The post-fracture care gap among Canadian First Nations peoples: a retrospective cohort study

Summary  

Despite targeted attempts to reduce post-fracture care gaps, we hypothesized that a larger care gap would be experienced by First Nations compared to non-First Nations people. First Nations peoples were eight times less likely to receive post-fracture care compared to non-First Nations peoples, representing a clinically significant ethnic difference in post-fracture care.     

All-cause and cause-specific mortality after hip fracture among Chinese women and men

Summary

All-cause mortality risk persisted for 5 years after hip fractures in both men and women. There may be gender-specific differences in effect and duration of excess risk for cause-specific mortality after hip fracture.

Introduction

To determine all-cause and cause-specific mortality risk in the first 5 years after hip fracture in an Asian Chinese population.

Methods

The Singapore Chinese Health Study is a population-based cohort of 63,257 middle-aged and elderly Chinese men and women in Singapore recruited between 1993 and 1998. This cohort was followed up for hip fracture and death via linkage with nationwide hospital discharge database and death registry. As of 31 December 2008, we identified 1,166 hip fracture cases and matched five non-fracture cohort subjects by age and gender for each fracture case. Cox proportional hazards and competing risks regression models with hip fracture as a time-dependent covariate were used to determine all-cause and cause-specific mortality risk, respectively.

Results

Increase in all-cause mortality risk persisted till 5 years after hip fracture (adjusted hazard ratio, aHR = 1.58 [95 % CI, 1.35–1.86] for females and aHR = 1.64 [95 % CI, 1.30–2.06] for males). Men had higher mortality risk after hip fracture than women for deaths from stroke and cancer up to 1 year post-fracture but women with hip fracture had higher coronary artery mortality risk than men for 5 years post-fracture. Men had higher risk of death from pneumonia while women had increased risk of death from urinary tract infections. There was no difference in mortality risk by types of hip fracture surgery.

Conclusions

All-cause mortality risk persisted for 5 years after hip fractures in men and women. There are gender-specific differences in effect size and duration of excess mortality risk from hip fractures between specific causes of death.     

Post-fracture pharmacotherapy for women with osteoporotic fracture: analysis of a managed care population in the USA

Summary

Pharmacologic therapy is recommended to reduce future fracture risk. We examined osteoporosis medications dispensed to older women after first fracture. Only 23 % received therapy during the first year post-fracture. Prior osteoporosis therapy, a prior osteoporosis diagnosis, and older age were good predictors of post-fracture osteoporosis therapy.

Introduction

Pharmacologic therapy is recommended after osteoporotic fracture to reduce future fracture risk. The objective of this retrospective study was to examine osteoporosis therapy dispensed to women post-fracture.

Methods

We identified women ≥50 years old in a large administrative claims database from 2003 to mid-2012 who were continuously enrolled 2 years before (baseline) and 1 year after first osteoporotic fracture. Exclusions were Paget’s disease or malignant neoplasm. Pre- and post-fracture osteoporosis therapies (oral and parenteral) were assessed overall and by fracture site.

Results

A total of 47,171 women of mean (SD) age of 63 (10) years were eligible; fractures included 8 % hip, 17 % vertebral, 73 % non-hip/non-vertebral, and 3 % multiple fracture sites. Only 18 % received osteoporosis therapy within 90 days and 23 % within 1 year post-fracture. Overall, 19 % of women had a prior osteoporosis diagnosis; 20 % had received osteoporosis therapy during baseline. Of 37,649 (80 %) women without baseline therapy, only 9 % initiated pharmacologic therapy within 1 year. The adjusted odds ratio (OR) of therapy within 1 year post-fracture was significantly greater for women who had received baseline osteoporosis therapy (versus none) and who had vertebral (OR 12.7, 95 % confidence interval (CI) 11.2–14.5), hip (15.2, 12.5–18.7), or non-hip/non-vertebral fracture (34.4, 31.7–37.3). Other significant predictors included pre-fracture osteoporosis diagnosis (1.6, 1.4–1.7) and older age (OR range, 1.3–1.7). Treatment adherence was significantly better among women with baseline osteoporosis diagnosis.

Conclusions

The substantial post-fracture treatment gap represents an important unmet need for women with osteoporotic fractures. Fracture liaison or adherence programs could lead to improved post-fracture treatment rates.     

FRAX provides robust fracture prediction regardless of socioeconomic status

Summary

We investigated the fracture risk assessment tool (FRAX) Canada calibration and discrimination according to income quintile in 51,327 Canadian women, with and without a competing mortality framework. Our data show that, under a competing mortality framework, FRAX provides robust fracture prediction and calibration regardless of socioeconomic status (SES).

