a hip fracture in England and 116 594 in Scotland. Both 30-day (DID -1.7%; 95% confidence interval (CI) -2.0 to -1.2) and 365-day (-1.9%; 95% CI -2.5 to -1.3) mortality fell in England post-intervention when compared with outcomes in Scotland. There were 7600 fewer deaths between 2010 and 2016 that could be attributed to interventions driven by pay-for-performance. A pre-existing annual trend towards increased 30-day re-admissions in England was halted post-intervention. Significant reductions were observed in the time to operation and length of stay. Conclusion This study provides evidence that a pay-for-performance programme improved the outcomes after a hip fracture in England. Cite this article: Bone Joint J 2019;101-B:1015–1023.
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Affiliation(s)
- D Metcalfe
- Oxford Trauma, Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), John Radcliffe Hospital, Oxford, UK
| | - C K Zogg
- Yale School of Medicine, New Haven, Connecticut, USA
| | - A Judge
- Centre for Statistics in Medicine, NDORMS, Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK.,Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Southmead Hospital, Bristol, UK.,National Institute for Health Research Bristol Biomedical Research Centre (NIHR Bristol BRC), University Hospitals Bristol NHS Foundation Trust, University of Bristol, Southmead Hospital, Bristol, UK.,MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - D C Perry
- Oxford Trauma, Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), John Radcliffe Hospital, Oxford, UK
| | - B Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - K Willett
- Oxford Trauma, Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), John Radcliffe Hospital, Oxford, UK
| | - M L Costa
- Oxford Trauma, Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), John Radcliffe Hospital, Oxford, UK
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25
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Collins FL, Stone MD, Turton J, McCabe LR, Wang ECY, Williams AS. Oestrogen-deficiency induces bone loss by modulating CD14 + monocyte and CD4 + T cell DR3 expression and serum TL1A levels. BMC Musculoskelet Disord 2019; 20:326. [PMID: 31299941 PMCID: PMC6626337 DOI: 10.1186/s12891-019-2704-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 07/03/2019] [Indexed: 12/13/2022] Open
Abstract
Background Oestrogen-deficiency induced by menopause is associated with reduced bone density and primary osteoporosis, resulting in an increased risk of fracture. While the exact etiology of menopause-induced primary osteoporotic bone loss is not fully known, members of the tumour necrosis factor super family (TNFSF) are known to play a role. Recent studies have revealed that the TNFSF members death receptor 3 (DR3) and one of its ligands, TNF-like protein 1A (TL1A) have a key role in secondary osteoporosis; enhancing CD14+ peripheral blood mononuclear cell (PBMC) osteoclast formation and bone resorption. Whether DR3 and TL1A contribute towards bone loss in menopause-induced primary osteoporosis however, remains unknown. Methods To investigate this we performed flow cytometry analysis of DR3 expression on CD14+ PBMCs isolated from pre- and early post-menopausal females and late post-menopausal osteoporotic patients. Serum levels of TL1A, CCL3 and total MMP-9 were measured by ELISA. In vitro osteoclast differentiation assays were performed to determine CD14+ monocyte osteoclastogenic potential. In addition, splenic CD4+ T cell DR3 expression was investigated 1 week and 8 weeks post-surgery, using the murine ovariectomy model. Results In contrast to pre-menopausal females, CD14+ monocytes isolated from post-menopausal females were unable to induce DR3 expression. Serum TL1A levels were decreased approx. 2-fold in early post-menopausal females compared to pre-menopausal controls and post-menopausal osteoporotic females; no difference was observed between pre-menopausal and late post-menopausal osteoporotic females. Analysis of in vitro CD14+ monocyte osteoclastogenic potential revealed no significant difference between the post-menopausal and post-menopausal osteoporotic cohorts. Interestingly, in the murine ovariectomy model splenic CD4+ T cell DR3 expression was significantly increased at 1 week but not 8 weeks post-surgery when compared to the sham control. Conclusion Our results reveals for the first time that loss of oestrogen has a significant effect on DR3; decreasing expression on CD14+ monocytes and increasing expression on CD4+ T cells. These data suggest that while oestrogen-deficiency induced changes in DR3 expression do not affect late post-menopausal bone loss they could potentially have an indirect role in early menopausal bone loss through the modulation of T cell activity.
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Affiliation(s)
- Fraser L Collins
- Division of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK. .,Department of Physiology, Michigan State University, East Lansing, MI, USA.
| | - Michael D Stone
- University Hospital Llandough, Cardiff & Vale University Health Board, Cardiff, UK
| | - Jane Turton
- University Hospital Llandough, Cardiff & Vale University Health Board, Cardiff, UK
| | - Laura R McCabe
- Department of Physiology, Michigan State University, East Lansing, MI, USA
| | - Eddie C Y Wang
- Division of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
| | - Anwen S Williams
- Division of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, UK
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26
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Nador G, Ramasamy K, Panitsas F, Pratt G, Sadler R, Javaid MK. Testing and management for monoclonal gammopathy of uncertain significance and myeloma patients presenting with osteoporosis and fragility fractures. Rheumatology (Oxford) 2019; 58:1142-1153. [PMID: 31225884 DOI: 10.1093/rheumatology/kez127] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 03/03/2019] [Indexed: 12/19/2022] Open
Abstract
Multiple myeloma, the second most frequent blood cancer, and its precursor, monoclonal gammopathy of uncertain significance, are associated with an increased risk of fragility fractures. However, current guidelines fail to offer explicit indications for healthcare professionals in terms of testing and thresholds for onward referral. The purpose of this review is to present the association of these conditions and metabolic bone disease and to highlight the importance of considering a diagnosis of monoclonal gammopathy of uncertain significance and myeloma in the context of a secondary fracture prevention assessment and of a multidisciplinary approach in managing these patients.
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Affiliation(s)
- Guido Nador
- Department of Clinical Haematology, Oxford University Hospitals, Oxford, UK
| | - Karthik Ramasamy
- Department of Clinical Haematology, Oxford University Hospitals, Oxford, UK.,NIHR, BRC Blood Theme, Oxford, UK
| | - Fotios Panitsas
- Haematology Department, Larissa University Hospital, Larissa, Greece
| | - Guy Pratt
- Haematology Department, University Hospitals Birmingham NHS Foundation Trust, Birmingham
| | - Ross Sadler
- Department of Immunology, Oxford University Hospitals, Oxford
| | - Muhammad Kassim Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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27
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Williams T, Wadeley A, Hardcastle S, Webb J, Shipley J, Ahmed T. Does measuring the bone mineral density of patients identified as having an osteopaenic X-ray appearance affect bone health treatment decisions? A real-world retrospective analysis. Clin Med (Lond) 2019. [DOI: 10.7861/clinmedicine.19-3-s16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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28
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Williams T, Wadeley A, Hardcastle S, Webb J, Shipley J, Ahmed T. Does measuring the bone mineral density of patients identified as having an osteopaenic X-ray appearance affect bone health treatment decisions? A real-world retrospective analysis. Clin Med (Lond) 2019. [DOI: 10.7861/clinmedicine.19-3s-s16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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29
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Naruphontjirakul P, Tsigkou O, Li S, Porter AE, Jones JR. Human mesenchymal stem cells differentiate into an osteogenic lineage in presence of strontium containing bioactive glass nanoparticles. Acta Biomater 2019; 90:373-392. [PMID: 30910622 DOI: 10.1016/j.actbio.2019.03.038] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 03/14/2019] [Accepted: 03/20/2019] [Indexed: 02/08/2023]
Abstract
While bioactive glass and ions released during its dissolution are known to stimulate osteoblast cells, the effect bioactive glass has on human stem cells is not clear. Here, we show that spherical monodispersed strontium containing bioactive nanoparticles (Sr-BGNPs) of composition 90.6 mol% SiO2, 5.0 mol% CaO, 4.4% mol% SrO (4.4%Sr-BGNPs) and 88.8 mol% SiO2, 1.8 mol% CaO, and 9.4 mol% SrO (9.4%Sr-BGNPs) stimulate bone marrow derived human stem cell (hMSC) differentiation down an osteogenic pathway without osteogenic supplements. The particles were synthesised using a modified Stӧber process and had diameters of 90 ± 10 nm. Previous work on similar particles that did not contain Sr (80 mol% SiO2, 20 mol% CaO) showed stem cells did not differentiate when exposed to the particles. Here, both compositions of the Sr-BGNPs (up to concentration of 250 μg/mL) stimulated the early-, mid-, and late-stage markers of osteogenic differentiation and accelerated mineralisation in the absence of osteogenic supplements. Sr ions play a key role in osteogenic stem cell differentiation. Sr-BGNP dissolution products did not adversely affect hMSC viability and no significant differences in viability were measured between each particle composition. Confocal and transmission electron microscopy (TEM) demonstrated that monodispersed Sr-BGNPs were internalised and localised within vesicles in the cytoplasm of hMSCs. Degradation of particles inside the cells was observed, whilst maintaining effective cations (Ca and Sr) in their silica network after 24 h in culture. The uptake of Sr-BGNPs by hMSCs was reduced by inhibitors of specific routes of endocytosis, indicating that the Sr-BGNPs uptake by hMSCs was probably via mixed endocytosis mechanisms. Sr-BGNPs have potential as injectable therapeutic devices for bone regeneration or treatment of conditions such as osteoporosis, because of their ability deliver a sustained release of osteogenic inorganic cations, e.g. calcium (Ca) or and strontium (Sr), through particle degradation locally to cells. STATEMENT OF SIGNIFICANCE: Here, we show that 90 nm spherical strontium containing bioactive nanoparticles of stimulate bone marrow derived human stem cell (hMSC) differentiation down an osteogenic pathway without the use of osteogenic supplements. While bioactive glass and its dissolution products are known to promote excellent bone regeneration in vivo and to stimulate osteoblast cells to produce bone matrix in vitro, their effect on human stem cells is not clear. Previously our nanoparticles that contained only SiO2 and CaO did not provoke human bone marrow or adipose derived stem cell differentiation.
