Vertebral compression fractures in primary care: recommendations from a consensus panel.
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Biomedical subjects
Alexandra Papaioannou
Publications and source records attributed to Alexandra Papaioannou.
Case report: osteogenesis imperfecta Elusive cause of fractures.
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Adult↗
Risk factors associated with incident clinical vertebral and nonvertebral fractures in postmenopausal women: the Canadian Multicentre Osteoporosis Study (CaMos).
Utilizing data from the Canadian Multicentre Osteoporosis Study (CaMos), we examined the association between potential risk factors and incident vertebral and nonvertebral fractures. A total of 5,143 postmenopausal women were enrolled. Information collected during the study included data from the CaMos baseline and annually mailed fracture questionnaires, the Short Form 36 (SF-36), the Health Utilities Index, and physical measurements. Participants were followed for 3 years. Postmenopausal women were classified into four groups according to their incident fracture status since baseline: those without a new fracture; those with a new clinically recognized vertebral fracture; those with an incident nonvertebral fracture at the wrist, hip, humerus, pelvis, or ribs (main nonvertebral fracture group); and those with any new nonvertebral fracture (any-nonvertebral-fracture group). We performed multivariate Cox proportional hazard analysis using all possible risk factors to determine the association between risk factors and the time to the first minimal trauma fracture. Best predictive models were also determined using variables that were included in the full models. The Bayesian information criterion was used for model selection. For all analyses, relative risks and associated 95% confidence intervals were calculated. During the follow-up period, 34, 163, and 280 women developed a vertebral, a main nonvertebral, or any nonvertebral fracture, respectively. The best predictive models indicated that a five point lower quality of life as measured by the SF-36 physical component summary score was associated with relative risks of 1.21 (95% CI, 1.02 to 1.44), 1.17 (95% CI, 1.07 to 1.28), and 1.19 (95% CI, 1.11 to 1.27) for incident vertebral, main nonvertebral, and all nonvertebral fractures, respectively. In addition, for a one standard deviation (SD=0.12) lower femoral neck BMD, the relative risks for incident vertebral, main nonvertebral, and any nonvertebral fractures increased by 2.73 (95% CI, 1.74 to 4.28), 1.39 (95% CI, 1.06 to 1.82), and 1.34 (95% CI, 1.09 to 1.65), respectively. Furthermore, various anthropometric measures, disease conditions, and medications are associated with a new fracture. Identifying postmenopausal women at risk is important given that fracture prevention therapies are now available.
Adult↗
Prediction of falls using a risk assessment tool in the acute care setting.
BACKGROUND: The British STRATIFY tool was previously developed to predict falls in hospital. Although the tool has several strengths, certain limitations exist which may not allow generalizability to a Canadian setting. Thus, we tested the STRATIFY tool with some modification and re-weighting of items in Canadian hospitals. METHODS: This was a prospective validation cohort study in four acute care medical units of two teaching hospitals in Hamilton, Ontario. In total, 620 patients over the age of 65 years admitted during a 6-month period. Five patient characteristics found to be risk factors for falls in the British STRATIFY study were tested for predictive validity. The characteristics included history of falls, mental impairment, visual impairment, toileting, and dependency in transfers and mobility. Multivariate logistic regression was used to obtain optimal weights for the construction of a risk score. A receiver-operating characteristic curve was generated to show sensitivities and specificities for predicting falls based on different threshold scores for considering patients at high risk. RESULTS: Inter-rater reliability for the weighted risk score indicated very good agreement (inter-class correlation coefficient = 0.78). History of falls, mental impairment, toileting difficulties, and dependency in transfer / mobility significantly predicted fallers. In the multivariate model, mental status was a significant predictor (P < 0.001) while history of falls and transfer / mobility difficulties approached significance (P = 0.089 and P = 0.077 respectively). The logistic regression model led to weights for a risk score on a 30-point scale. A risk score of 9 or more gave a sensitivity of 91% and specificity of 60% for predicting who would fall. CONCLUSION: Good predictive validity for identifying fallers was achieved in a Canadian setting using a simple-to-obtain risk score that can easily be incorporated into practice.