Introduction

FRAX® predicts 10-year fracture risk. Social factors may independently affect fracture risk. We investigated FRAX calibration and discrimination according to SES.

Methods

Women aged ≥50 years with baseline femoral neck bone mineral density (BMD) were identified from the Manitoba Bone Density Program, Canada (n?=?51,327), 1996–2011. Mean household income, extracted from 2006 census files, was categorized into quintiles. Ten-year fracture probabilities were calculated using FRAX Canada. Incident non-traumatic fractures were studied in relation to income quintile in adjusted Cox proportional hazards models. We compared observed versus predicted fractures with and without a competing mortality framework.

Results

During mean 6.2?±?3.7 years of follow up, there were 6,392 deaths, 3,723 women with ≥1 major osteoporotic fracture (MOF), and 1,027 with hip fractures. Lower income was associated with higher risk for death, MOF, and hip fracture in adjusted models (all p?<?0.005). More women in income quintile 1 (lowest) versus quintile 5 experienced death (19 vs. 8 %), MOF (10 vs. 6 %), or hip fracture (3.0 vs. 1.3 %) (all p?≤?0.001). Adjustment for competing mortality mitigated the effect of SES on FRAX calibration, and good calibration was observed. FRAX provided good fracture discrimination for MOF and hip fracture within each income quintile (all p?<?0.001). Area under the curve was slightly lower for income quintiles 1 versus 5 for FRAX with BMD to predict MOF (0.68, 95 % CI 0.66–0.70 vs. 0.71, 95 % CI 0.69–0.74) and hip fracture (0.79, 95 % CI 0.76–0.81 vs. 0.87, 95 % CI 0.84–0.89).

Conclusion

Increased fracture risk in individuals of lower income is offset by increased mortality. Under a competing mortality framework, FRAX provides robust fracture prediction and calibration regardless of SES.     

Hip fracture prevention with a multifactorial educational program in elderly community-dwelling Finnish women

Summary

Guidelines suggest identification of women at fracture risk by bone density measurement and subsequently pharmacotherapy. However, most women who sustain a hip fracture do not have osteoporosis in terms of bone density. The present non-pharmacological intervention among elderly women unselected for osteoporosis reduced hip fracture risk by 55 % providing an alternative approach to fracture prevention.

Introduction

Hip fractures are expensive for society and cause disability for those who sustain them. We studied whether a multifactorial non-pharmacological prevention program reduces hip fracture risk in elderly women.

Methods

A controlled trial concerning 60- to 70-year-old community-dwelling Finnish women was undertaken. A random sample was drawn from the Population Information System and assigned into the intervention group (IG) and control group (CG). Of the 2,547 women who were invited to the IG, 1,004 (39 %) and of the 2,120 invited to the CG, 1,174 (55 %) participated. The IG participated in a fracture prevention program for 1 week at a rehabilitation center followed by review days twice. The CG received no intervention. During the 10-year follow-up, both groups participated in survey questionnaire by mail. Outcome of interest was occurrence of hip fractures and changes in bone–health-related lifestyle.

Results

During the follow-up, 12 (1.2 %) women in the IG and 29 (2.5 %) in the CG sustained a hip fracture (P?=?0.039). The determinants of hip fractures by stepwise logistic regression were baseline smoking (odds ratio (OR) 4.32 (95 % confidence interval [CI] 2.14–8.71), age OR 1.15/year (95 % CI 1.03–1.28), fall history OR 2.7 (95 % CI 1.24–5.9), stroke history OR 2.99 (95 % CI 1.19–7.54) and participating in this program OR 0.45 (95 % CI 0.22–0.93). Starting vitamin D and calcium supplement use was more common in the IG compared with the CG.

Conclusions

The results suggest that this non-pharmacological fracture prevention program may reduce the risk of hip fractures in elderly Finnish women.     

Coffee, tea, and the risk of hip fracture: a meta-analysis

Summary

The present meta-analysis shows no clear association between coffee consumption and the risk of hip fractures. There was a nonlinear association between tea consumption and the risk of hip fracture. Compared to no tea consumption, drinking 1?4 cups of tea daily was associated with a lower risk of hip fracture.

Introduction

Prospective cohort and case–control studies have suggested that coffee and tea consumption may be associated with the risk of hip fracture; the results have, however, been inconsistent. We conducted a meta-analysis to assess the association between coffee and tea consumption and the risk of hip fracture.