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30
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Bhattacharya P, Altai Z, Qasim M, Viceconti M. A multiscale model to predict current absolute risk of femoral fracture in a postmenopausal population. Biomech Model Mechanobiol 2019; 18:301-318. [PMID: 30276488 PMCID: PMC6418062 DOI: 10.1007/s10237-018-1081-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 09/24/2018] [Indexed: 02/06/2023]
Abstract
Osteoporotic hip fractures are a major healthcare problem. Fall severity and bone strength are important risk factors of hip fracture. This study aims to obtain a mechanistic explanation for fracture risk in dependence of these risk factors. A novel modelling approach is developed that combines models at different scales to overcome the challenge of a large space-time domain of interest and considers the variability of impact forces between potential falls in a subject. The multiscale model and its component models are verified with respect to numerical approximations made therein, the propagation of measurement uncertainties of model inputs is quantified, and model predictions are validated against experimental and clinical data. The main results are model predicted absolute risk of current fracture (ARF0) that ranged from 1.93 to 81.6% (median 36.1%) for subjects in a retrospective cohort of 98 postmenopausal British women (49 fracture cases and 49 controls); ARF0 was computed up to a precision of 1.92 percentage points (pp) due to numerical approximations made in the model; ARF0 possessed an uncertainty of 4.00 pp due to uncertainties in measuring model inputs; ARF0 classified observed fracture status in the above cohort with AUC = 0.852 (95% CI 0.753-0.918), 77.6% specificity (95% CI 63.4-86.5%) and 81.6% sensitivity (95% CI 68.3-91.1%). These results demonstrate that ARF0 can be computed using the model with sufficient precision to distinguish between subjects and that the novel mechanism of fracture risk determination based on fall dynamics, hip impact and bone strength can be considered validated.
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Affiliation(s)
- Pinaki Bhattacharya
- Department of Mechanical Engineering, University of Sheffield, The Sir Frederick Mappin Building, Mappin Street, Sheffield, S1 3JD, UK.
- INSIGNEO Institute for in Silico Medicine, University of Sheffield, The Pam Liversidge Building, Mappin Street, Sheffield, S1 3JD, UK.
| | - Zainab Altai
- Department of Mechanical Engineering, University of Sheffield, The Sir Frederick Mappin Building, Mappin Street, Sheffield, S1 3JD, UK
- INSIGNEO Institute for in Silico Medicine, University of Sheffield, The Pam Liversidge Building, Mappin Street, Sheffield, S1 3JD, UK
| | - Muhammad Qasim
- Department of Mechanical Engineering, University of Sheffield, The Sir Frederick Mappin Building, Mappin Street, Sheffield, S1 3JD, UK
- INSIGNEO Institute for in Silico Medicine, University of Sheffield, The Pam Liversidge Building, Mappin Street, Sheffield, S1 3JD, UK
| | - Marco Viceconti
- Department of Mechanical Engineering, University of Sheffield, The Sir Frederick Mappin Building, Mappin Street, Sheffield, S1 3JD, UK
- INSIGNEO Institute for in Silico Medicine, University of Sheffield, The Pam Liversidge Building, Mappin Street, Sheffield, S1 3JD, UK
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31
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Craik J, Geleit R, Hiddema J, Bray E, Hampton R, Railton G, Ward D, Windley J. The effect of time to surgery on outcomes and complication rates following total hip arthroplasty for fractured neck of femur. Ann R Coll Surg Engl 2019; 101:342-345. [PMID: 30854861 DOI: 10.1308/rcsann.2019.0032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Total hip arthroplasty is recommended for elderly patients with fractured neck of femur who are independently mobile, have few co-morbidities and are not cognitively impaired. Providing a daily total hip arthroplasty service is challenging for some units in the UK and considering that these patients may be physiologically distinct from the average hip fracture patient, loss of the best practice tariff as a result of surgical delay may be unjustified. The aim of this study was to determine whether time to surgical intervention for patients eligible for total hip arthroplasty had a negative impact on patient complications, length of stay and functional outcomes. METHODS All patients undergoing total hip arthroplasty for fractured neck of femur at our institution over a ten-year period were identified. Complications and functional outcomes were compared between patients receiving total hip arthroplasty before and after 36 hours. RESULTS Of 112 consecutive patients undergoing total hip arthroplasty, 70 responded to a questionnaire or telephone consultation. Four patients were excluded owing to delayed presentation, the presence of advanced rheumatoid arthritis or a pathological fracture. Two-thirds (64%) of the remaining 66 patients underwent surgery within 36 hours of presentation. There were no significant differences between the groups of patients receiving surgery before or after 36 hours with regard to postoperative length of stay, complications, Oxford hip scores or visual analogue scale scores for state of health. CONCLUSIONS Delaying surgery for patients eligible for total hip arthroplasty as per the National Institute for Health and Care Excellence guidelines is justified and should not incur loss of the best practice tariff.
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Affiliation(s)
- J Craik
- Kingston Hospital NHS Foundation Trust , UK
| | - R Geleit
- Kingston Hospital NHS Foundation Trust , UK
| | - J Hiddema
- Kingston Hospital NHS Foundation Trust , UK
| | - E Bray
- Kingston Hospital NHS Foundation Trust , UK
| | - R Hampton
- Kingston Hospital NHS Foundation Trust , UK
| | - G Railton
- Kingston Hospital NHS Foundation Trust , UK
| | - D Ward
- Kingston Hospital NHS Foundation Trust , UK
| | - J Windley
- Kingston Hospital NHS Foundation Trust , UK
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Lawrence JE, Cundall-Curry D, Stewart ME, Fountain DM, Gooding CR. The use of an electronic health record system reduces errors in the National Hip Fracture Database. Age Ageing 2019; 48:285-290. [PMID: 30395143 DOI: 10.1093/ageing/afy177] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 07/31/2018] [Accepted: 10/14/2018] [Indexed: 12/24/2022] Open
Abstract
AIM to compare the validity of data submitted from a UK level 1 trauma centre to the National Hip Fracture Database (NHFD) before and after the introduction of an electronic health record system (EHRS). PATIENTS AND METHODS a total of 3224 records were reviewed from July 2009 to July 2017. 2,133 were submitted between July 2009 and October 2014 and 1,091 between October 2014 and July 2017, representing data submitted before and after the introduction of the EHRS, respectively. Data submitted to the NHFD were scrutinised against locally held data. RESULTS use of an EHRS was associated with significant reductions in NHFD errors. The operation coding error rate fell significantly from 23.2% (494/2133) to 7.6% (83/1091); P < 0.001. Prior to EHRS introduction, of the 109 deaths recorded in the NHFD, 64 (59%) were incorrect. In the EHRS dataset, all the 112 recorded deaths were correct (P < 0.001). There was no significant difference in the error rate for fracture coding. In the EHRS dataset, after controlling for sample month, entries utilising an operation note template with mandatory fields relevant to NHFD data were more likely to be error free than those not using the template (OR 2.69; 95% CI 1.92-3.78). CONCLUSION this study highlights a potential benefit of EHR systems, which offer automated data collection for auditing purposes. However, errors in data submitted to the NHFD remain, particularly in cases where an NHFD-specific operation note template is not used. Clinician engagement with new technologies is vital to avoid human error and ensure database integrity.
