Giulio Pioli

Predictors of mortality after hip fracture: results from 1-year follow-up

Background and aims: The study investigates one-year mortality risk associated with hip fracture in elderly people, and pre-fracture characteristics and events occurring during the acute phase which may represent significant predictors for acute and long-term mortality. Methods: The study is a prospective cohort study of 252 patients aged 70 and older, consecutively admitted with hip fracture to the Division of Orthopedic Surgery of the Galliera Hospital of Genoa, Italy. At admission, each subject received a standardized diagnostic evaluation, including demographic variables, biochemical markers of nutritional status and basic medical, functional and cognitive assessment. Patients were followed by telephone interviews at three months, six months and one year after fracture. The relationship between mortality and the risk factors recorded was assessed using logistic regression models. Results: 248 patients were eligible. Cumulative mortality was 4.8% during hospital stay, and 12.5% at 3, 18.9% at 6 and 24% at 12 months. The risk factors significantly associated with mortality were: sex, Acute Physiology Score (APS), comorbidity, functional and cognitive status, and albumin levels. In multivariate models, albumin below 3 g/dL remained the only significant predictor of in-hospital mortality (OR 6,8, 95% CI 1.56-29,7, p<0.001); functional status and comorbidity were significant risk factors of mortality after 6 and 12 months. Conclusions: These findings confirm the important role of serum albumin in assessing in-hospital health status and defining its role as a strong predictor of early and late mortality after hospital discharge. They also emphasize the effects of comorbidity and functional impairment on long-term mortality after hip fracture. Identifying these predictive factors may be helpful in improving case management during hospital stay and more accurate discharge planning.

Intermittent treatment with intravenous 4-amino-1-hydroxybutylidene-1,1-bisphosphonate (AHBuBP) in the therapy of postmenopausal osteoporosis

Since data on the efficacy of 4-amino-2-hydroxybutylidene-1,1-bisphosphonate (AHBuBP) in the therapy of osteoporosis are not yet available, we have examined in an open, randomized study, the effects of an intravenous intermittent treatment with this drug on the vertebral and radial bone mass in postmenopausal osteoporosis. Forty postmenopausal osteoporotic women were randomly assigned to one of two groups, one treated with AHBuBP (5 mg/day on two consecutive days every 3 months for one year; n = 20), the other with oral calcium (n = 20). The bone mineral density (BMD) of the spine increased significantly in women receiving AHBuBP, whereas it tended to decrease in patients given calcium. The differences in the vertebral BMD changes between groups was highly significant (P less than 0.01). Radial BMD tended to increase in patients treated with AHBuBP, and to decrease in patients receiving calcium. The difference in the linear trends was statistically significant (P less than 0.05). The side effects of AHBuBP (a transient acute phase reaction in 3 out of 20 subjects) were slight and well-tolerated. A good effect of AHBuBP was observed also on back pain (P less than 0.05). We conclude that intermittent treatment with AHBuBP is capable of increasing spinal BMD and conserving radial BMD in postmenopausal osteoporosis and may represent a convenient therapeutic choice in this condition.

Orthogeriatric care for the elderly with hip fractures: where are we?

Hip fracture (HF) is a major health care problem in the Western world, associated with significant morbidity, mortality and loss of function. Its incidence is expected to increase as the population ages. The authors discuss the role of a coordinated multidisciplinary team in the management of patients during hospital stay, at discharge and during rehabilitation. Orthogeriatric care should not just be viewed as a multidisciplinary activity, but as a radical alternative to the traditional model of care, an alternative based on all those strategies in which evidence shows an improvement in outcomes in the fractured elderly. Therefore, key points of the care are early surgery, immediate mobilization, prevention and management of delirium, pain and malnutrition, as well as an integrated and multidisciplinary approach. Comprehensive geriatric assessment is useful in identifying frail elderly and in providing information that is essential in formulating clinical recommendations and making care plans. In each hospital, the orthogeriatric unit should represent a center of excellence for treating elderly patients with major fractures. However, when an orthogeriatric project is implemented, it is essential that detailed data about the case-mix of patients, process of care and outcomes are collected, to compare the results with historical data and to be able to participate in audit processes.

Osteocalcin levels in diabetic subjects

SummaryBecause a series of reports suggests the existence of altered bone and mineral metabolism in diabetes mellitus, we studied 106 diabetic subjects (42 insulin-dependent (IDD) and 64 noninsulin dependent (NIDD)) to determine whether a difference in bone turnover (evaluated by serum osteocalcin (OC)) could be found in comparison with normal controls. OC levels in diabetic subjects were lower than the age- and sex-specific predicted values. The reduction was especially evident in male and female NIDD (Z-score: −1.12±0.92, t=8.4,P<0.001 and −0.84±0.86, t=4.0,P<0.01, respectively) and male IDD (Z-score: −0.90±0.86, t=4.5,P<0.01). The mean Z-score for female IDD, albeit negative (−0.31±0.79; t=1.6; 0.2>P>0.1), was not significantly different from normal. Total serum calcium (Ca) and calcitonin (CT) showed an apposite pattern, being higher in all the diabetic subgroups (with the exception of Ca in female IDD), whereas parathyroid hormone (PTH) was lower than expected in each diabetic subset. By multiple regression analysis, the reduction of OC was related to PTH and CT levels and to the type of treatment. Subjects controlled with diet showed differences of greater magnitude from the expected normal values than those treated with oral hypoglycemic agents or insulin (Z-score: −1.28±1.05 vs. −0.85±0.90 and −0.63±0.97, respectively;P=0.05). However, the variance explained by these three factors was small, suggesting that other variables (possibly α,25(OH)2D) exerted important influences on OC levels.

