The Association Between Older Age, Co-Morbidity, and Treatment Status of Incident Osteoporotic Fractures: A Population-Based Nested Cohort Study

I attended and presented a poster at the International Symposium on Osteoporosis hosted by the National Osteoporosis Foundation in Las Vegas, NV. This was a very well attended conference with over 800 attendees including clinicians and researchers interested / working in the area of osteoporosis. The research I presented was well received and added to the body of knowledge related to osteoporosis and treatment of new fractures. Attending this conference allowed me to meet other researchers with similar research interests and I look forward to possible collaborations in the future.BACKGROUND: Despite strong evidence-based rationale for both the primary and secondary prevention of osteoporosis, there remains an overall low prevalence of osteoporosis treatment in older adults. Furthermore, there is some question whether low treatment rates in older adults are simply age related variations (in treatments) or due to the presence of co-morbid conditions. Therefore, we sought to examine the association between older age, co-morbidity, and the use of osteoporosis medications following an incident osteoporosis related fracture. METHODS: We performed a retrospective nested cohort analysis using de-identified administrative healthcare data from the province of British Columbia, Canada (pop. 4.1 million). We included patients 65 years and older, who had continuous enrollment in the provinces’ prescription drug plan, with a study-defined osteoporosis-related fracture during the study period of April 1, 1999 to March 31, 2002. A multivariate logistic regression model was used to examine the association between the dependent variable - osteoporosis medication dispensation within six months of index fracture and the predictor variables - age, sex, co-morbidity, fracture site, year of fracture, health region, and osteoporosis treatment prior to the index fracture. RESULTS: After exclusion criteria were applied, we identified 11,870 consecutive patients who had been hospitalized with 12,025 incident (study-defined) fractures during the study period. The mean age of the sample was 81.1 years (SD 7.7; range 65–104 years), and 74% of the subjects were women. The majority of patients (99%) sustained one fracture (range 1 to 4); the fractures were predominately of the hip (63%) followed by fractures of the wrist (17%), pelvis (9%), vertebra (7%), and ribs (4%). The majority of subjects had no co-morbid conditions or only one (63%); 31% had two to three co-morbidities, and 6% had four or more co-morbid conditions. Overall, there was a low rate of osteoporosis treatment before the incident fracture (15% treatment); this rate improved to 19% at six months post fracture. Those receiving treatment after the index fracture were significantly younger, more often female, and had fewer co-morbid conditions (P < .001). The use of an osteoporosis medication prior to the index fracture was the strongest predictor of post-fracture treatment (adjusted OR = 15.89; 95% CI = 9.69–26.04). Increasing age, more than one co-morbid condition, and male sex were all associated with a significant decrease in the likelihood of dispensing osteoporosis drugs when compared to younger and healthier women. CONCLUSION: Despite the wide availability of osteoporosis medications, our findings suggest that the majority of older adults, many of who have at least one co-morbid condition, are not receiving treatment to prevent the progression of the disease and to prevent further fractures

Physical trauma and risk of multiple sclerosis: A systematic review and meta-analysis of observational studies

AbstractBackgroundWe aimed to examine physical trauma as a risk factor for the subsequent diagnosis of MS.MethodsWe searched for observational studies that evaluated the risk for developing MS after physical trauma that occurred in childhood (≤20years) or “premorbid” (>20years). We performed a meta-analysis using a random effects model.ResultsWe identified 1362 individual studies, of which 36 case–control studies and 4 cohort studies met the inclusion criteria for the review. In high quality case–control studies, there were statistically significant associations between those sustaining head trauma in childhood (OR=1.27; 95% CI, 1.12–1.44; p<0.001), premorbid head trauma (OR=1.40; 95% CI, 1.08–1.81; p=0.01), and other traumas during childhood (OR=2.31; 95% CI, 1.06–5.04; p=0.04) and the risk of being diagnosed with MS. In lesser quality studies, there was a statistical association between “other traumas” premorbid and spinal injury premorbid. No association was found between spinal injury during childhood, or fractures and burns at any age and the diagnosis of MS. The pooled OR of four cohort studies looking at premorbid head trauma was not statistically significant.ConclusionsThe result of the meta-analyses of high quality case–control studies suggests a statistically significant association between premorbid head trauma and the risk for developing MS. However, cohort studies did not. Future prospective studies that define trauma based on validated instruments, and include frequency of traumas per study participant, are needed

The Association Between Dementia Status, Co-morbidity, and Osteoporosis Treatment: A Population-Based Nested Case-Control Study