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Affiliation(s)
- John E Lawrence
- Department of Trauma and Orthopaedic Surgery, Cambridge University NHS Foundation Trust, Addenbrooke’s Hospital, Hills Road, Cambridge, UK
| | - Duncan Cundall-Curry
- Department of Trauma and Orthopaedic Surgery, Cambridge University NHS Foundation Trust, Addenbrooke’s Hospital, Hills Road, Cambridge, UK
| | - Max E Stewart
- School of Clinical Medicine, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Daniel M Fountain
- Department of Neurosciences, Division of Neurosurgery, Cambridge University NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK
| | - Christopher R Gooding
- Department of Trauma and Orthopaedic Surgery, Cambridge University NHS Foundation Trust, Addenbrooke’s Hospital, Hills Road, Cambridge, UK
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Raffin M, Bonnot O, Giannitelli M, Xavier J, Bodeau N, Bibrac B, Leban M, Fautrel B, Menard ML, Consoli A, Cohen D. Hormonal Risk Factors for Osteoporosis: Different Profile Among Antipsychotics. J Child Adolesc Psychopharmacol 2018; 28:719-726. [PMID: 30421978 DOI: 10.1089/cap.2017.0158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Objectives: Osteoporosis is a major risk factor for fracture and treatment is mainly preventive. Patients with severe psychiatric condition and treated with antipsychotics are at risk for vitamin D deficiency and iatrogenic hyperprolactinemia, two serious risk factors of osteoporosis. We aim to determine whether all antipsychotics are similar regarding the risk of osteoporosis in young patients. Methods: From January 2009 to March 2015, we determined the vitamin D blood level (VDBL) among 484 inpatients and from January 2012 to March 2015, we determined the prolactin blood level (PBL) among 205 inpatients. We systematically recorded well-documented risk factors (e.g., age, gender, ethnic origin, body mass index, or season) and suspected risk factors (e.g., disease type or antipsychotic treatment). Results: Up to 89% of the inpatients had a VDBL under the recommended threshold. Up to 60% of the inpatients had hyperprolactinemia. The multivariate model found a significant effect on VDBL for seasonality (higher VDBL in summer), ethnicity (lower VDBL in Black individuals), and treatment exposure. The multivariate model found a significant effect on PBL for gender and treatment exposure. In both models, aripiprazole had a safer profile compared with other antipsychotics. Conclusion: Because adolescence is a period of bone construction and a critical window of opportunity for maximizing bone mass, we recommend vitamin D supplementation in young patients with severe mental condition. It could be interesting to reconsider to regularly monitor PBL among youth patients treated with antipsychotic, with the exception of aripiprazole.
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Affiliation(s)
- Marie Raffin
- Department of Child and Adolescent Psychiatry, Assistance Publique-Hôpitaux de Paris, University Hospital Pitié-Salpêtrière, Paris, France.,Groupe de Recherche Clinique n°15 (PSYDEV), Assistance Publique-Hôpitaux de Paris, Sorbonne Université, UPMC Univ Paris 06, Paris, France
| | - Olivier Bonnot
- Department of Child and Adolescent Psychiatry, Nantes University Hospital, Nantes, France
| | - Marianna Giannitelli
- Department of Child and Adolescent Psychiatry, Assistance Publique-Hôpitaux de Paris, University Hospital Pitié-Salpêtrière, Paris, France.,Groupe de Recherche Clinique n°15 (PSYDEV), Assistance Publique-Hôpitaux de Paris, Sorbonne Université, UPMC Univ Paris 06, Paris, France
| | - Jean Xavier
- Department of Child and Adolescent Psychiatry, Assistance Publique-Hôpitaux de Paris, University Hospital Pitié-Salpêtrière, Paris, France.,Groupe de Recherche Clinique n°15 (PSYDEV), Assistance Publique-Hôpitaux de Paris, Sorbonne Université, UPMC Univ Paris 06, Paris, France.,CNRS UMR 7222, Institut des Systèmes Intelligents et Robotiques, UPMC, Paris, France
| | - Nicolas Bodeau
- Department of Child and Adolescent Psychiatry, Assistance Publique-Hôpitaux de Paris, University Hospital Pitié-Salpêtrière, Paris, France
| | - Barbara Bibrac
- Department of Child and Adolescent Psychiatry, Assistance Publique-Hôpitaux de Paris, University Hospital Pitié-Salpêtrière, Paris, France
| | - Monique Leban
- Pierre Louis Institute for Epidemiology and Public Health, Assistance Publique-Hôpitaux de Paris, UPMC-GRC 08, Paris, France
| | - Bruno Fautrel
- Department of Rheumatology, Assistance Publique-Hôpitaux de Paris, University Hospital Pitié-Salpêtrière, Paris, France
| | - Marie-Line Menard
- Department of Child and Adolescent Psychiatry, Nice Children's Hospitals CHU-Lenval, Nice, France
| | - Angele Consoli
- Department of Child and Adolescent Psychiatry, Assistance Publique-Hôpitaux de Paris, University Hospital Pitié-Salpêtrière, Paris, France.,Groupe de Recherche Clinique n°15 (PSYDEV), Assistance Publique-Hôpitaux de Paris, Sorbonne Université, UPMC Univ Paris 06, Paris, France
| | - David Cohen
- Department of Child and Adolescent Psychiatry, Assistance Publique-Hôpitaux de Paris, University Hospital Pitié-Salpêtrière, Paris, France.,Groupe de Recherche Clinique n°15 (PSYDEV), Assistance Publique-Hôpitaux de Paris, Sorbonne Université, UPMC Univ Paris 06, Paris, France.,CNRS UMR 7222, Institut des Systèmes Intelligents et Robotiques, UPMC, Paris, France
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Stirling ERB, Johnson NA, Dias JJ. Epidemiology of distal radius fractures in a geographically defined adult population. J Hand Surg Eur Vol 2018; 43:974-982. [PMID: 30016904 DOI: 10.1177/1753193418786378] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Distal radial fractures are the most common adult orthopaedic fracture. We sought to determine whether the incidence of this injury is changing and identify trends in its occurrence. We analysed data for all adult patients presenting to University Hospitals of Leicester with a distal radial fracture from 2007-2016. Incidence rates were calculated using United Kingdom population data. Poisson regression techniques were used to analyse weekly, seasonal and annual variation in fracture incidence. There was no significant change in average age or incidence of fracture. Increased incidence was associated with inclement weather conditions. Younger patients more commonly sustain fractures on weekends. We predict a 23% rise in the number of fractures in the United Kingdom in the next 20 years. The incidence of fracture does not appear to be changing, although the number of fractures is growing. Weekly and seasonal trends are apparent. Level of evidence: III.
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Affiliation(s)
- Euan R B Stirling
- Academic Team of Musculoskeletal Surgery, Leicester General Hospital, Leicester, UK
| | - Nick A Johnson
- Academic Team of Musculoskeletal Surgery, Leicester General Hospital, Leicester, UK
| | - Joseph J Dias
- Academic Team of Musculoskeletal Surgery, Leicester General Hospital, Leicester, UK
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Leal J, Manetti S, Buchanan J. The Impact of Hospital Costing Methods on Cost-Effectiveness Analysis: A Case Study. PHARMACOECONOMICS 2018; 36:1263-1272. [PMID: 29785689 PMCID: PMC6132447 DOI: 10.1007/s40273-018-0673-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
BACKGROUND Several methods exist to cost hospital contacts when estimating the cost effectiveness of a new intervention. However, the implications of choosing a particular approach remain unclear. We compare the use of the three main diagnosis-related group (DRG)-based national unit costs in England to determine whether choice of approach can impact on economic evaluation results. METHODS A cost-utility model was developed to compare secondary fracture prevention models of care for hip fracture patients, using data from large primary and hospital care administrative datasets in England. A healthcare and personal social services payer perspective was adopted, and utilities were informed by a meta-regression. Hospital resource use was valued using three DRG-based unit costs, and regression-based costing models were developed using data from 13,906 patients to inform the model health states. RESULTS Finished consultant episode (FCE)-level reference costs resulted in the highest costs on admission (£9075) and in the year of the fracture (£14,440). Relative to FCE-level costs, spell-level tariffs led to the lowest total hospital care costs per patient within 1 year of fracture (- £3691) compared with spell-level reference costs (- £2106). At a £20,000/quality-adjusted life-year threshold, using spell-level reference costs or spell-level tariffs, the introduction of a nurse-led fracture liaison service model of care was the cost-effective alternative. However, using FCE-level reference costs, usual care was the cost-effective option. CONCLUSIONS Our results show that, conditional on the set of national unit costs adopted, the costs of hip fracture may vary considerably and different decisions may be reached regarding the introduction of new healthcare interventions.