Methods

We performed systematic searches using MEDLINE, EMBASE, and OVID until February 20, 2013, without limits of language or publication year. Relative risks (RRs) with 95 % confidence intervals (CI) were derived using random-effects models throughout all analyses. We conducted categorical, dose–response, heterogeneity, publication bias, and subgroup analyses.

Results

Our study was based on 195,992 individuals with 9,958 cases of hip fractures from 14 studies, including six cohort and eight case–control studies. The pooled RRs of hip fractures for the highest vs. the lowest categories of coffee and tea consumption were 0.94 (95 % CI 0.71–1.17) and 0.84 (95 % CI 0.66–1.02), respectively. For the dose–response analysis, we found evidence of a nonlinear association between tea consumption and the risk of hip fracture (p _nonlinearity?<?0.01). Compared to no tea consumption, 1–4 cups of tea per day may reduce the risk of hip fracture by 28 % (0.72; 95 % CI 0.56–0.88 for 1–2 cups/day), 37 % (0.63; 95 % CI 0.32–0.94 for 2–3 cups/day), and 21 % (0.79; 95 % CI 0.62–0.96 for 3–4 cups/day).

Conclusions

We found no significant association between coffee consumption and the risk of hip fracture. A nonlinear association emerged between tea consumption and the risk of hip fracture; individuals drinking 1–4 cups of tea per day exhibited a lower risk of hip fractures than those who drank no tea. The association between 5 daily cups of tea, or more, and hip fracture risk should be investigated.     

Racial Disparities in Mortality in Patients Undergoing Bariatric Surgery in the USA

Background

Non-Hispanic blacks bear a disproportionate burden of the growing obesity epidemic. Bariatric surgery is an effective treatment for morbid obesity. We sought to assess for racial disparities in short-term outcomes following bariatric surgery.

Methods

Patients undergoing bariatric surgery were extracted from the Nationwide Inpatient Sample between 1999 and 2007. In-hospital mortality and length of stay were compared between different racial groups undergoing bariatric surgery after stratification by gender, and multivariate analysis was conducted to adjust for demographic, surgery year, and clinical and hospital characteristics.

Results

There were 115,507 bariatric surgeries. Overall mortality rate was 2.5 deaths per 1,000 and was higher among non-Hispanic blacks compared to non-Hispanic whites (3.7 vs. 2.3 per 1,000; P?=?0.007). Racial mortality disparities were most pronounced among males and at hospitals with lowest surgical volumes. In multivariate analysis, predictors of mortality were non-Hispanic black race (odds ratio [OR], 1.73; 95 % confidence interval [CI], 1.22–2.45), increasing age, increasing Charlson index (OR, 1.26; 95 % CI, 1.16–1.37), Medicare (OR, 2.13; 95 % CI, 1.57–2.91), and Medicaid (OR, 3.35; 95 % CI, 2.29–4.91) insurance. Incremental calendar year had reduced odds of mortality (OR, 0.80; 95 % CI, 0.76–0.83). Above national median neighborhood income (OR, 0.59; 95 % CI, 0.42–0.83) was protective in males, while teaching hospital status conveyed greater mortality (OR, 2.12; 95 % CI, 1.40–3.22).

Conclusions

Non-Hispanic blacks undergoing bariatric surgery demonstrate higher in-hospital mortality than their racial counterparts. It is unclear if this disparity is due to susceptibility to obesity-related mortality or suboptimal delivery of healthcare in the perioperative setting.     

Is lower income associated with an increased likelihood of qualification for treatment for osteoporosis in Canadian women?

Summary

We examined whether low income was associated with an increased likelihood of treatment qualification for osteoporotic fracture probability determined by Canada FRAX in women aged ≥50 years. A significant negative linear association was observed between income and treatment qualification when FRAX included bone mineral density (BMD), which may have implications for clinical practice.

Introduction

Lower income has been associated with increased fracture risk. We examined whether lower income in women was associated with an increased likelihood of treatment qualification determined by Canada FRAX®.

Methods

We calculated 10-year FRAX probabilities in 51,327 Canadian women aged ≥50 years undergoing baseline BMD measured by dual energy x-ray absorptiometry 1996–2001. FRAX probabilities for hip fracture ≥3 % or major osteoporotic fracture (MOF) ≥20 % were used to define treatment qualification. Mean household income from Canada Census 2006 public use files was used to categorize the population into quintiles. Logistic regression analyses were used to model the association between income and treatment qualification.