Accidental Falls↗
Rational use of oral bisphosphonates for the treatment of osteoporosis.
Osteoporosis has become a major public health concern worldwide. Significant morbidity, mortality, and health expenditures are associated with osteoporotic fractures. Evidence from randomized controlled trials and meta- analyses supports the efficacy and safety of oral bisphosphonates as first-line pharmacologic agents for the prevention and treatment of osteoporosis. This article reviews the evidence demonstrating the beneficial effects of etidronate, alendronate, and risedronate on improving bone mass and preventing fractures in individuals with or at risk for osteoporosis. Issues surrounding dosing intervals and optimal duration of therapy are also discussed. We conclude that the nitrogen-containing bisphosphonates alendronate and risedronate are safe and efficacious agents in preventing and treating osteoporosis. They are superior to cyclical etidronate in improving appendicular bone mass, and in reducing future risk for nonvertebral fractures. Once-weekly dosing options with alendronate and risedronate are effective and reduce serious adverse drug effects, and therefore, are welcome additions to our therapeutic armamentarium.
Administration, Oral↗
Attitudes of women who are currently using or recently stopped estrogen replacement therapy with or without progestins: results of the AWARE survey.
OBJECTIVE: To examine the level of awareness of the findings of the Women's Health Initiative (WHI) study among recent users of hormone therapy (HT). METHODS: A survey was conducted on Canadian women older than 45 years of age who had used either an oral, topical, or vaginal HT within the preceding 3 years. Questionnaires were mailed to a random sample of 210 eligible women within an academic subspecialty rheumatology/osteoporosis practice between April and June 2003. Questionnaires were also provided upon request to women attending tertiary care multidisciplinary clinics and 6 community pharmacies in Hamilton, Ontario. The 98 questions in the survey were either categorical in nature (yes or no response) or followed by a Likert scale. Using chi-square and Student t tests, the responses of women who used combination estrogen/progestin were compared to those who used estrogen alone. RESULTS: Of the 161 women who responded to the survey (128 from the osteoporosis practice, 33 from other clinics and pharmacies), 102 (63%) had used HT for more than 5 years. Ninety-one of 159 respondents (57%) discontinued HT, and 63% (57/91) of those stopped using HT after publication of the WHI principal findings. Sixty-four percent (33/52) of women on combination estrogen/progestin discontinued HT, compared to 50% (46/93) who were on estrogen only, and 5 other women who also discontinued HT but did not know what type of preparation they had been taking (P = .04 for the difference in rates between the 3 groups). Knowledge of the findings of the estrogen/progestin arm of the WHI study did not significantly differ among users of different types of hormone preparations. Of the women who indicated that they did not know if HT affected the risk of WHI-studied medical conditions, 44% (69/156) indicated being unaware of HT risks for stroke, 28% (44/157) for hip fracture, 39% (60/155) for myocardial infarction, 25% (39/155) for breast cancer, and 48% (73/152) for blood clots. Women who had recently taken HT generally did not regret their use of HT. CONCLUSION: Although many women discontinued HT following the publication of the principal findings of the estrogen/progestin arm of the WHI study, the majority of these women lacked a clear understanding of those findings.
Estrogen Replacement Therapy↗
The detection and management of vaginal atrophy.