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Affiliation(s)
- José Leal
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK
| | - Stefania Manetti
- Institute of Management, Scuola Superiore Sant'Anna, Pisa, Italy
| | - James Buchanan
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7LF, UK.
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Richards T, Glendenning A, Benson D, Alexander S, Thati S. The independent patient factors that affect length of stay following hip fractures. Ann R Coll Surg Engl 2018; 100:556-562. [PMID: 29692191 PMCID: PMC6214067 DOI: 10.1308/rcsann.2018.0068] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2018] [Indexed: 11/22/2022] Open
Abstract
Introduction Management of hip fractures has evolved over recent years to drive better outcomes including length of hospital stay. We aimed to identify and quantify the effect that patient factors influence acute hospital and total health service length of stay. Methods A retrospective observational study based on National Hip Fracture Database data was conducted from 1 January 2014 to 31 December 2015. A multiple regression analysis of 330 patients was carried out to determine independent factors that affect acute hospital and total hospital length of stay. Results American Society of Anesthesiologists (ASA) grade 3 or above, Abbreviated Mental Test Score (AMTS) less than 8 and poor mobility status were independent factors, significantly increasing length of hospital stay in our population. Acute hospital length of stay can be predicted as 8.9 days longer when AMTS less than 8, 4.2 days longer when ASA grade was 3 or above and 20.4 days longer when unable to mobilise unaided (compared with independently mobile individuals). Other factors including total hip replacement compared with hemiarthroplasty did not independently affect length of stay. Conclusions Our analysis in a representative and generalisable population illustrates the importance of identifying these three patient characteristics in hip fracture patients. When recognised and targeted with orthogeriatric support, the length of hospital stay for these patients can be reduced and overall hip fracture care improved. Screening on admission for ASA grade, AMTS and mobility status allows prediction of length of stay and tailoring of care to match needs.
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Affiliation(s)
- T Richards
- Trauma and Orthopaedic Department, Ysbyty Gwynedd, Bangor, Wales, UK
| | - A Glendenning
- Swansea University Medical School, Swansea, Wales, UK
| | - D Benson
- Trauma and Orthopaedic Department, Ysbyty Gwynedd, Bangor, Wales, UK
| | - S Alexander
- Orthogeriatrics Department, Ysbyty Gwynedd, Bangor, Wales, UK
| | - S Thati
- Trauma and Orthopaedic Department, Ysbyty Gwynedd, Bangor, Wales, UK
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Sims AL, Parsons N, Achten J, Griffin XL, Costa ML, Reed MR. A randomized controlled trial comparing the Thompson hemiarthroplasty with the Exeter polished tapered stem and Unitrax modular head in the treatment of displaced intracapsular fractures of the hip: the WHiTE 3: HEMI Trial. Bone Joint J 2018; 100-B:352-360. [PMID: 29589786 PMCID: PMC6413801 DOI: 10.1302/0301-620x.100b3.bjj-2017-0872.r2] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Aims This study aimed to compare the change in health-related quality of life of patients receiving a traditional cemented monoblock Thompson hemiarthroplasty compared with a modern cemented modular polished-taper stemmed hemiarthroplasty for displaced intracapsular hip fractures. Patients and Methods This was a pragmatic, multicentre, multisurgeon, two-arm, parallel group, randomized standard-of-care controlled trial. It was embedded within the WHiTE Comprehensive Cohort Study. The sample size was 964 patients. The setting was five National Health Service Trauma Hospitals in England. A total of 964 patients over 60 years of age who required hemiarthroplasty of the hip between February 2015 and March 2016 were included. A standardized measure of health outcome, the EuroQol (EQ-5D-5L) questionnaire, was carried out on admission and at four months following the operation. Results Of the 964 patients enrolled, 482 died or were lost to follow-up (50%). No significant differences were noted in EQ-5D between groups, with a mean difference at four months of 0.037 in favour of the Exeter/Unitrax implant (95% confidence interval (CI) 0.014 to 0.087, p = 0.156), rising to 0.045 (95% CI 0.007 to 0.098, p = 0.09) when patients who died were excluded. The minimum clinically important difference for EQ-5D-5L used in this study is 0.08, therefore any benefit between implants is unlikely to be noticeable to the patient. There was no difference in mortality or mobility score. Conclusion Allowing for the high rate of loss to follow-up, the use of the traditional Thompson hemiarthroplasty in the treatment of the displaced intracapsular hip fracture shows no difference in health outcome when compared with a modern cemented hemiarthroplasty. Cite this article: Bone Joint J 2018;100-B:352-60.
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Affiliation(s)
- A L Sims
- Health Education North East, Waterfront, 4 Goldcrest Way, Newburn Riverside, Newcastle Upon Tyne, NE15 8NY, UK
| | - N Parsons
- Statistics and Epidemiology, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - J Achten
- Department of Orthopaedic Trauma, Oxford Trauma, University of Oxford, Kadoorie Centre, Level 3, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - X L Griffin
- Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford and Oxford Trauma, Nuffield Department of Rheumatology, Orthopaedics and Musculoskeletal Science, University of Oxford, OX3 9DU, UK
| | - M L Costa
- NDORMS, Oxford Trauma, Kadoorie Centre, University of Oxford, John Radcliffe Hospital, Windmill Road, Oxford, OX3 9DU, UK
| | - M R Reed
- Northumbria Healthcare NHS Foundation Trust, Woodhorn Lane, NE63 9JJ, UK
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Karim JS, Reynolds J, Salar O, Davis ET, Quraishi S, Ahmed M. Home, No Follow-Up: Are we ignoring the significance of unplanned clinic attendances, re-admission and mortality in the first 12 months post-operatively in over 65 year olds' hip fractures treated with DHS fixation? Injury 2018; 49:662-666. [PMID: 29422294 DOI: 10.1016/j.injury.2018.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 12/16/2017] [Accepted: 01/06/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION 80,000 hip fractures are admitted to UK hospitals annually (Royal College of Physicians, 2016). Little is known about 12-month post-operative re-admission, unplanned clinic attendance and mortality. We aimed to determine if there is a role for routine follow-up for certain strata of our hip fracture population treated by Dynamic Hip Screw (DHS) Fixation based on unplanned attendance to clinics and whether it is possible to stratify risk of re-admission, re-operation and mortality within the first 12 months post-operatively. METHODS A prospectively collated single centre database of patients >65 years old undergoing DHS fixation for traumatic hip fractures between August 2007 and February 2011 was retrospectively analysed. Pre-operative data regarding patient demographics, mobility, residence and co-morbidities were collected. Post-operative (1, 4, 12 months) place of residence, mobility status, unplanned attendance to an orthopaedic clinic with symptoms relating to the respective limb, re-admission to hospital and mortality was collated. Regression analysis was performed (SPSS, IBM Corporation, version 24). P < 0.05 was considered significant. RESULTS 648 consecutive patients were identified. Increasing age (p = 0.006) and presence of pressure sores during initial admission (p = 0.0019) increased the frequency of unplanned clinic attendance. No significant predictors of re-admission to hospital were found. Overall mortality was related to increasing age (p = 0.042), male gender (p = 0.004) and ASA grade (p = 0.009). CONCLUSION There is no current vogue to follow-up such patients in this post-operative period. We have identified variables that should be sought prior to discharge in this population. 22% of our population had at least one unplanned clinic attendance with a cost implication of approximately £50,132 (£151 per appointment) over the study period and potentially over £1.6 million pounds annually in the U.K. IMPLICATIONS Formal follow-up/rehabilitation programs could be offered for those at risk of unplanned clinic attendance. Post-operative orthogeriatric and/or general practitioner follow-up may reduce 12-month mortality in those at risk but validated scoring and risk stratification systems are required to fully justify this.