Results

Percentages of women who qualified for treatment based upon high hip fracture probability increased linearly with declining income quintile (all p trend <0.001), but this was partially explained by older age among lower income quintiles (p trend <0.001). Compared to the highest income quintile, women in the lowest income quintile had a greater likelihood of treatment qualification based upon high hip fracture probability determined with BMD (age-adjusted odds ratio [OR], 1.34; 95 % confidence intervals (CI), 1.23–1.47) or high MOF fracture probability determined with BMD (age-adjusted OR, 1.31; 95 % CI, 1.18–1.46). Differences were nonsignificant when FRAX was determined without BMD, implying that BMD differences may be the primary explanatory factor.

Conclusions

FRAX determined with BMD identifies a larger proportion of lower income women as qualifying for treatment than higher income women.     

Socioeconomic and living conditions are determinants of hip fracture incidence and age occurrence among community-dwelling elderly

Summary

In this prospective, 10-year study in community-dwelling elderly aged 50 years and over, hip fracture incidence and accordingly age at hip fracture were inversely associated with the area-level income, independently of the geographical area. Age at hip fracture also depended of marital status but in a gender-specific way.

Purpose

The purpose of this study is to investigate the impact of socioeconomic and living conditions on hip fracture incidence and age occurrence among community-dwelling elderly.

Method

Between January 1991 and December 2000, 2,454 hip fractures were recorded in community-dwelling adults aged 50 years and over in the Geneva University Hospital, State of Geneva, Switzerland. Median annual household income by postal code of residence (referred to as area-level income) based on the 1990 Census was used as a measure of socioeconomic condition and was stratified into tertiles (<53,170; 53,170–58,678; and ≥58,678 CHF). Hip fracture incidence and age occurrence were calculated according to area-level income categories and adjusted for confounding factors among community-dwelling elderly.

Results

Independently of the geographical area (urban versus rural), community-dwelling persons residing in areas with the medium income category presented a lower hip fracture incidence [OR 0.91 (0.82–0.99), p?=?0.049] compared to those from the lowest income category. Those in the highest income category had a hip fracture at a significant older age [+1.58 (0.55–2.61) year, p?=?0.003] as compared to those in the lowest income category. Age at hip fracture also depended on marital status but in a gender-specific way, with married women fracturing earlier.

Conclusions

These results indicate that incidence and age occurrence of hip fracture are influenced by area-level income and living conditions among community-dwelling elderly. Prevention programs may be encouraged in priority in communities with low income.     

Hip fracture,mortality risk,and cause of death over two decades

Summary

Men and women with hip fracture have higher short-term mortality. This study investigated mortality risk over two decades post-fracture; excess mortality remained high in women up to 10 years and in men up to 20 years. Cardiovascular disease (CVD) and pneumonia were leading causes of death with a long-term doubling of risk.

Introduction

Hip fractures are associated with increased mortality, particularly short term. In this study with a two-decade follow-up, we examined mortality and cause of death compared to the background population.

Methods

We followed 1013 hip fracture patients and 2026 matched community controls for 22 years. Mortality, excess mortality, and cause of death were analyzed and stratified for age and sex. Hazard ratio (HR) was estimated by Cox regression. A competing risk model was fitted to estimate HR for common causes of death (CVD, cancer, pneumonia) in the short and long term (>1 year).

Results

For both sexes and at all ages, mortality was higher in hip fracture patients across the observation period with men losing most life years (p?<?0.001). Mortality risk was higher for up to 15 years (women (risk ratio (RR) 1.9 [95 % confidence interval (CI) 1.7–2.1]); men (RR 2.8 [2.2–3.5])) and until end of follow-up ((RR 1.8 [1.6–2.0]); (RR 2.7 [2.1–3.3])). Excess mortality by time intervals, censored for the first year, was evident in women (<80 years, up to 10 years; >80 years, for 5 years) and in men <80 years throughout. CVD and pneumonia were predominant causes of death in men and women with an associated higher risk in all age groups. Pneumonia caused excess mortality in men over the entire observation period.

Conclusion

In a remaining lifetime perspective, all-cause and excess mortality after hip fracture was higher even over two decades of follow-up. CVD and pneumonia reduce life expectancy for the remaining lifetime and highlights the need to further improve post-fracture management.

     

Associations between adverse social position and bone mineral density in women aged 50 years or older: data from the Manitoba Bone Density Program

Summary

We examined the independent contribution of income to low bone mineral density in women aged 50 years and older. A significant dose–response association was observed between low income and low (bone mineral density) BMD, which was not explained by clinical risk factors or osteoporotic treatment in the year prior.