OBJECTIVE: To support the practitioner in the diagnosis of vaginal atrophy and in the management of the related symptoms. OPTIONS: The modalities of evaluation range from basic pelvic examination, examination of the vulva, and laboratory tests. OUTCOMES: A comprehensive approach to the detection of vaginal atrophy and a discussion of available therapeutic and nontherapeutic options. EVIDENCE: Published opinions of experts, supplemented by evidence from clinical trials, where appropriate. VALUES: The quality of the evidence is rated using the criteria described by the Canadian Task Force on the Periodic Health Examination. BENEFITS, HARMS, AND COSTS: Diagnosis of vaginal atrophy is often a challenge because women are unwilling to report symptoms, which have the potential to significantly decrease their quality of life. Increased clinical suspicion is the first step in the diagnosis of vaginal atrophy, which will prompt the initiation of safe therapies with proven efficacy. RECOMMENDATIONS: 1. Health-care providers should routinely assess postmenopausal women for the symptoms and signs of vaginal atrophy, a common condition that exerts significant negative effects on quality of life. (III-C) 2. Regular sexual activity should be encouraged to maintain vaginal health. (II-2B)3. Women experiencing recurrent urinary tract infections should be instructed that consumption of pure cranberry-lingonberry juice, rather than cranberry drink, will decrease their risk of urinary tract infections. (I-A) 4. Vaginal moisturizers applied on a regular basis have an efficacy equivalent to local hormone replacement for the treatment of local urogenital symptoms such as vaginal itching, irritation, and dyspareunia, and should be offered to women wishing to avoid use of hormone replacement therapy. (I-A) 5. Women experiencing vaginal atrophy can be offered any of the following effective vaginal estrogen replacement therapies: conjugated equine estrogen cream (I-A), a sustained-release intravaginal estradiol ring (I-A), or a low-dose estradiol tablet (I-A). 6. Although systemic absorption of estrogen can occur with local preparations, there is insufficient data to recommend annual endometrial surveillance in asymptomatic women using local estrogens. (III-C) 7. For menopausal women experiencing recurrent urinary tract infections and who have no contraindication to local hormone replacement, vaginal estrogen therapy should be offered. (I-A).
Administration, Intravaginal↗
Estimating the prevalence of renal insufficiency in seniors requiring long-term care.
BACKGROUND: Renal function declines with age, but little is known about the extent of renal insufficiency among the institutionalized elderly. The objective of this study was to estimate the prevalence of low glomerular filtration rate (GFR) in a large sample of elderly adults living in long-term care facilities, and to compare two commonly used methods for estimating GFR. METHODS: A total of 9931 residents aged 65 years and older participated in a retrospective cross-sectional study of 87 long-term care facilities in Ontario. GFR was estimated by the Cockcroft-Gault and Modification of Diet in Renal Disease Study (MDRD) equations. The prevalence of low GFR, using the Cockcroft-Gault equation (<30 mL/min), was compared with the MDRD equation (<30 mL/min/1.73 m2). RESULTS: A total of 17.0% (95% CI 15.6 to 18.5) of men and 14.4% (95% CI 13.6 to 15.3) of women had a serum creatinine concentration above the laboratory reported upper reference limit of normal. The prevalence of both elevated serum creatinine and low GFR were observed to increase with age (P < 0.0001). The Cockcroft-Gault equation produced a consistently lower estimate of GFR than did the MDRD equation, a discrepancy most pronounced in the oldest residents. Among all men, a low GFR was more prevalent using the Cockcroft-Gault (10.3%, 95% CI 9.2 to 11.5) than MDRD (3.5%, 95% CI 2.8 to 4.2) equation, with a similar difference also seen in women (23.3%, 95% CI 22.4 to 24.3 versus 4.0%, 95% CI 3.6 to 4.5, respectively). Of all residents whose Cockcroft-Gault estimated GFR was under 30 mL/min, 14.7% (95% CI 13.2 to 16.3) were found to have GFR greater than 60 mL/min/1.73 m2 according to the MDRD equation. CONCLUSION: Age-associated renal impairment is common among elderly long-term care residents, but there exists a clear discrepancy between the Cockcroft-Gault and MDRD equations in predicting GFR. Consideration should be given to medication dose adjustment, based on a practical estimate of GFR. However clarification is needed about which method, if either, is most valid among the frail elderly. Complex patient and societal issues surrounding advanced care directives, treatments associated with renal insufficiency, and, if and when to initiate dialysis, require further attention.
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Are there differences between men and women prescribed bisphosphonate therapy in canadian subspecialty osteoporosis practices?