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Affiliation(s)
- J S Karim
- Department of Orthopaedic Surgery, Russells Hall Hospital, The Dudley Group of Hospitals, Dudley, United Kingdom.
| | - J Reynolds
- Department of Orthopaedic Surgery, Russells Hall Hospital, The Dudley Group of Hospitals, Dudley, United Kingdom
| | - O Salar
- Department of Orthopaedic Surgery, Russells Hall Hospital, The Dudley Group of Hospitals, Dudley, United Kingdom
| | - E T Davis
- Department of Orthopaedic Surgery, Russells Hall Hospital, The Dudley Group of Hospitals, Dudley, United Kingdom
| | - S Quraishi
- Department of Orthopaedic Surgery, Russells Hall Hospital, The Dudley Group of Hospitals, Dudley, United Kingdom
| | - M Ahmed
- Department of Orthopaedic Surgery, Russells Hall Hospital, The Dudley Group of Hospitals, Dudley, United Kingdom
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Davis S, Martyn-St James M, Sanderson J, Stevens J, Goka E, Rawdin A, Sadler S, Wong R, Campbell F, Stevenson M, Strong M, Selby P, Gittoes N. A systematic review and economic evaluation of bisphosphonates for the prevention of fragility fractures. Health Technol Assess 2018; 20:1-406. [PMID: 27801641 DOI: 10.3310/hta20780] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Fragility fractures are fractures that result from mechanical forces that would not ordinarily result in fracture. OBJECTIVES To evaluate the clinical effectiveness and safety of bisphosphonates [alendronic acid (Fosamax® and Fosamax® Once Weekly, Merck Sharp & Dohme Ltd), risedronic acid (Actonel® and Actonel Once a Week®, Warner Chilcott UK Ltd), ibandronic acid (Bonviva®, Roche Products Ltd) and zoledronic acid (Aclasta®, Novartis Pharmaceuticals UK Ltd)] for the prevention of fragility fracture and to assess their cost-effectiveness at varying levels of fracture risk. DATA SOURCES For the clinical effectiveness review, six electronic databases and two trial registries were searched: MEDLINE, EMBASE, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Web of Science and BIOSIS Previews, Clinicaltrials.gov and World Health Organization International Clinical Trials Registry Platform. Searches were limited by date from 2008 until September 2014. REVIEW METHODS A systematic review and network meta-analysis (NMA) of effectiveness studies were conducted. A review of published economic analyses was undertaken and a de novo health economic model was constructed. Discrete event simulation was used to estimate lifetime costs and quality-adjusted life-years (QALYs) for each bisphosphonate treatment strategy and a strategy of no treatment for a simulated cohort of patients with heterogeneous characteristics. The model was populated with effectiveness evidence from the systematic review and NMA. All other parameters were estimated from published sources. A NHS and Personal Social Services perspective was taken, and costs and benefits were discounted at 3.5% per annum. Fracture risk was estimated from patient characteristics using the QFracture® (QFracture-2012 open source revision 38, Clinrisk Ltd, Leeds, UK) and FRAX® (web version 3.9, University of Sheffield, Sheffield, UK) tools. The relationship between fracture risk and incremental net benefit (INB) was estimated using non-parametric regression. Probabilistic sensitivity analysis (PSA) and scenario analyses were used to assess uncertainty. RESULTS Forty-six randomised controlled trials (RCTs) were included in the clinical effectiveness systematic review, with 27 RCTs providing data for the fracture NMA and 35 RCTs providing data for the femoral neck bone mineral density (BMD) NMA. All treatments had beneficial effects on fractures versus placebo, with hazard ratios varying from 0.41 to 0.92 depending on treatment and fracture type. The effects on vertebral fractures and percentage change in BMD were statistically significant for all treatments. There was no evidence of a difference in effect on fractures between bisphosphonates. A statistically significant difference in the incidence of influenza-like symptoms was identified from the RCTs for zoledronic acid compared with placebo. Reviews of observational studies suggest that upper gastrointestinal symptoms are frequently reported in the first month of oral bisphosphonate treatment, but pooled analyses of placebo-controlled trials found no statistically significant difference. A strategy of no treatment was estimated to have the maximum INB for patients with a 10-year QFracture risk under 1.5%, whereas oral bisphosphonates provided maximum INB at higher levels of risk. However, the PSA suggested that there is considerable uncertainty regarding whether or not no treatment is the optimal strategy until the QFracture score is around 5.5%. In the model using FRAX, the mean INBs were positive for all oral bisphosphonate treatments across all risk categories. Intravenous bisphosphonates were estimated to have lower INBs than oral bisphosphonates across all levels of fracture risk when estimated using either QFracture or FRAX. LIMITATIONS We assumed that all treatment strategies are viable alternatives across the whole population. CONCLUSIONS Bisphosphonates are effective in preventing fragility fractures. However, the benefit-to-risk ratio in the lowest-risk patients may be debatable given the low absolute QALY gains and the potential for adverse events. We plan to extend the analysis to include non-bisphosphonate therapies. STUDY REGISTRATION This study is registered as PROSPERO CRD42013006883. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Sarah Davis
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Marrissa Martyn-St James
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Jean Sanderson
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - John Stevens
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Edward Goka
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Andrew Rawdin
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Susi Sadler
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Ruth Wong
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Fiona Campbell
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Matt Stevenson
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Mark Strong
- Health Economics and Decision Science, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Peter Selby
- Department of Medicine, University of Manchester, Manchester Royal Infirmary, Manchester, UK
| | - Neil Gittoes
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, University Hospitals Birmingham, Birmingham, UK
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Effect of tranexamic acid use on blood loss and thromboembolic risk in hip fracture surgery: systematic review and meta-analysis. Hip Int 2018; 28:3-10. [PMID: 28983887 DOI: 10.5301/hipint.5000556] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Intravenous tranexamic acid (IV TXA) is a recognised pharmaceutical intervention utilised to minimise blood loss and allogenic blood transfusion. However, the use of IV TXA in hip fracture surgery remains inconclusive. We conducted a meta-analysis to investigate the role of TXA in operative hip fracture management on operative and total blood loss, allogenic blood transfusion requirements and impact on venous thromboembolic (VTE) event incidence. METHODS A systematic computerised literature search of PubMed, Medline, Embase, Ovid, The Cochrane Controlled Trials Register, Trip and Google was conducted. We reviewed the efficacy of IV TXA on perioperative blood loss, total blood loss, pre- and postoperative haemoglobin differences, duration of surgery, allogenic blood transfusion requirements and VTE events. RESULTS 8 studies were eligible including 6 randomised control trials and 2 cohort studies. Patients receiving IV TXA had reduced mean total blood loss of 442.9 mls (95% CI, 426.5-459.3; p<0.00001), reduced operative blood loss of 88.5 mls (95% CI, 59.9-117.2; p<0.00001), a decrease in the need for allogenic blood transfusion (OR 0.37; 95% CI, 0.26-0.53; p<0.00001) and a reduction in pre- and postoperative haemoglobin difference (p = 0.013.) There was no significant increase in VTE risk (OR 1.59; 95% CI 0.67-3.75; p>0.29) or significant difference on duration of surgery seen with IV TXA usage (p>0.06). CONCLUSIONS Our review demonstrated the efficacy of IV TXA in minimising perioperative, reducing total blood loss and lowering the necessity for allogenic blood transfusions with no significant increased risk in VTE events.
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Rath S, Yadav L, Tewari A, Chantler T, Woodward M, Kotwal P, Jain A, Dey A, Garg B, Malhotra R, Goel A, Farooque K, Sharma V, Webster P, Norton R. Management of older adults with hip fractures in India: a mixed methods study of current practice, barriers and facilitators, with recommendations to improve care pathways. Arch Osteoporos 2017; 12:55. [PMID: 28577286 PMCID: PMC5486685 DOI: 10.1007/s11657-017-0344-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 05/03/2017] [Indexed: 02/03/2023]
Abstract
Evidence-based management can reduce deaths and suffering of older adults with hip fractures. This study investigates the evidence-practice gaps in hip fracture care in three major hospitals in Delhi, potential barriers and facilitators to improving care, and consequently, identifies contextually appropriate interventions for implementing best practice for management of older adults with hip fractures in India. PURPOSE Hip fracture in older adults is a significant public health issue in India. The current study sought to document current practices, identify barriers and facilitators to adopting best practice guidelines and recommend improvements in the management of older adults with hip fractures in Delhi, India. METHODS This mixed methods observational study collected data from healthcare providers, patients, carers and medical records from three major public tertiary care hospitals in Delhi, India. All patients aged ≥50 years with an X-ray confirmed hip fracture that were admitted to these hospitals over a 10-week period were recruited. Patients' data were collected at admission, discharge and 30 days post-injury. Eleven key informant interviews and four focus group discussions were conducted with healthcare providers. Descriptive data for key quantitative variables were computed. The qualitative data were analysed and interpreted using a behaviour change wheel framework. RESULTS A total of 136 patients, 74 (54%) men and 62 women, with hip fracture were identified in the three participating hospitals during the recruitment period and only 85 (63%) were admitted for treatment with a mean age of 66.5 years (SD 11.9). Of these, 30% received surgery within 48 h of hospital admission, 95% received surgery within 39 days of hospital admission and two (3%) had died by 30 days of injury. According to the healthcare providers, inadequate resources and overcrowding prevent adequate caring of the hip fracture patients. They unanimously felt the need for protocol-based management of hip fracture in India. CONCLUSION The development and implementation of national guidelines and standardized protocols of care for older people with hip fractures in India has the potential to improve both care and patient-related outcomes.