Introduction

The association between social disadvantage and osteoporosis is attracting increased attention; however, little is known of the role played by income. We examined associations between income and bone mineral density (BMD) in 51,327 women aged ≥50 years from Manitoba, Canada.

Methods

Low BMD was defined as a T-score ≥2.5SD (femoral neck or minimum) measured by dual energy X-ray absorptiometry (DXA) 1996–2001. Mean household income was extracted from Canada Census 2006 public use files and categorized into quintiles. Age, weight and height were recorded at time of DXA. Parental hip fracture was self-reported. Diagnosed comorbidities, including osteoporotic fracture and rheumatoid arthritis, were ascertained from hospital records and physician billing claims. Chronic obstructive pulmonary disease was used as a proxy for smoking and alcohol abuse as a proxy for high alcohol intake. Corticosteroid use was obtained from the comprehensive provincial pharmacy system. Logistic regression was used to assess relationships between income (highest income quintile held as referent) and BMD, accounting for clinical risk factors.

Results

Compared to quintile 5, the adjusted odds ratio (OR) for low BMD at femoral neck for quintiles 1 through 4 were, respectively, OR1.41 (95 %CI 1.29–1.55), OR1.32 (95 %CI 1.20–1.45), OR1.19 (95 %CI 1.08–1.30) and OR1.10 (95 %CI 1.00–1.21). Similar associations were observed when further adjustment was made for osteoporotic drug treatment 12 months prior and when low BMD was defined by minimum T-score.

Conclusions

Lower income was associated with lower BMD, independent of clinical risk factors. Further work should examine whether lower income increases the likelihood of treatment qualification.     

Utilization of Sentinel Lymph Node Biopsy in Patients with Ductal Carcinoma In Situ Undergoing Mastectomy

Background

Current guidelines suggest consideration of sentinel lymph node biopsy (SLNB) for patients with ductal carcinoma in situ (DCIS) undergoing mastectomy. Our objective was to identify factors influencing the utilization of SLNB in this population.

Methods

We used the Surveillance Epidemiology and End Results database to identify all women with breast DCIS treated with mastectomy from 2000 to 2008. We excluded patients without histologic confirmation, those diagnosed at autopsy, those who had axillary lymph node dissections performed without a preceding SLNB, and those for whom the status of SLNB was unknown. We used multivariate logistic regression reporting odds ratios (OR) and 95 % confidence intervals (CI) to evaluate the relationship of patient- and tumor-related factors to the likelihood of undergoing SLNB.

Results

Of 20,177 patients, 51 % did not receive SLNB. Factors associated with a decreased likelihood of receiving a SLNB included advancing age (OR 0.66; 95 % CI 0.62–0.71), Asian (OR 0.75; CI 0.68–0.83) or Hispanic (OR 0.84; 95 % CI 0.74–0.96) race/ethnicity, and history of prior non-breast (OR 0.57; 95 % CI 0.53–0.61). Factors associated with an increased likelihood of receiving a SLNB included treatment in the east (OR 1.28; 95 % CI 1.17–1.4), intermediate (OR 1.25; 95 % CI 1.11–1.41), high (OR 1.84; 95 % CI 1.62–2.08) grade tumors, treatment after the year 2000, and DCIS size 2–5 cm (OR 1.54; 95 % CI 1.42–1.68) and >5 cm (OR 2.43; 95 % CI 2.16–2.75).

Conclusions

SLNB is increasingly utilized in patients undergoing mastectomy for DCIS, but disparities in usage remain. Efforts at improving rates of SLNB in this population are warranted.     

Gender-specific hip fracture risk in community-dwelling and institutionalized seniors age 65 years and older

Summary

In this study of acute hip fracture patients, we show that hip fracture rates differ by gender between community-dwelling seniors and seniors residing in nursing homes. While women have a significantly higher rate of hip fracture among the community-dwelling seniors, men have a significantly higher rate among nursing home residents.

Introduction

Differences in gender-specific hip fracture risk between community-dwelling and institutionalized seniors have not been well established, and seasonality of hip fracture risk has been controversial.

Methods

We analyzed detailed data from 1,084 hip fracture patients age 65 years and older admitted to one large hospital center in Zurich, Switzerland. In a sensitivity analysis, we extend to de-personalized data from 1,265 hip fracture patients from the other two large hospital centers in Zurich within the same time frame (total n?=?2,349). The denominators were person-times accumulated by the Zurich population in the corresponding age/gender/type of dwelling stratum in each calendar season for the period of the study.