OBJECTIVE: To determine if there are differences between men and women referred for treatment of osteoporosis in Canada. METHODS: We performed an observational study of 1588 patients (163 men, 1425 women), 50 years of age and older, who were prescribed cyclic etidronate or alendronate for treatment of osteoporosis or osteopenia and had at least 2 years of followup registered in the Canadian Database for Osteoporosis and Osteopenia Patients (CANDOO). Comparisons of characteristics between men and women were performed using Pearson chi-square test, Student's t test, or a Kruskal-Wallis test, whichever was most appropriate. RESULTS: Mean baseline femoral neck and lumbar spine bone mineral densities were significantly higher in men than women at both the femoral neck and lumbar spine (p < 0.05, respectively). Men had double the rate of prevalent vertebral fractures (44%, 72/163) compared to women (22%, 315/1425; p < 0.001) and triple the rate of multiple prevalent vertebral fractures (10%, 17/163) compared to women (3%, 37/1425, p < 0.001). Furthermore, men were twice as likely as women to sustain a fracture within 2 years of starting treatment during observation in the CANDOO study (men: 4%, 7/163, women: 2%, 24/1425, p = 0.033). CONCLUSION: Osteoporosis may be under-recognized in men until the condition is at an advanced stage. A form of gender bias may exist in recognition and treatment (or referral for treatment) of osteoporosis in men.
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Adherence to bisphosphonates and hormone replacement therapy in a tertiary care setting of patients in the CANDOO database.
Therapies for osteoporosis must be taken for at least 1 year to be effective. The purpose of this study was to determine the difference in adherence to etidronate, alendronate and hormone replacement therapy in a group of patients seen at our tertiary care centres. The Canadian Database of Osteoporosis and Osteopenia (CANDOO), a prospective observational database designed to capture clinical data, was searched for patients who started therapy following entry into CANDOO. There were 1196 initiating etidronate, 477 alendronate and 294 hormone replacement therapy women and men aged (mean, SD) 65.8 (8.7) years in the study. A Cox proportional hazards regression model was used to assess differences between treatment groups in the time to discontinuation of therapy. Several potential covariates such as anthropometry, medications, illnesses, fractures and lifestyle factors were entered into the model. A forward selection technique was used to generate the final model. Hazard ratios and 95% confidence intervals (CI) were calculated. Adjusted results indicated that alendronate-treated patients were more likely to discontinue therapy as compared with etidronate-treated patients (1.404; 95% CI: 1.150, 1.714). After 1 year, 90.3% of patients were still taking etidronate compared with 77.6% for alendronate. No statistically significant differences were found between hormone replacement therapy and etidronate users (0.971; 95% CI: 0.862, 1.093) and hormone replacement therapy and alendronate users (0.824; 95% CI: 0.624, 1.088) after controlling for potential covariates. After 1 year, 80.1% of patients were still taking hormone replacement therapy, which decreased to 44.5% after 6 years. Increasing age and presence of incident non-vertebral fractures were found to be independent predictors of adherence. In conclusion, alendronate users were more likely to discontinue therapy than etidronate users over the follow-up period. Potential barriers to long-term patient adherence to osteoporosis therapies need to be evaluated.
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Osteoporosis in Canadian adult cystic fibrosis patients: a descriptive study.
BACKGROUND: Cystic fibrosis is the most common fatal autosomal recessive genetic disease in the Caucasian population. Osteoporosis is increasingly being recognised as an important complication in people with cystic fibrosis. METHODS: A descriptive study of adult cystic fibrosis patients receiving care at a Canadian tertiary care hospital was conducted to evaluate the prevalence of osteoporosis, the prevalence of non-vertebral fractures, and the change in bone mineral density during the course of a year. Data on bone mineral density were obtained for 40 adult cystic fibrosis patients by reviewing dual x-ray absorptiometry scans taken at baseline (when annual scans became standard clinical practice) and one year prior to baseline. Data on prevalent fractures were obtained by reviewing all available patient charts. Clinical and laboratory data were collected from an existing clinic database. RESULTS: Over half of the 40 patients had reduced T- and Z-scores at baseline. For the 27 patients who had data available one year prior to baseline, total hip and lumbar spine bone mineral density had decreased by 3.04% and 0.86% after one year while total body bone mineral density had not changed significantly. Four prior non-vertebral fractures were reported in three patients (1,146 patient-years). CONCLUSION: This study confirms that osteoporosis is a significant problem in adult cystic fibrosis patients, and constitutes the first published evidence of cystic fibrosis bone disease in Canadians.