Secondary Hyperparathyroidism Due to Hypovitaminosis D Affects Bone Mineral Density Response to Alendronate in Elderly Women with Osteoporosis: A Randomized Controlled Trial

OBJECTIVES: To determine whether secondary hyperparathyroidism (HPTH) due to hypovitaminosis D affects bone mineral density (BMD) response to alendronate (ALN) in elderly women with osteoporosis.

High prevalence of secondary hyperparathyroidism due to hypovitaminosis D in hospitalized elderly with and without hip fracture

Objectives: To determine and compare the prevalence of secondary hyperparathyroidism (HPTH) in a population of community-dwelling and institutionalized older adults hospitalized with and without hip fracture, and to evaluate factors correlated with secondary HPTH in this population. Methods: Circulating concentrations of serum intact PTH, 25-hydroxyvitamin D [25(OH)D] total serum calcium and albumin were measured in 160 subjects with an osteoporotic fracture of the proximal femur and in 160 matched controls hospitalized for a disease unrelated to bone status. Patients with secondary causes of bone loss and taking medications affecting bone metabolism were excluded. Age, sex, place of residence and the ability to perform basic activities of daily living (BADL) two weeks before hospital admission were recorded at baseline. Results: Patients were comparable with regard to the baseline demographic, biochemical and functional characteristics. The overall prevalence of secondary hyperparathyroidism was 51.2%, without significant differences between hip fractured patients and controls (50.6 vs 51.9%, p=0.911). In bivariate analysis only the age and functional status (BADL) demonstrated a significant relationship with secondary HPTH, while sex and place of residence were not significant. These results were also confirmed in multivariate analysis. Particularly, the risk of secondary HPTH increased with age and with the number of functions lost in BADL: patients fully dependent showed a 3 times as high risk (odd ratio 3.07, 95% confidence interval 1.73 to 5.46, p=0.000) compared to patients independent in BADL, and subject aged >88 yr had a twice as high risk of developing secondary HPTH compared to younger ones (odd ratio 2.28, 95% confidence interval 1.20 to 4.32, p=0.012). Conclusion: These results show that secondary HPTH due to hypovitaminosis D is a frequent disorder in hospitalized elderly, strongly correlated with the functional status, irrespective of sex and place of residence.

Predictors of hospital readmission in a cohort of 236 elderly discharged after surgical repair of hip fracture: one-year follow-up

Background and aims: Few studies have investigated predictors for hospital readmission after hip fracture repair. Methods: In a prospective cohort study we evaluated factors associated with early (within 3 months) and late (between 3–12 months), single and multiple hospital readmission in 236 hip-fractured older adults admitted to an orthopedic unit. Baseline patient characteristics and hospital course (functional and cognitive status, comorbidity, type of fracture, time to surgery, in-hospital stay, complications) were recorded. Hospital readmission over 12 months and ICD-9 principal diagnosis were ascertained from administrative sources. Functional status at the end of the rehabilitation program was assessed by telephone interviews. Results: Seventy-one patients (30.1%) were readmitted to hospital within twelve months of discharge and 22 (9.3%) had two or more readmission. The total number of readmissions was 105, 43 (41%) occurred in the first three months. The most common readmission causes were cardiac, infectious and cerebrovascular; surgical complication accounted for 5.7%. Patients with a single readmission, like those with multiple readmissions, were sicker (CIRS-CIsubscore 4.0±1.8 vs 3.2±1.6, p=0.010) and more functionally impaired at the end of rehabilitation (2 months’ Katz index 2.1±2 vs 2.9±2.3, p=0.007) than controls. In a multiple logistic regression model, comorbidity and functional status at the end of rehabilitation were the only factors associated with the risk of readmission. Conclusions: Subjects at high risk of readmission can be reliably assessed, since few significant variables were associated with rehospitalization. Subgroups of patients with an elevated risk of rehospitalization after hip fracture may be the target for strategies to reduce the burden of excessive hospital use and improve overall outcomes.

A COMPREHENSIVE GERIATRIC INTERVENTION REDUCES SHORT‐ AND LONG‐TERM MORTALITY IN OLDER PEOPLE WITH HIP FRACTURE

To the Editor: In their article recently published in the Journal of the American Geriatrics Society, Vidan et al. demonstrated that an early multidisciplinary geriatric intervention reduces in-hospital mortality in elderly patients with hip fracture, without a significant effect on length of hospital stay. We want to contribute to this topic by presenting data from a cohort of 819 patients admitted over a 3-year period (2000–02) in the orthopedic ward of the Galliera Hospital (Genoa, Italy) and managed on an alternate annual basis with a traditional approach or an orthogeriatric care model.

Spontaneous release of interleukin-1 (IL-1) from medullary mononuclear cells of pagetic subjects

SummaryThe Authors examined interleukin 1 (IL-1) secretion from the peripheral and medullary mononuclear cells, obtained with sequential separation on Ficoll-Hypaque and 45% Percoll gradient, in 6 pagetic subjects and 6 normal controls. Both peripheral and medullary cells from pagetic subjects showed a significantly greater IL-1 production after stimulation with lipopolyshaccarides (LPS); moreover, we observed a spontaneous IL-1 release from medullary cells in pagetic subjects but not in normal controls. These findings suggest a possible role of IL-1 in the elevated bone turnover of Pagets disease of bone.

Heterogeneity in Serum 25-Hydroxy-Vitamin D Response to Cholecalciferol in Elderly Women with Secondary Hyperparathyroidism and Vitamin D Deficiency

OBJECTIVES: To compare the effects on parathyroid hormone (PTH) and 25‐hydroxy‐vitamin D (25(OH)D) of two dosing regimens of cholecalciferol in women with secondary hyperparathyroidism (sHPTH) and hypovitaminosis D and to investigate variables affecting 25(OH)D response to cholecalciferol.