Summary
This study showed additional clinical risk factors for the occurrence of multiple fractures with regards to a single fracture, with often higher hazard ratios. It would be important to ...include the risk of the occurrence of multiple fractures in future prediction models.
Purpose
To identify clinical risk factors (CRFs) which would specifically increase the risk of multiple fractures.
Methods
Data of the 3560 postmenopausal women of the FRISBEE study were analysed. The CRFs and the fractures are collected annually. The cohort was divided into three groups: those who had no incident fracture, those who had a single incident fracture and those who had 2 two or more incident fractures (i.e. multiple fractures). Statistical analyses were performed using Cox proportional hazards models.
Results
Among the 3560 subjects (followed for 9.1 (7.2–10.6) years), 261 subjects had two or more validated fractures during follow-up (146 were major osteoporotic fractures (MOFs)), 628 had one fracture (435 MOFs), 2671 had no fracture (2979 had no MOF); 157 subjects had two or more central fractures, 389 had only one and 3014 had none. The risk factors for those with multiple fractures at any site were age, history of fracture, history of fall, total hip bone mineral density (BMD), spine BMD and rheumatoid arthritis. For those with multiple MOFs, significant CRFs were age, history of fracture, parental hip fracture, total hip BMD and rheumatoid arthritis.
Conclusion
We found in a prospective cohort study that there were more CRFs and higher hazard ratios for the occurrence of multiple fractures than for a single fracture.
The association between obesity and fracture sites in postmenopausal women has been little studied. We examined the most common types of fractures in obese and overweight postmenopausal women ...compared to subjects with a normal BMI in the FRISBEE study, a cohort of postmenopausal women followed since 9.1 (7.2–10.6) years. Chi-squared tests and logistic regressions were used to compare the percentages of fracture sites in overweight/obese subjects to subjects with a normal BMI. Their mean (± SD) age was 76.7 ± 6.9 years and their mean BMI was 26.4 ± 4.4. Seven hundred seventy-seven subjects suffered at least one validated fragility fracture with a total of 964 fractures in the whole cohort. Subjects with a BMI higher than 25 had significantly more ankle fractures and less pelvic fractures than subjects with a normal BMI (OR 1.63, 95% CI 1.02–2.56,
P
= 0.04 and OR 0.55, 95% CI 0.34–0.89,
P
= 0.01, respectively). There were no significant differences between overweight and obese subjects. Among those older than 75, there were significantly fewer pelvic fractures in overweight/obese subjects (OR 0.49, 95% CI 0.27–0.87,
P
= 0.01), but before 75, ankle fractures were significantly more frequent in overweight/obese subjects than in subjects with a normal BMI (OR 1.89, 95% CI 1.01–3.57,
P
= 0.04). In conclusion, the proportion of ankle and pelvic fractures in obese and overweight subjects differs from that in subjects with a normal BMI, but these differences are age dependent. Fracture prevention strategies should take into account the differential effects of excess weight according to age and the site of fracture.
Summary
Multiple factors increase the risk of an imminent fracture, including a recent fracture, older age, osteoporosis, comorbidities, and the fracture site. These findings could be a first step in ...the development of a model to predict an imminent fracture and select patients most at need of immediate treatment.
Introduction
The risk of a recurrent fragility fracture is maximal during the first 2 years following an incident fracture. In this prospective cohort study, we looked at the incidence of recurrent fractures within 2 years after a first incident fracture and we assessed independent clinical risk factors (CRFs) increasing this imminent fracture risk.
Methods
A total of 3560 postmenopausal women recruited from 2007 to 2013 were surveyed yearly for the occurrence of fragility fractures. We identified patients who sustained a fracture during the first 2 years following a first incident fragility fracture. We quantified the risk of a new fracture and assessed independent CRFs, associated with an imminent fracture at various sites.
Results
A recent fracture was a significant CRF for an imminent fracture (OR (95% CI): 3.7 (2.4–5.7)
p
< 0.0001). The incidence of an imminent fracture was higher in subjects above 80 years (
p
< 0.001). Other CRFs highly predictive in a multivariate analysis were osteoporosis diagnosis (
p
< 0.01), a central fracture as the index fracture (
p
< 0.01), and the presence of comorbidities (
p
< 0.05), with likelihood ratios of 1.9, 1.9, and 2.2, respectively. An imminent fracture was better predicted by a central fracture (
p
< 0.01) than by a major osteoporotic fracture. The hazard ratio was the highest for a central fracture.
Conclusion
In patients with a recent fracture, older age, osteoporosis, comorbidities, and fracture site were associated with an imminent fracture risk. These findings could be a first step in the development of a model to predict an imminent fracture and select patients most at need of immediate and most appropriate treatment.