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Affiliation(s)
- Santosh Rath
- The George Institute for Global Health, University of Oxford, Oxford, UK
- IGHI, Imperial College, Kensington, London, SW7 2AZ UK
| | - Lalit Yadav
- The George Institute for Global Health, New Delhi, India
| | - Abha Tewari
- The George Institute for Global Health, New Delhi, India
| | | | - Mark Woodward
- The George Institute for Global Health, University of Oxford, Oxford, UK
- The George Institute for Global Health, University of Sydney, Sydney, Australia
| | - Prakash Kotwal
- Department of Orthopaedics, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Anil Jain
- Department of Orthopaedics, University College of Medical Sciences, Delhi, India
| | - Aparajit Dey
- Department of Geriatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Bhavuk Garg
- Department of Orthopaedics, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Rajesh Malhotra
- Department of Orthopaedics, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Ashish Goel
- Department of Medicine, University College of Medical Sciences, Delhi, India
| | - Kamran Farooque
- JPN Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Vijay Sharma
- JPN Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Premila Webster
- School of Public Health, Nuffield Department of Population Sciences, University of Oxford, Oxford, UK
| | - Robyn Norton
- The George Institute for Global Health, University of Sydney, Sydney, Australia
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Vun JSH, Ahmadi M, Panteli M, Pountos I, Giannoudis PV. Dementia and fragility fractures: Issues and solutions. Injury 2017; 48 Suppl 7:S10-S16. [PMID: 28851522 DOI: 10.1016/j.injury.2017.08.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Dementia and fragility fractures are two conditions that pose significant morbidity and mortality to the elderly population. The occurrence of the 'gerontic' boom as a result of improved healthcare meant a continued increase in the prevalence of fragility fractures and dementia. This represents a major public health problem with significant socioeconomic repercussions. It is therefore important for healthcare professionals to gain a better understanding on the relationship between these two commonly co-existing conditions. In this review, we present the available literature surrounding the relationship between fragility fractures and dementia, and the common challenges faced in the management of these two conditions. Combining evidence from the literature along with our current clinical practice, we propose a management pathway aimed at early diagnosis, prevention and management of these two often co-existing conditions. This alongside with a multidisciplinary approach will not only translate to improved patient outcomes and survivorship, but also reduced healthcare cost and socio-economic burden. To date, there is insufficient evidence from the literature to suggest whether dementia is the cause or effect for fragility fractures, or if indeed there is a bidirectional relationship between the two conditions. Further studies are required to shed light onto this important clinical topic.
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Affiliation(s)
- James S H Vun
- Trauma & Orthopaedic Specialist Registrar, Pinderfields General Hospital, Wakefield, UK
| | - Milad Ahmadi
- Trauma & Orthopaedic Specialist Registrar, Huddersfield General Hospital, Huddersfield, UK
| | - Michalis Panteli
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, UK.
| | - Ippokratis Pountos
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, UK
| | - Peter V Giannoudis
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, UK; NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, UK
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Abstract
With ageing, bone tissue undergoes significant compositional, architectural and metabolic alterations potentially leading to osteoporosis. Osteoporosis is the most prevalent bone disorder, which is characterised by progressive bone weakening and an increased risk of fragility fractures. Although this metabolic disease is conventionally associated with ageing and menopause, the predisposing factors are thought to be established during childhood and adolescence. In light of this, exercise interventions implemented during maturation are likely to be highly beneficial as part of a long-term strategy to maximise peak bone mass and hence delay the onset of age- or menopause-related osteoporosis. This notion is supported by data on exercise interventions implemented during childhood and adolescence, which confirmed that weight-bearing activity, particularly if undertaken during peripubertal development, is capable of generating a significant osteogenic response leading to bone anabolism. Recent work on human ageing and epigenetics suggests that undertaking exercise after the fourth decade of life is still important, given the anti-ageing effect and health benefits provided, potentially occurring via a delay in telomere shortening and modification of DNA methylation patterns associated with ageing. Exercise is among the primary modifiable factors capable of influencing bone health by preserving bone mass and strength, preventing the death of bone cells and anti-ageing action provided.
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Hannam K, Deere KC, Hartley A, Clark EM, Coulson J, Ireland A, Moss C, Edwards MH, Dennison E, Gaysin T, Cooper R, Wong A, McPhee JS, Cooper C, Kuh D, Tobias JH. A novel accelerometer-based method to describe day-to-day exposure to potentially osteogenic vertical impacts in older adults: findings from a multi-cohort study. Osteoporos Int 2017; 28:1001-1011. [PMID: 27798733 PMCID: PMC5306163 DOI: 10.1007/s00198-016-3810-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 10/12/2016] [Indexed: 10/26/2022]
Abstract
UNLABELLED This observational study assessed vertical impacts experienced in older adults as part of their day-to-day physical activity using accelerometry and questionnaire data. Population-based older adults experienced very limited high-impact activity. The accelerometry method utilised appeared to be valid based on comparisons between different cohorts and with self-reported activity. INTRODUCTION We aimed to validate a novel method for evaluating day-to-day higher impact weight-bearing physical activity (PA) in older adults, thought to be important in protecting against osteoporosis, by comparing results between four cohorts varying in age and activity levels, and with self-reported PA levels. METHODS Participants were from three population-based cohorts, MRC National Survey of Health and Development (NSHD), Hertfordshire Cohort Study (HCS) and Cohort for Skeletal Health in Bristol and Avon (COSHIBA), and the Master Athlete Cohort (MAC). Y-axis peaks (reflecting the vertical when an individual is upright) from a triaxial accelerometer (sampling frequency 50 Hz, range 0-16 g) worn at the waist for 7 days were classified as low (0.5-1.0 g), medium (1.0-1.5 g) or higher (≥1.5 g) impacts. RESULTS There were a median of 90, 41 and 39 higher impacts/week in NSHD (age 69.5), COSHIBA (age 76.8) and HCS (age 78.5) participants, respectively (total n = 1512). In contrast, MAC participants (age 68.5) had a median of 14,322 higher impacts/week. In the three population cohorts combined, based on comparison of beta coefficients, moderate-high-impact activities as assessed by PA questionnaire were suggestive of stronger association with higher impacts from accelerometers (0.25 [0.17, 0.34]), compared with medium (0.18 [0.09, 0.27]) and low impacts (0.13 [0.07,0.19]) (beta coefficient, with 95 % CI). Likewise in MAC, reported moderate-high-impact activities showed a stronger association with higher impacts (0.26 [0.14, 0.37]), compared with medium (0.14 [0.05, 0.22]) and low impacts (0.03 [-0.02, 0.08]). CONCLUSIONS Our new accelerometer method appears to provide valid measures of higher vertical impacts in older adults. Results obtained from the three population-based cohorts indicate that older adults generally experience very limited higher impact weight-bearing PA.
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Affiliation(s)
- K Hannam
- Musculoskeletal Research Unit, University of Bristol School of Clinical Sciences, Bristol, BS10 5NB, UK
| | - K C Deere
- Musculoskeletal Research Unit, University of Bristol School of Clinical Sciences, Bristol, BS10 5NB, UK
| | - A Hartley
- Musculoskeletal Research Unit, University of Bristol School of Clinical Sciences, Bristol, BS10 5NB, UK
| | - E M Clark
- Musculoskeletal Research Unit, University of Bristol School of Clinical Sciences, Bristol, BS10 5NB, UK
| | - J Coulson
- School of Healthcare Sciences, Manchester Metropolitan University, Manchester, M15 6BH, UK
| | - A Ireland
- School of Healthcare Sciences, Manchester Metropolitan University, Manchester, M15 6BH, UK
| | - C Moss
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK
| | - M H Edwards
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK
| | - E Dennison
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK
| | - T Gaysin
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 6BT, UK
| | - R Cooper
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 6BT, UK
| | - A Wong
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 6BT, UK
| | - J S McPhee
- School of Healthcare Sciences, Manchester Metropolitan University, Manchester, M15 6BH, UK
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, SO16 6YD, UK
| | - D Kuh
- MRC Unit for Lifelong Health and Ageing at UCL, London, WC1E 6BT, UK
| | - J H Tobias
- Musculoskeletal Research Unit, University of Bristol School of Clinical Sciences, Bristol, BS10 5NB, UK.