Results

In the primary analysis of 1,084 hip fracture patients (mean age 85.1 years; 78 % women): Among community-dwelling seniors, the risk of hip fracture was twofold higher among women compared with men (RR?=?2.16; 95 % CI, 1.74–2.69) independent of age, season, number of comorbidities, and cognitive function; among institutionalized seniors, the risk of hip fracture was 26 % lower among women compared with men (RR?=?0.77; 95 % CI: 0.63–0.95) adjusting for the same confounders. In the sensitivity analysis of 2,349 hip fracture patients (mean age 85.0 years, 76 % women), this pattern remained largely unchanged. There is no seasonal swing in hip fracture incidence.

Conclusion

We confirm for seniors living in the community that women have a higher risk of hip fracture than men. However, among institutionalized seniors, men are at higher risk for hip fracture.     

Low serum concentrations of alpha-tocopherol are associated with increased risk of hip fracture. A NOREPOS study

Summary

We investigated the risk of hip fracture according to circulating alpha-tocopherol, a plant-derived substance with antioxidant properties, in community-dwelling older Norwegians. We found a linear increasing risk of hip fracture with lower serum alpha-tocopherol concentrations, with a 51 % higher risk in the lowest compared to the highest quartile.

Introduction

Oxidative stress is a suggested contributing cause of osteoporosis and fractures. Vitamin E (α-tocopherol) has potent antioxidant properties in humans. The relationship between circulating α-tocopherol and fracture risk is not established. The aim of this study was to investigate the association between serum α-tocopherol concentrations and risk of hip fracture during up to 11 years of follow-up.

Methods

We performed a case-cohort analysis among 21,774 men and women aged 65–79 years who participated in four community-based health studies in Norway 1994–2001. Serum α-tocopherol concentrations at baseline were determined in 1,168 men and women who subsequently suffered hip fractures (median follow-up 8.2 years) and in a random sample (n?=?1,434) from the same cohort. Cox proportional hazard regression adapted for gender-stratified case-cohort data was performed.

Results

Median (25, 75 percentile) serum α-tocopherol was 30.0 (22.6, 38.3) μmol/L, and it showed a linear inverse association with hip fracture: hazard ratio (HR) 1.11 (95 % confidence interval (CI) 1.04–1.20) per 10-μmol/L decrease in serum α-tocopherol, adjusted for gender and study center. The lowest compared to the highest quartile conferred an HR of 1.51 (95 % CI 1.17–1.95), adjusted for gender and study center. Adjustment for smoking, month of blood sample, BMI, education, physical inactivity, self-rated health, and serum 25-hydroxyvitamin D (25(OH)D) yielded similar results. Taking serum total cholesterol concentration into account attenuated the association somewhat: HR of hip fracture was 1.37 (95 % CI 1.05–1.77) in first versus fourth quartile of serum α-tocopherol/total cholesterol ratio.

Conclusions

Low serum concentrations of α-tocopherol were associated with increased risk of hip fracture in older Norwegians.     

Value of Geriatric Frailty and Nutritional Status Assessment in Predicting Postoperative Mortality in Gastric Cancer Surgery

Objectives

This study seeks to evaluate assessment of geriatric frailty and nutritional status in predicting postoperative mortality in gastric cancer surgery.

Methods

Preoperatively, patients operated for gastric adenocarcinoma underwent assessment of Groningen Frailty Indicator (GFI) and Short Nutritional Assessment Questionnaire (SNAQ). We studied retrospectively whether these scores were associated with in-hospital mortality.

Results

From 2005 to September 2012 180 patients underwent surgery with an overall mortality of 8.3 %. Patients with a GFI?≥?3 (n?=?30, 24 %) had a mortality rate of 23.3 % versus 5.2 % in the lower GFI group (OR 4.0, 95%CI 1.1–14.1, P?=?0.03). For patients who underwent surgery with curative intent (n?=?125), this was 27.3 % for patients with GFI?≥?3 (n?=?22, 18 %) versus 5.7 % with GFI?<?3 (OR 4.6, 95 % CI 1.0–20.9, P?=?0.05). SNAQ?≥?1 (n?=?98, 61 %) was associated with a mortality rate of 13.3 % versus 3.2 % in patients with SNAQ?=?0 (OR 5.1, 95 % CI 1.1–23.8, P?=?0.04). Given odds ratios are corrected in multivariate analyses for age, neoadjuvant chemotherapy, type of surgery, tumor stage and ASA classification.