Introduction
Several surveys report that post-COVID-19 patients (pts) could be at risk of persistent emotional distress, fatigue and impaired neurocognitive function (NCF).
Objectives
The aim was to ...assess emotional distress, fatigue and NCF in order to provide adequate care.
Methods
Patients with persistent physical or mental symptoms, at least 8 weeks post-COVID-19, were eligible for this ongoing prospective longitudinal single center trial. Data on depression, anxiety, cognition, post-traumatic stress symptoms (PTSS) and fatigue were collected using 4 validated questionnaires at study entry (T0) and at 6 months (T1).
Results
Ninety-three pts were recruited between November 2020-March 2021. Test results from 64 eligible pts (15 male pts) were analyzed at T0; 63 pts (98%) were treated in outpatient settings. Median age was 47 years range 27-75). Median time since COVID-19 was 29 weeks range 8-53. Twenty-two pts (34%) had a history of psychiatric disorders. According to the Hospital Anxiety Depression Scale (HADS), 44 pts (73%) reported anxiety symptoms and 26 pts (41%) reported depressive symptoms; 48 pts (69%) reported cognitive complaints according to the Cognitive Failure Questionnaire and 29 pts (45%) suffered from PTSS, according to the Post-Traumatic Stress Disorder Checklist-Civilian Version (PCL-C). Fifty-five pts (86%) had an elevated score on the Fatigue Severity Scale, indicating severe fatigue. Twenty-seven pts (42%) were still on sick leaf. Diminished social support and psychiatric history were predictive factors for neurocognitive dysfunction and PTSS.
Conclusions
A majority of patients who recovered physically from COVID-19, are at risk for suffering from persistent anxiety, PTSS and neurocognitive dysfunction.
Disclosure
No significant relationships.
Summary
Our imminent model was less sensitive but more selective than FRAX® in the choice of treatment to prevent imminent fractures. This new model decreased NNT by 30%, which could reduce the ...treatment costs. In the Belgian FRISBEE cohort, the effect of recency further decreased the selectivity of FRAX®.
Purpose
We analyzed the selection for treatment of patients at high risk of fracture by the Belgian FRISBEE imminent model and the FRAX® tool.
Methods
We identified in the FRISBEE cohort subjects who sustained an incident MOF (mean age 76.5 ± 6.8 years). We calculated their estimated 10-year risk of fracture using FRAX® before and after adjustment for recency and the 2-year probability of fracture using the FRISBEE model.
Results
After 6.8 years of follow-up, we validated 480 incident and 54 imminent MOFs. Of the subjects who had an imminent fracture, 94.0% had a fracture risk estimated above 20% by the FRAX® before correction for recency and 98.1% after adjustment, with a specificity of 20.2% and 5.9%, respectively. The sensitivity and specificity of the FRISBEE model at 2 years were 72.2% and 55.4%, respectively, for a threshold of 10%.
For these thresholds, 47.3% of the patients were identified at high risk in both models before the correction, and 17.2% of them had an imminent MOF. The adjustment for recency did not change this selection. Before the correction, 34.2% of patients were selected for treatment by FRAX® only, and 18.8% would have had an imminent MOF. This percentage increased to 47% after the adjustment for recency, but only 6% of those would suffer a MOF within 2 years.
Conclusion
In our Belgian FRISBEE cohort, the imminent model was less sensitive but more selective in the selection of subjects in whom an imminent fracture should be prevented, resulting in a lower NNT. The correction for recency in this elderly population further decreased the selectivity of FRAX®. These data should be validated in additional cohorts before using them in everyday practice.
Summary
Despite the availability of efficient drugs to prevent osteoporotic fractures, only a minority of women receives osteoporosis therapy after a fracture. The high treatment gap in our cohort ...consisted of unselected volunteer patients highlights the urgent need of additional education, especially for the medical profession, regarding the risk-benefit balance of treatment.
Introduction
Despite the availability of efficient drugs to prevent osteoporotic fractures, only a minority of women receives osteoporosis therapy after a fracture, with a treatment gap around 80%. This can have dramatic consequences for patients and the healthcare systems.
Methods
In this study based on longitudinal data from the FRISBEE (Fracture RIsk Brussels Epidemiological Enquiry) cohort of 3560 volunteer women aged 60 to 85 years, we evaluated the 1-year treatment gap after a first major incident fragility fracture.