Using administrative healthcare data, we examined the association between dementia, co-morbidity, and the prescription of osteoporosis medications among community-dwelling older adults. We found that despite the availability of osteoporosis medications, the majority of patients with a concurrent diagnosis of dementia and osteoporosis did not receive treatment to prevent osteoporosis complications.BACKGROUND: Increasing age and a diagnosis of dementia both dramatically increase the risk of serious osteoporosis related sequela. At the same time, there remains an overall low rate of osteoporosis treatment particularly in older, frail adults despite the availability of effective antiresorptive treatments such as bisphosphonate drugs. In addition, the frequency in which community dwelling persons with dementia are treated with osteoporosis medications has not been well described. Furthermore, existing literature does not adequately delineate whether the low treatment rates are simply age related variations (in treatments) or due to the presence of co-morbid conditions, particularly dementia. METHODS: We performed a retrospective population based nested case-control study using de-identified administrative healthcare data from a Canadian province (pop. 4.1 million). We included patients 65 years and older, with a diagnosis of osteoporosis, who had continuous prescription drug coverage during the study period of 1991 to 2007. A multivariate logistic regression model was assembled to examine the relationship between osteoporosis medication dispensation and dementia status while controlling for age, sex, co-morbidity, and residence. RESULTS: We included 39,452 patients in the osteoporosis cohort; the mean age of the sample was 80.1 years (SD 7.5; range 65–104 years), 79% of the subjects were female, and 34% had a dementia diagnosis. Only 5% of the sample had no co-morbid conditions; the majority of patients (52%) had at least 3 co-morbid conditions (SD 2.0; range 0–12 conditions). When stratified by dementia status, there were significant differences in age, frequency of co-morbidity, and residence by health region (P < .001) and sex (P < .05). Almost half of the total osteoporosis cohort were dispensed an osteoporosis medication during the study period (43%; P < .001). Those who had been dispensed drug treatment were more often younger, female, and had no diagnosis of dementia (P < .001). Drug dispensation was directly related to the frequency of co-morbid conditions; those with 4 or more conditions were dispensed treatment significantly more often (54%) than those with fewer co-morbid conditions (P < .001). A diagnosis of dementia was a significant negative predictor of drug dispensation (adjusted OR = 0.55; 95% CI = 0.44–0.69). Increasing age, male sex, and a more remote residence were all associated with a significant decrease in the likelihood of treatment. Increasing co-morbidity was significantly associated with receiving treatment (adjusted OR = 3.30; 95% CI = 2.88–3.78). CONCLUSION: Despite the wide availability of osteoporosis medications, our findings suggest that the majority of older adults with a diagnosis of dementia, but not necessarily fewer co-morbid conditions, are not receiving treatment to prevent progression of the disease including fragility fractures

Calcitonin for Treating Acute and Chronic Pain of Recent and Remote Osteoporotic Vertebral Compression Fractures: A Systematic Review and Meta Analysis

I attended and presented a poster at the joint conference of the International Society of Bone Densitometry and the National Osteoporosis Foundation in San Antonio, Texas. This was a very well attended conference with over 800 attendees including clinicians and researchers interested / working in the area of osteoporosis. The research I presented was well received and added to the body of knowledge related to osteoporosis and the non-narcotic treatment of fracture pain. Attending this conference allowed me to meet other researchers with similar research interests and I look forward to possible collaborations in the future.Background: Vertebral collapse is one of the most common fractures associated with osteoporosis. The subsequent back pain may be severe and often requires medications and bed rest to control pain and improve mobilization. Recent studies have suggested the use of calcitonin as an initial and adjunctive treatment for severe, unrelenting back pain secondary to an osteoporotic vertebral compression fracture (OVCF), as it exhibits known analgesic properties and does not produce the unpleasant side effects associated with narcotics. Therefore, we sought to determine the analgesic efficacy of calcitonin for the treatment of acute or chronic back pain in stable patients sustaining a recent or remote OVCF. Methods: We searched the Cochrane Musculoskeletal Group (CMSG) specialized trial register , the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, and other databases and conference proceedings up until June 2009. Primary study authors and pharmaceutical manufacturers were contacted, and bibliographies of relevant papers were hand searched. We included randomized, placebo, and controlled trials that evaluated the analgesic efficacy of calcitonin on pain levels in people with acute or chronic back pain attributed to OVCFs. Two reviewer’s extracted data, scored trial quality, preformed numeric calculations, and extrapolated graphical data independently. Where appropriate, we calculated mean differences, standardized mean differences, or risk ratios using a fixed or random effects model. Results: The combined results from 13 controlled trials, involving 589 patients, determined that calcitonin significantly reduced the severity of acute pain in recent OVCFs. Pain at rest was reduced as early as one week (MD -3.42; 95% CI: -3.96, -2.88) and this effect continued weekly to four weeks (MD -4.49; 95% CI: -4.96, -4.03). A similar pattern was seen for pain scores with mobility; at week 4 the difference in pain scores between groups was even more profound (SMD -5.99; 95% CI: -6.78, -5.19). When chronic back pain of a more remote OVCF was examined with patients at rest, there was no statistical difference between groups. When the same patients were assessed while mobile at six months, there was a statistically significant difference between groups (SMD -0.49; 95% CI: -0.85, -0.13; P = 0.008). Side effects were generally mild and self-limiting with enteric disturbances (47%) and flushing (32%) reported most frequently. Conclusions: Calcitonin has proven efficacy in the management of acute back pain associated with a recent OVCF and improves the quality of life by shortening time to mobilization. Although there was a slight improvement in back pain for patients with chronic pain at six months, this is unlikely to be of clinical significance. Therefore, there is no convincing evidence to support the use of calcitonin for the chronic pain associated with remote fractures of the same origin