Adult↗
Effects of weight loss on QT interval in morbidly obese patients.
BACKGROUND: Obesity causes structural changes to the heart that may influence its function. Furthermore, morbid obesity is associated with an acquired prolongation of the QTc interval that may lead to potentially hazardous arrhythmias. The present study investigated the effect of body weight loss following vertical banded gastroplasty (VBG) on the QTc interval. METHODS: 17 morbidly obese patients, scheduled for elective VBG, were studied before the operation and 8-10 months postoperatively, when each patient had achieved a weight loss of >/= 25% of the preoperative body weight. RESULTS: 15 patients achieved significant body weight loss of >/= 25% within the first 8-10 postoperative months (P <0.001). This weight loss, corresponding to an excess weight loss of 48.7% and a mean body mass index (BMI) reduction from 49.7 kg/m2 to 36.6 kg/m2, was followed by significant shortening of the QTc interval from 428 msec to 393 msec (P <0.001). CONCLUSIONS: The significant postoperative weight loss following VBG was accompanied by shortening of the QTc interval. This effect is expected to reduce the incidence of fatal conditions associated with the long QT syndrome, such as malignant ventricular arrhythmias and sudden death, and therefore improve morbidity and mortality.
Adult↗
What predicts early fracture or bone loss on bisphosphonate therapy?
Factors predicting early fracture or bone loss on bisphosphonate therapy are not well defined. We studied 1588 patients over the age of 50 yr who were started on cyclic etidronate (1119) or alendronate (469) in the CANDOO (Canadian Database for Osteoporosis and Osteopenia Patients) Study. Incident fracture within 2 yr of starting therapy occurred in 31 patients and was independently predicted by a previous history of nonvertebral fracture (odds ratio [OR], 2.98, 95% confidence interval [CI], 1.30, 6.83, p = 0.010). Two hundred and fifty-seven patients lost >/=3% bone mass at the hip or spine (early bone loss) while on bisphosphonate therapy. Protection from early bone loss was most strongly independently predicted by treatment with alendronate with no previous history of etidronate use (OR, 0.29, CI, 0.13, 0.62, p = 0.002). In conclusion, early fracture on bisphosphonate therapy is most strongly predicted by a previous history of fracture and early bone loss is most strongly predicted by the potency of the prescribed bisphosphonate.
Alendronate↗
A 6-mo home-based exercise program may slow vertebral height loss.
Twenty-one of 46 postmenopausal women were assigned to a home-based exercise program consisting of 60 min of exercise, 3 d/wk. The 25 nonexercisers continued usual daily activities. Each woman had at least one prevalent vertebral fracture and suffered from osteoporosis as defined by the application of WHO criteria to lumbar spine bone mineral density. Vertebral heights were measured using bone densitometry at baseline and 12 mo later. Vertebrae T9 to L4 were all identified for each of the 46 subjects in both the baseline and end-of-study lateral scans. The change in mean vertebral height over the course of the study was -0.3 mm anteriorly, -0.7 mm at the mid-location, and -0.4 mm posteriorly for the nonexercisers. For the exercisers, the corresponding changes were +0.1 mm anteriorly, -0.3 mm at the mid-location, and +0.2 mm posteriorly. The benefit of exercise in preserving vertebral morphometry in patients with osteoporosis deserves further investigation.
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Renal impairment and medication use among psychogeriatric inpatients.
OBJECTIVES: To determine the prevalence of renal impairment and the dosage appropriateness of several medications for which dosing guidelines in the advent of renal impairment are available. METHOD: The authors assessed the renal function and medication use of 37 psychogeriatric patients (mean age of 75 years) living in a psychiatric hospital. Renal function was determined by serum creatinine (SCr) levels and creatinine clearance (CCr) data using the Cockcroft and Gault equation. RESULTS: Thirteen of 37 patients (35%) were found to have renal impairment according to CCr data but only two patients (6%) were considered impaired according to SCr levels (k=0.19). Of 44 medications for which dosing guidelines were available, only two (5%) were prescribed inappropriately. CONCLUSION: These data suggest that CCr data should be used over SCr levels to determine renal impairment and to support the monitoring of psychogeriatric patients for declines in renal function and required medication adjustments.