Results
There were 386 first validated fragility fractures, 285 major osteoporotic fractures (MOF) and 101 “other major” fractures. The rate of untreated patients was 85.0% (82.8% for MOF versus 91.0 % for “other major” fracture sites) (
p
= 0.04), with a lower rate for spine (70.5%) and hip (72.5%) versus shoulder (91.6%) and wrist (94.1%) (
p
< 0.0001). More specifically, the treatment gap for patients with osteoporosis, defined by a
T
-score < − 2.5 SD was 74.6% versus 76.5% for patients with osteoporosis defined by the presence of hip, shoulder, or spine fractures, independently of DXA results. When considering age groups, the rate of untreated women was 87.9% for women 60–70 years old, 88.2% between 70 and 80 years and 77.8% above 80 years (
p
= 0.03), with a greater difference between women who were younger or older than 80 years at inclusion: 88.1% versus 77.8% (
p
= 0.009). A diagnosis of osteoporosis (
p
= 0.01) and age (
p
= 0.03) were the only clinical risk factors (CRFs) significantly associated with treatment initiation.
Conclusions
This study highlights the urgent need of additional education, especially for the medical profession, regarding the risk-benefit balance of treatment.
The ratio between major osteoporotic fractures (MOFs) and hip fractures in the Belgian FRAX® tool to predict fractures is currently based on Swedish data. We determined these ratios in a prospective ...cohort of Belgian postmenopausal women. 3560 women, aged 60–85 years (70.1 ± 6.4 years), were included in a prospective study from 2007 to 2013 and surveyed yearly (FRISBEE). We analyzed the number of validated incident fractures until October 2020 by age and sites and compared the MOFs/hip ratios in this cohort with those from the Swedish databases. We registered 1336 fractures (mean follow-up of 9.1 years). The MOFs/hip ratios extracted from the FRISBEE cohort were 10.7 95% CI: (5.6–20.5), 6.4 4.7–8.7, and 5.0 3.9–6.5 for women of 60–69, 70–79, and 80–89 years old, respectively. These ratios were 1.7–1.8 times higher for all age groups than those from the Swedish data, which decreased from 6.5 (60–64 years group) down to 1.8 (85–89 age group). The overall MOFs/hip ratio in Frisbee was 6.0 5.9–6.1, which was higher than any Swedish ratio between 65 and 85 years. Nevertheless, the decrease of the ratios with age paralleled that observed in Sweden. In this Brussels prospective cohort, MOFs/hip ratios were 1.7–1.8 times those observed in Sweden currently used for MOFs prediction in the Belgian FRAX® version. This discrepancy can greatly modify the estimation of the risk of MOFs, which is among the main criteria used to recommend a pharmacological treatment for osteoporosis in several countries.
Prediction models, especially the FRAX®, are largely used to estimate the fracture risk at ten years, but the current algorithm does not take into account the time elapsed after a fracture. Kanis et ...al. recently proposed correction factors allowing to adjust the FRAX® score for fracture recency. The objective of this work was to analyze the effect of fracture recency in the FRISBEE cohort.
We identified in the FRISBEE cohort subjects who sustained a validated fracture during the first 5 years following an incident MOF. We calculated their estimated 5-year risk of fracture using FRAX® uncorrected, adjusted for recency and further adjusted for the MOF/hip ratios calibration factors previously derived for the Belgian FRAX®. We compared the fracture risk estimated by FRAX® before and after these corrections to the observed incidence of validated fractures in our cohort.
In our ongoing cohort, 376 subjects had a first non-traumatic incident validated MOF after inclusion; 81 had a secondary fracture during the 5 years follow-up period after this index fracture. The FRAX® score significantly under-evaluated the observed incidence of fractures in our cohort by 54.7 % (fracture rate of 9.7 %; 95 % CI, 6.8–12.9 %) if uncorrected (p < 0.001) and by 32.6 % after correction for recency (14.5 %; 95 % CI, 11.1–18.2 %) (p = 0.01). The calibration for MOF/hip ratios improved the prediction (17.5 %; 95 % CI: 13.7–21.4 %) (p = 0.2). After correcting for recency and for calibration, the predicted value was over-evaluated by 22 % (fracture rate of 26.1 %; 95 % CI, 21.6–30.5 %) but this over-evaluation was not significant (p = 0.1).
Our data indicate that the correction of the FRAX® score for fracture recency improves fracture prediction. However, correction for calibration and recency tends to overestimate fracture risk in this population of elderly women.
•The FRAX® score underestimated the probability of recurrent fractures after a MOF.•The correction of FRAX® for calibration, with or without an adjustment for recency, improved the prediction.•The correction for recency tends to overestimate fracture risk in a population of elderly women.•The effect of fracture recency on further fracture risk is attenuated in an older population.
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