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Johnson NA, Stirling ERB, Divall P, Thompson JR, Ullah AS, Dias JJ. Risk of hip fracture following a wrist fracture-A meta-analysis. Injury 2017; 48:399-405. [PMID: 27839795 DOI: 10.1016/j.injury.2016.11.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 10/31/2016] [Accepted: 11/01/2016] [Indexed: 02/02/2023]
Abstract
AIMS This purpose of this meta analysis was to investigate and quantify the relative risk of hip fracture in patients who have sustained a wrist fracture. METHOD Studies were identified by searching Medline, Embase, Cochrane CENTRAL database and CINAHL from their inception to August 2015. Studies reporting confirmed hip fracture following wrist fracture were included. Data extraction was carried out using a modified Cochrane data collection form by two reviewers independently. Quality assessment was carried out using a modified Coleman score and the Newcastle Ottawa scale for cohort studies. An assessment of bias was performed for each study using a modified Cochrane Risk of Bias tool. A pooled relative risk(RR) was estimated with 95% CI from the RR/HRs and CIs reported in the studies. RESULTS 12 studies were included in the final meta-analysis (4 male, 8 female only). Relative risk of hip fracture following wrist fracture for women was 1.43 (CI 1.27 to 1.60). In men it was not significantly increased (RR 2.11, 95% CI: 0.93-4.85). Heterogeneity was low (I squared 0%) for both groups so a fixed effects model was used. CONCLUSION Risk of a subsequent hip fracture is increased for women who suffer a wrist fracture (RR 1.43). Resources and preventative measures should be targeted towards these high risk patients to prevent the catastrophic event of a hip fracture. This meta analysis confirms and quantifies the increased relative risk of hip fracture after wrist fracture in women.
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Affiliation(s)
| | | | - P Divall
- University Hospitals of Leicester, UK
| | | | - A S Ullah
- University Hospitals of Leicester, UK
| | - J J Dias
- University Hospitals of Leicester, UK
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Sprowson AP, Jensen C, Chambers S, Parsons NR, Aradhyula NM, Carluke I, Inman D, Reed MR. The use of high-dose dual-impregnated antibiotic-laden cement with hemiarthroplasty for the treatment of a fracture of the hip: The Fractured Hip Infection trial. Bone Joint J 2017; 98-B:1534-1541. [PMID: 27803231 PMCID: PMC5102031 DOI: 10.1302/0301-620x.98b11.34693] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 07/06/2016] [Indexed: 12/27/2022]
Abstract
Aims A fracture of the hip is the most common serious orthopaedic
injury, and surgical site infection (SSI) is one of the most significant
complications, resulting in increased mortality, prolonged hospital
stay and often the need for further surgery. Our aim was to determine
whether high dose dual antibiotic impregnated bone cement decreases the
rate of infection. Patients and Methods A quasi-randomised study of 848 patients with an intracapsular
fracture of the hip was conducted in one large teaching hospital
on two sites. All were treated with a hemiarthroplasty. A total
of 448 patients received low dose single-antibiotic impregnated
cement (control group) and 400 patients received high dose dual-antibiotic impregnated
cement (intervention group). The primary outcome measure was deep
SSI at one year after surgery. Results The rate of deep SSI was 3.5% in the control group and 1.1% in
the intervention group
(p = 0.041; logistic regression adjusting for age and gender). The
overall rate of non-infective surgical complications did not differ
between the two groups (unadjusted chi-squared test; p > 0.999). Conclusion The use of high dose dual-antibiotic impregnated cement in these
patients significantly reduces the rate of SSI compared with standard
low dose single antibiotic loaded bone cement. Cite this article: Bone Joint J 2016;98-B:1534–1541.
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Affiliation(s)
| | - C Jensen
- Northumbria Healthcare NHS Foundation Trust, Wansbeck General Hospital, Woodhorn Lane, Ashington, NE63 9JJ, UK
| | - S Chambers
- Northern Deanery Training Programme, Waterfront 4, Goldcrest Way, Newburn Riverside, Newcastle-upon-Tyne, NE15 8NY, UK
| | - N R Parsons
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - N M Aradhyula
- Northumbria Healthcare NHS Foundation Trust, Wansbeck General Hospital, Woodhorn Lane, Ashington, NE63 9JJ, UK
| | - I Carluke
- Northumbria Healthcare NHS Foundation Trust, Wansbeck General Hospital, Woodhorn Lane, Ashington, NE63 9JJ, UK
| | - D Inman
- Northumbria Healthcare NHS Foundation Trust, North Tyneside General Hospital, Rake Lane, North Shields, NE29 8NH, UK
| | - M R Reed
- Northumbria Healthcare NHS Foundation Trust, Wansbeck General Hospital, Woodhorn Lane, Ashington, NE63 9JJ, UK
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van der Velde RY, Wyers CE, Teesselink E, Geusens PPMM, van den Bergh JPW, de Vries F, Cooper C, Harvey NC, van Staa TP. Trends in oral anti-osteoporosis drug prescription in the United Kingdom between 1990 and 2012: Variation by age, sex, geographic location and ethnicity. Bone 2017; 94:50-55. [PMID: 27742502 PMCID: PMC5124498 DOI: 10.1016/j.bone.2016.10.013] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 09/28/2016] [Accepted: 10/10/2016] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Given the expected increase in the number of patients with osteoporosis and fragility fractures it is important to have concise information on trends in prescription rates of anti-osteoporosis drugs (AOD). METHODS We undertook a retrospective observational study using the UK Clinical Practice Research Datalink (CPRD) in the UK between 1990 and 2012 in subjects 50years or older, stratified by age, sex, geographic region and ethnicity. Yearly prescription incidence rates of any AOD and of each specific AOD were calculated as the number of patients first prescribed these AODs per 10,000person-years (py). RESULTS In women, yearly rates of first prescription of any AOD increased from 1990 to 2006 (from 2.3 to 169.7 per 10,000py), followed by a plateau and a 12% decrease in the last three years. In men, a less steep increase from 1990 to 2007 (from 1.4 to 45.3 per 10,000py) was followed by a plateau from 2008 onwards. Yearly rates of first prescription of any AOD increased up to the age of 85-89years (248.9 per 10,000py in women and 119.3 in men). There were marked differences between ethnic groups and regions. Bisphosphonates were the most frequently prescribed AODs: etidronate till 2000, and then subsequently alendronate. CONCLUSION We have demonstrated marked secular changes in rates of anti-osteoporosis drug prescription over the last two decades. The plateau (and decrease amongst women) in rates in recent years, set against an ever ageing population, is worrying, suggesting that the well-documented care gap in osteoporosis treatment persists. The differences in prescription rates by geographic location and ethnicity raise intriguing questions in relation to underlying fracture rates, provision of care and health behaviour. SUMMARY We studied the prescription incidence of anti-osteoporosis drugs (AOD) from 1990 to 2012 in the UK CPRD. Overall AOD prescription incidence showed a strong increase from 1990 to 2006, followed by a plateau in both sexes and a decrease amongst women in the last three years.