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An amantadine hydrochloride dosing program adjusted for renal function during an influenza outbreak in elderly institutionalized patients.
OBJECTIVE: We tested the hypothesis that individualized dosing of amantadine hydrochloride, based upon a patient's creatinine clearance, would maintain efficacy against influenza A infection while reducing adverse reactions to the drug. DESIGN: A prospective cohort study PARTICIPANTS: Residents of two nursing homes with a total population of 301 individuals INTERVENTION: Amantadine hydrochloride was administered prophylactically subsequent to a confirmed influenza A outbreak. The dose was individualized based upon the resident's calculated creatinine clearance. RESULTS: The concentration of amantadine hydrochloride in the circulation at steady-state in patients who had doses adjusted for their estimated creatinine clearance was not different by nursing home or by sex of the resident. The mean concentration was within the 95% CI for the target concentration of 1.6 micromol/L. Side effects were modest and did not require discontinuation of amantadine hydrochloride therapy. Only the presence of concurrent influenza-like illness was significantly associated with adverse events during amantadine hydrochloride therapy. CONCLUSIONS: Adjustment of doses for estimated creatinine clearance is feasible in a long term care facility when amantadine hydrochloride is indicated for influenza A prophylaxis. These data form the basis for a definitive study of amantadine hydrochloride efficacy in patients with reduced renal function. Concurrent influenza-like illness is likely to confound attempts to associate adverse reactions to the administration of amantadine hydrochloride therapy.
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Development and use of a computer program to detect potentially inappropriate prescribing in older adults residing in Canadian long-term care facilities.
BACKGROUND: Inappropriate prescribing has been estimated to be as high as 40% in long-term care. The purpose of this study was to develop a computer program that identifies potentially inappropriate drug prescriptions and to test its reliability. METHODS: Potentially inappropriate prescriptions were identified based on modified McLeod guidelines. A database from one pharmacy servicing long-term care facilities in Ontario was utilized for this cross-sectional study. Prescription information was available for the 356 long-term care residents and included: the date the prescription was filled, the quantity of drug prescribed and the eight-digit drug identification number. The pharmacy database was linked to the computer-based program for targeting potential inappropriate prescriptions. The computer program's reliability was assessed by comparing its results to a manual search conducted by two independent research assistants. RESULTS: There was complete agreement between the computer and manual abstraction for the total number of potentially inappropriate prescriptions detected. In total, 83 potentially inappropriate prescriptions were identified. Fifty-three residents (14.9%) received at least one potentially inappropriate prescription. Of those, twenty (37.7%) received two potential inappropriate prescriptions and eight (15.1%) received 3 or more potential inappropriate prescriptions. The most common potential inappropriate prescriptions were identified as long-term use of non-steroidal anti-inflammatory agents and tricyclic antidepressants with active metabolites. CONCLUSION: A computer program can accurately and automatically detect inappropriate prescribing in residents of long-term care facilities. This tool may be used to identify potentially inappropriate drug combinations and educate health care professionals.
Journal Article↗
Diagnosis and management of vertebral fractures in elderly adults.
We reviewed the epidemiology, diagnosis, and treatment of vertebral fractures due to osteoporosis in the elderly. Vertebral fractures are underdiagnosed despite their high prevalence in both men and women. Clinical consequences of vertebral fractures include increased risk of future vertebral and hip fracture, acute and chronic back pain, decreased quality of life, and increased mortality. Patients with vertebral fractures have functional impairment and increased mortality similar to those with hip fractures. Asymptomatic fractures identified on radiograph also affect quality of life and mortality. A vertebral fracture is a clinical marker for a subsequent fracture and should trigger assessment and diagnosis of osteoporosis. The care of patients with vertebral fractures includes pain management, rehabilitation, and prevention of further fractures. There is evidence from randomized controlled trials that pharmacologic therapy can reduce the risk of future fractures by 40% to 50%. Vertebroplasty may be effective in the control of pain and in obtaining stability of the spine.
Age Distribution↗