Conclusions

This study shows a significant relationship between gastric cancer surgical mortality and geriatric frailty as well as nutritional status using a simple questionnaire. This may have implications in preoperative decision making in selecting patients who optimally benefit from surgery.     

Competing mortality and fracture risk assessment

Summary

Failure to account for competing mortality gave higher estimates of 10-year fracture probability than if appropriate adjustment is made for competing mortality, particularly among subgroups with higher mortality. A modified Kaplan–Meier method is easy to implement and provides an alternative approach to existing methods for competing mortality risk adjustment.

Introduction

A unique feature of FRAX^® is that 10-year fracture probability accounts for mortality as a competing risk. We compared the effect of competing mortality adjustment on nonparametric and parametric methods of fracture probability estimation.

Methods

The Manitoba Bone Mineral Density (BMD) database was used to identify men and women age ≥50 years with FRAX probabilities calculated using femoral neck BMD (N?=?39,063). Fractures were assessed from administrative data (N?=?2,543 with a major osteoporotic fracture, N?=?549 with a hip fracture during mean 5.3 years follow-up).

Results

The following subgroups with higher mortality were identified: men, age >80 years, high fracture probability, and presence of diabetes. Failure to account for competing mortality in these subgroups overestimated fracture probability by 16–56 % with the standard nonparametric (Kaplan–Meier) method and 15–29 % with the standard parametric (Cox) model. When the outcome was hip fractures, failure to account for competing mortality overestimated hip fracture probability by 18–36 % and 17–35 %, respectively. A simple modified Kaplan–Meier method showed very close agreement with methods that adjusted for competing mortality (within 2 %).

Conclusions

Failure to account for competing mortality risk gives considerably higher estimates of 10-year fracture probability than if adjustment is made for this competing risk.     

Ethnic Disparities in Trauma Mortality Outcomes

Background

Ethnic disparities in trauma mortality outcomes have been demonstrated in the United States according to the US National Trauma Data Bank. The aim of this study was to determine the effect of race/ethnicity on trauma mortality in Singapore.

Methods

This was a retrospective review of patients aged 18–64 years with an injury severity score (ISS) ≥9 in the Trauma Registry of Tan Tock Seng Hospital, a 1,300-bed trauma center in Singapore, from 2006 to 2010. Chinese, Malay, and Indian patients were compared with patients of other ethnic groups. Multiple logistic regression analyses determined differences in survival rates after adjusting for demographics, anatomic and physiologic ISS and revised trauma score, mechanism or type of injury.

Results

A total of 4,186 patients (66.4 % of the database) met the inclusion criteria. Most patients were male (76.3 %) and young (mean age 40 years). Using Chinese as the reference group, we found no statistically significant differences in unadjusted or adjusted mortality rates among the ethnic groups. Independent predictors of mortality included age [odds ratio (OR) 1.05, 95 % confidence interval (CI) 1.03–1.06, p < 0.0001], presence of severe head injury (OR 1.75, 95 % CI 1.13–2.69, p = 0.012), and increasing ISS (p < 0.0001).

Conclusions

Ethnicity is not an independent predictor of trauma mortality outcomes in the Singapore population. Our findings contrast with those from the United States, where race/ethnicity (Black and Hispanic) remains a strong independent risk factor for trauma mortality. This study attests to the success of the Singapore health care/trauma system in delivering the same quality of care regardless of ethnicity.     

Diuretic initiation and the acute risk of hip fracture

Summary

We found the risk of hip fracture was transiently elevated around twofold shortly after initiation of a loop or thiazide diuretic drug in a case-crossover and case–control study. No statistical association was found following the initiation of a comparator medication: ACE inhibitors. Awareness of these short-term risks may reduce hip fractures.

Introduction

Little is known about the acute effects of initiating a diuretic drug on risk of fracture. We evaluated the relationship between initiating a diuretic drug and the occurrence of hip fracture.

Methods

The study sample included 2,118,793 persons aged ≥50 years enrolled in The Health Improvement Network (THIN) between 1986 and 2010. The effect of a new start of a diuretic drug or comparator medication (ACE inhibitor) on risk of hip fracture was assessed using a case-crossover and case–control study during the 1–7, 8–14, 15–21, and 22–28 days following drug initiation.