Factors influencing health-related quality of life among long-term care residents experiencing pain: a systematic review protocol

Abstract Background Pain is highly burdensome, affecting over 30% of long-term care (LTC) residents. Pain significantly reduces residents’ health-related quality of life (HRQoL), limits their ability to perform activities of daily living (ADLs), restricts their social activities, and can lead to hopelessness, depression, and unnecessary healthcare costs. Although pain can generally be prevented or treated, eliminating pain may not always be possible, especially when residents have multiple chronic conditions. Therefore, improving the HRQoL of LTC residents with pain is a priority goal. Understanding factors influencing HRQoL of LTC residents with pain is imperative to designing and evaluating targeted interventions that complement pain management to improve residents’ HRQoL. However, these factors are poorly understood, and we lack syntheses of available research on this topic. This systematic review protocol outlines the methods to identify, synthesize, and evaluate the available evidence on these factors. Methods This mixed methods review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. We will systematically search Medline, EMBASE, PsycINFO, CINAHL, Scopus, Cochrane Database of Systematic Reviews and ProQuest Dissertation and Thesis Global from database inception. We will include primary studies and systematically conducted reviews without restrictions to language, publication date, and study design. We will also include gray literature (dissertation and reports) and search relevant reviews and reference lists of all included studies. Two reviewers will independently screen articles, conduct quality appraisal, and extract data. We will synthesize results thematically and conduct meta-analyses if statistical pooling is possible. Residents and family/friend caregivers will assist with interpreting the findings. Discussion This proposed systematic review will address an important knowledge gap related to the available evidence on factors influencing HRQoL of LTC residents with pain. Findings will be crucial for researchers, LTC administrators, and policy makers in uncovering research needs and in planning, developing, and evaluating strategies in addition to and complementary with pain management to help improve HRQoL among LTC residents with pain. Systematic review registration PROSPERO CRD4202340542

Depressive symptoms in long term care facilities in Western Canada: a cross sectional study

Background: The main objective is to better understand the prevalence of depressive symptoms, in long-term care (LTC) residents with or without cognitive impairment across Western Canada. Secondary objectives are to examine comorbidities and other factors associated with of depressive symptoms, and treatments used in LTC. Methods: 11,445 residents across a random sample of 91 LTC facilities, from 09/2014 to 05/2015, were stratified by owner-operator model (private for-profit, public or voluntary not-for-profit), size (small:  120 beds), location (Calgary and Edmonton Health Zones, Alberta; Fraser and Interior Health Regions, British Columbia; Winnipeg Health Region, Manitoba). Random intercept generalized linear mixed models with depressive symptoms as the dependent variable, cognitive impairment as primary independent variable, and resident, care unit and facility characteristics as covariates were used. Resident variables came from the Resident Assessment Instrument – Minimum Data Set (RAI-MDS) 2.0 records (the RAI-MDS version routinely collected in Western Canadian LTC). Care unit and facility variables came from surveys completed with care unit or facility managers. Results: Depressive symptoms affects 27.1% of all LTC residents and 23.3% of LTC resident have both, depressive symptoms and cognitive impairment. Hypertension, urinary and fecal incontinence were the most common comorbidities. Cognitive impairment increases the risk for depressive symptoms (adjusted odds ratio 1.65 [95% confidence interval 1.43; 1.90]). Pain, anxiety and pulmonary disorders were also significantly associated with depressive symptoms. Pharmacologic therapies were commonly used in those with depressive symptoms, however there was minimal use of non-pharmacologic management. Conclusions: Depressive symptoms are common in LTC residents –particularly in those with cognitive impairment. Depressive symptoms are an important target for clinical intervention and further research to reduce the burden of these illnesses.Science, Faculty ofNon UBCReviewedFacult