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Affiliation(s)
- R Y van der Velde
- Department of Internal Medicine, VieCuri Medical Centre, PO Box 1926, 5900 BX Venlo, The Netherlands; Department of Internal Medicine, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Centre (MUMC), PO Box 616, 6200 MD Maastricht, The Netherlands
| | - C E Wyers
- Department of Internal Medicine, VieCuri Medical Centre, PO Box 1926, 5900 BX Venlo, The Netherlands; Department of Internal Medicine, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Centre (MUMC), PO Box 616, 6200 MD Maastricht, The Netherlands
| | - E Teesselink
- Department of Clinical Pharmacology and Toxicology, University Medical Centre Maastricht, Maastricht, The Netherlands
| | - P P M M Geusens
- Department of Internal Medicine, Subdivision Rheumatology, CAPHRI, Maastricht University Medical Centre (MUMC), PO Box 616, 6200 MD Maastricht, The Netherlands; Biomedical Research Centre, Hasselt University, Agoralaan - gebouw D, 3590 Diepenbeek, Belgium
| | - J P W van den Bergh
- Department of Internal Medicine, VieCuri Medical Centre, PO Box 1926, 5900 BX Venlo, The Netherlands; Department of Internal Medicine, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Centre (MUMC), PO Box 616, 6200 MD Maastricht, The Netherlands; Biomedical Research Centre, Hasselt University, Agoralaan - gebouw D, 3590 Diepenbeek, Belgium
| | - F de Vries
- Department of Clinical Pharmacology and Toxicology, University Medical Centre Maastricht, Maastricht, The Netherlands
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK; NIHR Southampton Biomedical Research Centre, University of Southampton, University Hospital Southampton NHS Foundation Trust, Southampton, UK; NIHR Musculoskeletal Biomedical Research Unit, Institute of Musculoskeletal Sciences, University of Oxford, Oxford, UK.
| | - N C Harvey
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK; NIHR Southampton Biomedical Research Centre, University of Southampton, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - T P van Staa
- Health eResearch Centre, University of Manchester, Manchester, UK; Department of Pharmacoepidemiology & Clinical Pharmacology, University of Utrecht, Utrecht 3508 TB, The Netherlands
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Reed M, Haddad FS. Randomised trials of total hip arthroplasty for fracture : is our failure to deliver symptomatic of a wider scrutiny? Bone Joint J 2016; 98-B:1425-1426. [PMID: 27803214 DOI: 10.1302/0301-620x.98b11.38079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 09/19/2016] [Indexed: 11/05/2022]
Affiliation(s)
- M Reed
- Wansbeck Hospital, Northumbria Healthcare NHS Trust, Woodhorn Lane, Ashington, NE63 9JJ, UK
| | - F S Haddad
- The Bone & Joint Journal, 22 Buckingham Street, London, WC2N 6ET and NIHR University College London Hospitals Biomedical Research Centre, UK
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Judge A, Javaid MK, Leal J, Hawley S, Drew S, Sheard S, Prieto-Alhambra D, Gooberman-Hill R, Lippett J, Farmer A, Arden N, Gray A, Goldacre M, Delmestri A, Cooper C. Models of care for the delivery of secondary fracture prevention after hip fracture: a health service cost, clinical outcomes and cost-effectiveness study within a region of England. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04280] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BackgroundProfessional bodies have produced comprehensive guidance about the management of hip fracture. They recommend orthogeriatric services focusing on achieving optimal recovery, and fracture liaison services (FLSs) focusing on secondary fracture prevention. Despite such guidelines being in place, there is significant variation in how services are structured and organised between hospitals.ObjectivesTo establish the clinical effectiveness and cost-effectiveness of changes to the delivery of secondary fracture prevention services, and to identify barriers and facilitators to changes.DesignA service evaluation to identify each hospital’s current models of care and changes in service delivery. A qualitative study to identify barriers and facilitators to change. Health economics analysis to establish NHS costs and cost-effectiveness. A natural experimental study to determine clinical effectiveness of changes to a hospital’s model of care.SettingEleven acute hospitals in a region of England.ParticipantsQualitative study – 43 health professionals working in fracture prevention services in secondary care.InterventionsChanges made to secondary fracture prevention services at each hospital between 2003 and 2012.Main outcome measuresThe primary outcome is secondary hip fracture. Secondary outcomes include mortality, non-hip fragility fracture and the overall rate of hip fracture.Data sourcesClinical effectiveness/cost-effectiveness analyses – primary hip fracture patients identified from (1) Hospital Episode Statistics (2003–13,n = 33,152); and (2) Clinical Practice Research Datalink (1999–2013,n = 11,243).ResultsService evaluation – there was significant variation in the organisation of secondary fracture prevention services, including staffing levels, type of service model (consultant vs. nurse led) and underlying processes. Qualitative – fracture prevention co-ordinators gave multidisciplinary health professionals capacity to work together, but communication with general practitioners was challenging. The intervention was easily integrated into practice but some participants felt that implementation was undermined by under-resourced services. Making business cases for a service was particularly challenging. Natural experiment – the impact of introducing an orthogeriatrician on 30-day and 1-year mortality was hazard ratio (HR) 0.73 [95% confidence interval (CI) 0.65 to 0.82] and HR 0.81 (95% CI 0.75 to 0.87), respectively. Thirty-day and 1-year mortality were likewise reduced following the introduction or expansion of a FLS: HR 0.80 (95% CI 0.71 to 0.91) and HR 0.84 (95% CI 0.77 to 0.93), respectively. There was no significant impact on time to secondary hip fracture. Health economics – the annual cost in the year of hip fracture was estimated at £10,964 (95% CI £10,767 to £11,161) higher than the previous year. The annual cost associated with all incident hip fractures in the UK among those aged ≥ 50 years (n = 79,243) was estimated at £1215M. At a £30,000 per quality-adjusted life-year threshold, the most cost-effective model was introducing an orthogeriatrician.ConclusionIn hip fracture patients, orthogeriatrician and nurse-led FLS models are associated with reductions in mortality rates and are cost-effective, the orthogeriatrician model being the most cost-effective. There was no evidence for a reduction in second hip fracture. Qualitative data suggest that weaknesses lie in treatment adherence/monitoring, a possible reason for the lack of effectiveness on second hip fracture outcome. The effectiveness on non-hip fracture outcomes remains unanswered.Future workReliable estimates of health state utility values for patients with hip and non-hip fractures are required to reduce uncertainty in health economic models. A clinical trial is needed to assess the clinical effectiveness and cost-effectiveness of a FLS for non-hip fracture patients.FundingThe National Institute for Health Research (NIHR) Health Services and Delivery Research programme and the NIHR Musculoskeletal Biomedical Research Unit, University of Oxford.
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Affiliation(s)
- Andrew Judge
- Oxford National Institute for Health Research (NIHR) Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Medical Research Council (MRC) Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - M Kassim Javaid
- Oxford National Institute for Health Research (NIHR) Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Medical Research Council (MRC) Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - José Leal
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Samuel Hawley
- Oxford National Institute for Health Research (NIHR) Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sarah Drew
- Oxford National Institute for Health Research (NIHR) Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sally Sheard
- Oxford National Institute for Health Research (NIHR) Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Daniel Prieto-Alhambra
- Oxford National Institute for Health Research (NIHR) Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Medical Research Council (MRC) Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
- GREMPAL Research Group (IDIAP Jordi Gol) and Musculoskeletal Research Unit (Fundació IMIM-Parc Salut Mar), Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Janet Lippett
- Elderly Care Unit, Royal Berkshire Hospital, Reading, UK
| | - Andrew Farmer
- Nuffield Department of Primary Care Health Sciences, Oxford, UK
| | - Nigel Arden
- Oxford National Institute for Health Research (NIHR) Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Medical Research Council (MRC) Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Alastair Gray
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Michael Goldacre
- Unit of Health Care Epidemiology, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Antonella Delmestri
- Oxford National Institute for Health Research (NIHR) Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Cyrus Cooper
- Oxford National Institute for Health Research (NIHR) Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Medical Research Council (MRC) Lifecourse Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, UK
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50
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Abstract
INTRODUCTION Osteoporosis is a significant public health issue affecting over half of women aged over 50. With an aging population, its importance is set to increase further over time. Prevention of fragility fractures avoids significant mortality and morbidity as well as saving significant direct and indirect costs to the economy. In this review, we discuss existing treatments to contextualize the treatment landscape, and demonstrate how our understanding of bone pathophysiology has led to novel therapies-in the form of combinations and altered durations of existing treatments, as well as newer drug therapies. SOURCES OF DATA PubMed and Embase were searched for randomized controlled trials of new therapies for osteoporosis. These searches were supplemented with material presented in abstract form at international meetings. AREAS OF AGREEMENT New drugs that appear promising in the treatment of osteoporosis include the cathepsin K inhibitor, monoclonal antibodies against sclerostin and parathyroid hormone-related protein analog. AREAS OF CONTROVERSY Separate to the development of novel drug therapies is the issue of how best to use agents that are currently available to us; specifically which agent to choose, alone or in combination; duration of therapy; how best to identify patients at highest risk of fracture, and to ensure the highest possible adherence to medication. Many of these issues have been addressed in other excellent review papers, and will not be considered in detail here. GROWING POINTS As with all new treatments, we await results of long-term use and experience in 'real life' patient populations. AREAS TIMELY FOR DEVELOPING RESEARCH As alluded to above, data are urgently required regarding the optimal duration of therapy; use of combination therapy; ordering of therapies for best therapeutic effect. As stratified medicine becomes more strongly considered in all areas of therapy, its merits in osteoporosis as in other musculoskeletal conditions, is timely and valuable.
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Affiliation(s)
| | - Alice Mason
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Cyrus Cooper
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | - Elaine Dennison
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
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