Results

Included were 28,703 individuals with an incident hip fracture over a mean of 7.9 years follow-up. In the case-crossover study, the risk of experiencing a hip fracture was increased during the first 7 days following loop diuretic drug initiation (OR?=?1.8; 95 % CI, 1.2, 2.7). The elevated risk did not continue during the 8–14, 15–21, or 22–28 days following drug initiation. For thiazide diuretics, the risk of hip fracture was elevated 8–14 days after drug initiation (OR?=?2.2; 95 % CI, 1.2, 3.9). No such association was observed in the 1–7, 15–21, or 22–28 days following thiazide drug initiation. ACE inhibitor initiation was not associated with a statistically significant increased risk of hip fracture. Similar results were observed using a case–control study.

Conclusions

The risk of hip fracture was transiently elevated around twofold shortly after the new start of a loop or thiazide diuretic drug. Awareness of these short-term risks may reduce hip fractures and other injurious falls in vulnerable adults.     

A Case-matched Series of Immediate Total-body CT Scanning Versus the Standard Radiological Work-up in Trauma Patients

Background

In recent years computed tomography (CT) has become faster and more available in the acute trauma care setting. The aim of the present study was to compare injured patients who underwent immediate total-body CT (TBCT) scanning with patients who underwent the standard radiological work-up with respect to 30-day mortality.

Methods

Between January 2009 and April 2011, 152 consecutive patients underwent immediate TBCT scanning as part of a prospective pilot study. These patients were case-matched by age, gender, and Injury Severity Score (ISS) category with control patients from a historical cohort (July 2006–November 2007) who had undergone X-rays and focused assessment with sonography for trauma, followed by selective CT scanning.

Results

Despite comparable demographics, TBCT patients had a lower median Glasgow Coma Score (GCS) than controls (10 vs. 15; p < 0.001) and on-scene endotracheal intubation was performed more often (33 vs. 19 %; p = 0.004). 30-day mortality was 13 % in the TBCT patient group versus 13 % in the control group (p = 1.000). A generalized linear mixed model analysis showed that a higher in-hospital GCS [odds ratio (OR) 0.8, 95 % confidence interval (CI) 0.745–0.86; p < 0.001] and immediate TBCT scanning (OR 0.46, 95 % CI 0.236–0.895; p = 0.022) were associated with decreased 30-day mortality, while a higher ISS (OR 1.054, 95 % CI 1.028–1.08) p < 0.001) was associated with increased 30-day mortality.

Conclusions

Trauma patients who underwent immediate TBCT scanning had similar absolute 30-day mortality rates compared to patients who underwent conventional imaging and selective CT scanning. However, immediate TBCT scanning was associated with a decreased 30-day mortality after correction for the impact of differences in raw ISS and in-hospital GCS.     

Excess risk of hip fractures attributable to the use of antidepressants in five European countries and the USA

Summary

The association between antidepressant use and hip fracture remains unclear. We conducted a systematic review to estimate Population Attributable Risks (PAR) for France, Germany, Italy, Spain, UK, and the USA. We report a heterogeneous prevalence of antidepressant use and related PARs, both lowest for Italy and highest for the USA.

Introduction

Antidepressant use has been associated with an increased hip fracture risk in observational studies. However, the potential contribution of antidepressant consumption on the population rate of hip fractures has not been described. Our aim was to estimate the impact of the use of different classes of antidepressants on the rate of hip fracture at a population-level in France, Germany, Italy, Spain, the UK, and the USA.

Methods

We conducted a systematic literature review to estimate the pooled relative risk (RR) of hip fracture according to use of antidepressants. Prevalence rates of antidepressant use (Pe) in 2009 were calculated for each country using the The Intercontinental Medical Statistics database and three public databases from Denmark, the Netherlands, and Norway. Both the RR and Pe were used to calculate PAR of hip fractures associated with antidepressant use.

Results

The literature review showed an increased risk of hip fractures in antidepressant users (RR, 1.7; 95 % confidence interval (CI), 1.5–2.0). Rates of antidepressant use showed considerable differences between countries, ranging from 4.4 % (Italy) to 11.2 % (USA) in the year 2009. The estimated PAR of antidepressants on hip fracture rates were 3.0 % (95 % CI, 2.0–4.1; Italy), 3.1 % (95 % CI, 2.1–4.3; Germany), 3.8 % (95 % CI, 2.6–5.3; France), 4.8 % (95 % CI, 3.3–6.5; Spain), 4.9 % (95 % CI, 3.4–6.8; UK), and 7.2 % (95 % CI, 5.0–9.9; USA). PARs differed for different types of antidepressants, with highest attributable risks for selective serotonin reuptake inhibitors.

Conclusions

These findings suggest that the potential contribution of antidepressant use to the population rate of hip fractures in the five large EU countries and the USA varies between 3 and 7 %.