Inhaled magnesium sulfate in the treatment of acute asthma

Background Asthma exacerbations can be frequent and range in severity from relatively mild to status asthmaticus. The use of magnesium sulfate (MgSO4) is one of numerous treatment options available during acute exacerbations. While the efficacy of intravenous MgSO4 has been demonstrated, little is known of the role of inhaled MgSO4. Objectives To determine the efficacy of inhaled MgSO4 administered in acute asthma on pulmonary functions and admission rates. Specific aims: To quantify the effects of inhaled MgSO4 i) in addition to inhaled β2-agonist, ii) in comparison to inhaled β2-agonist alone or iii) in addition to combination treatment with inhaled β2 -agonist and ipratropium bromide. Search methods Randomised controlled trials were identified from the Cochrane Airways Group register of trials in September 2012. These trials were supplemented with trials found in the reference list of published studies, studies found using extensive electronic search techniques, as well as a review of the grey literature and conference proceedings. Selection criteria Randomised (or pseudo-randomised) controlled trials including adults or children with acute asthma were eligible for inclusion in the review. Studies were included if patients were treated with nebulised MgSO4 alone or in combination with β2-agonist and/or ipratropium bromide and were compared with β2-agonist alone or inactive control. Data collection and analysis Trial selection, data extraction and risk of bias were assessed independently by two review authors. Efforts were made to collect missing data from authors. Results are presented as standardised mean differences (SMD) for pulmonary function and risk ratios (RR) for hospital admission; both are displayed with their 95% confidence intervals (CI). Main results Sixteen trials (21 references) of unclear and high risk of bias were eligible and included 896 patients who were randomised (838 patients completed). Seven of the 16 included studies involved adults exclusively, three included adults and paediatric patients, four studies enrolled paediatric patients and in the remaining two studies the age of participants was not stated. The design, definitions, intervention and outcomes were different in all 16 studies; this heterogeneity made direct comparisons difficult (see additional tables 1-3). The overall risk of bias among the included studies was variable and this is reflected in the 'Summary of findings' table with most outcomes being judged as only moderate or less. Inhaled magnesium sulfate in addition to inhaled β2-agonist There was no statistically significant improvement in pulmonary function when inhaled MgSO4 and β2-agonist was compared with β2-agonist alone (SMD 0.23; 95% CI -0.27 to 0.74; three studies, n = 188); however, there was considerable between study heterogeneity. There was no clear advantage in terms of hospital admissions (RR 0.76 95% CI 0.49, 1.16; four studies, n = 249), and there were no serious adverse events reported. Inhaled magnesium sulfate versus inhaled β2-agonist The results of pulmonary function in three studies that compared inhaled MgSO4 versus β2-agonist were too heterogeneous to combine; however, two of the studies found poorer lung function on MgSO4. There was no significant difference in terms of hospital admissions in a single small study when MgSO4 was compared to β2-agonist (RR 0.53 95% CI 0.05, 5.31; one study, n = 33), and there were no serious adverse events reported. Inhaled magnesium sulfate in addition to inhaled β2-agonist and ipratropium A further comparison has been included in the 2012 update of this review of MgSO4 given in addition to inhaled ipratropium and β2-agonist therapy (as recommended by the GINA guidelines). However, there is not yet enough data for this outcome to come to any definite conclusions, but both small studies in adults with severe asthma exacerbation found improvements in pulmonary function with additional inhaled MgSO4. Authors' conclusions There is currently no good evidence that inhaled MgSO4 can be used as a substitute for inhaled β2-agonists. When used in addition to inhaled β2-agonists (with or without inhaled ipratropium), there is currently no overall clear evidence of improved pulmonary function or reduced hospital admissions. However, individual study results from three trials suggest possible improved pulmonary function in those with severe asthma exacerbations (FEV1 less than 50% predicted). Heterogeneity among trials included in this review precludes a more definitive conclusion. Further studies should focus on inhaled MgSO4 in addition to the current guideline treatment for acute asthma (inhaled β2 -agonist and ipratropium bromide). As the evidence suggests that the most effective role of nebulised MgSO4 may be in those with severe acute features and this is where future research should be focused. A set of core outcomes needs to be agreed upon both in adult and paediatric studies to allow improved study comparison in future