Patricia Dargent-Molina

Ultrasonographic heel measurements to predict hip fracture in elderly women: the EPIDOS prospective study

BACKGROUND The ability of ultrasonographic measurements to discriminate between patients with hip fracture and age-matched controls has until now been tested mainly through cross-sectional studies. We report the results of a prospective study to assess the value of measurements with ultrasound in predicting the risk of hip fracture. METHODS 5662 elderly women (mean age 80.4 years) had both baseline calcaneal ultrasonography measurements and femoral radiography (dual-photon X-ray absorptiometry, DPXA) to assess their bone quality. Follow-up every 4 months enabled us to identify incident fractures. 115 hip fractures were recorded during a mean follow-up duration of 2 years. FINDINGS Low calcaneal ultrasonographic variables (obtained from measurements of broadband ultrasound attenuation by, and speed of sound through the bone) were able to predict an increased risk of hip fracture, with similar accuracy to low femoral bone mineral density (BMD) obtained by DPXA. The relative risk of hip fracture for 1 SD reduction was 2.0 (95% CI 1.6-2.4) for ultrasound attenuation and 1.7 (1.4-2.1) for speed of sound, compared with 1.9 (1.6-2.4) for BMD. After control for the femoral neck BMD, ultrasonographic variables remained predictive of hip fracture. The incidence of hip fracture among women with values above the median for both calcaneal ultrasound attenuation and femoral neck BMD was 2.7 per 1000 woman-years, compared with 19.6 per 1000 woman-years for those with values below the median for both measures. INTERPRETATION Ultrasonographic measurements of the os calcis predict the risk of hip fracture in elderly women living at home as well as DPXA of the hip does, and the combination of both methods makes possible the identification of women at very high or very low risk of fracture.

Fall-related factors and risk of hip fracture: the EPIDOS prospective study

BACKGROUND Most hip fractures result from falls. However, the role of fall-related factors has seldom been examined. Comparison of the predictive value of these factors with that of bone mineral density (BMD) has important implications for the prevention of hip fractures. METHODS We assessed femoral-neck BMD by dual-photon X-ray absorptiometry and potential fall-related risk factors, which included self-reported physical capacity, neuromuscular function, mobility, visual function, and use of medication in 7575 women, aged 75 years or older, with no history of hip fracture recruited at five centres in France. We followed up these women every 4 months to record incident hip fractures. During an average of 1.9 years of follow-up 154 women suffered a first hip fracture. FINDINGS In age-adjusted multivariate analyses, we found four independent fall-related predictors of hip fracture: slower gait speed (relative risk = 1 . 4 for 1 SD decrease [95% Cl 1.1-1.6)]; difficulty in doing a tandem (heel-to-toe) walk (1.2 for 1 point on the difficulty score [1.0-1.5]); reduced visual acuity (2.0 for acuity < or = 2/10 [1.1-3.7]); and small calf circumference (1.5 [1.0-2.2]). After adjustment for femoral-neck BMD, neuromuscular impairment--gait speed, tandem walk--and poor vision remained significantly associated with an increased risk of subsequent hip fracture. With high risk defined as the top quartile of risk, the rate of hip fracture among women classified as high risk based on both a high fall-risk status and low BMD was 29 per 1000 women-years, compared with 11 per 1000 for women classified as high risk by either a high fall-risk status or low BMD; for women classified as low risk based on both criteria the rate was five per 1000. INTERPRETATION We conclude that neuromuscular and visual impairments, as well as femoral-neck BMD, are significant and independent predictors of the risk of hip fracture in elderly mobile women, and that their combined assessment improves the prediction of hip fractures.

An Assessment Tool for Predicting Fracture Risk in Postmenopausal Women

Abstract: Due to the magnitude of the morbidity and mortality associated with untreated osteoporosis, it is essential that high-risk individuals be identified so that they can receive appropriate evaluation and treatment. The objective of this investigation was to develop a simple clinical assessment tool based on a small number of risk factors that could be used by women or their clinicians to assess their risk of fractures. Using data from the Study of Osteoporotic Fractures (SOF), a total of 7782 women age 65 years and older with bone mineral density (BMD) measurements and baseline risk factors were included in the analysis. A model with and without BMD T-scores was developed by identifying variables that could be easily assessed in either clinical practice or by self-administration. The assessment tool, called the FRACTURE Index, is comprised of a set of seven variables that include age, BMD T-score, fracture after age 50 years, maternal hip fracture after age 50, weight less than or equal to 125 pounds (57 kg), smoking status, and use of arms to stand up from a chair. The FRACTURE Index was shown to be predictive of hip fracture, as well as vertebral and nonvertebral fractures. In addition, this index was validated using the EPIDOS fracture study. The FRACTURE Index can be used either with or without BMD testing by older postmenopausal women or their clinicians to assess the 5-year risk of hip and other osteoporotic fractures, and could be useful in helping to determine the need for further evaluation and treatment of these women.

How Hip and Whole-Body Bone Mineral Density Predict Hip Fracture in Elderly Women: The EPIDOS Prospective Study

Abstract: We conducted a population-based cohort study in 7598 white healthy women, aged 75 years and over, recruited from the voting lists. We measured at baseline bone mineral density (BMD g/cm2) of the proximal femur (neck, trochanter and Wards triangle) and the whole body, as well as fat and lean body mass, by dual-energy X-ray absorptiometry (DXA). One hundred and fifty-four women underwent a hip fracture during an average 2 years follow-up. Each standard deviation decrease in BMD increased the risk of hip fracture adjusted for age, weight and centre by 1.9 (95% CL 1.5, 2.3) for the femoral neck, 2.6 times (2.0, 3.3) for the trochanter, 1.8 times (1.4, 2.2) for Wards triangle, 1.6 times (1.2, 2.0) for the whole body, and 1.3 times (1.0, 1.5) for the fat mass. The areas under the receiver operating characteristic (ROC) curves were not significantly different between trochanter and femoral neck BMD, whereas ROC curves of femoral neck and trochanter BMD were significantly better than those for Wards triangle and whole-body BMD.emsp;Women who sustained an intertrochanteric fracture were older (84 ± 4.5 years) than women who had a cervical fracture (81 ± 4.5 years) and trochanter BMD seemed to be a stronger predictor of intertrochanteric ([RR = 4.5 (3.1, 6.5)] than cervical fractures ([RR = 1.8 (1.5, 2.3]).emsp;In very elderly women aged 80 years and more, hip BMD was still a significant predictor of hip fracture but the relative risk was significantly lower than in women younger than 80 years.emsp;In the 48% of women who had a femoral neck BMD T-score less than –2.5, the relative risk of hip fracture was increased by 3, and the unadjusted incidence of hip fracture was 16.4 per 1000 woman-years compared with 1.1 in the population with a femoral neck BMD T-score 5–1.

The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults: systematic review and meta-analysis of randomised controlled trials

STUDY QUESTION Are fall prevention exercise interventions for older people living in the community effective in preventing different types of fall related injuries? SUMMARY ANSWER Exercise programmes designed to prevent falls in older adults seem also to prevent injuries caused by falls, including the most severe injuries. Such programmes also reduce the rate of falls leading to medical care.STUDY QUESTION Are fall prevention exercise interventions for older people living in the community effective in preventing different types of fall related injuries? SUMMARY ANSWER Exercise programmes designed to prevent falls in older adults seem also to prevent injuries caused by falls, including the most severe injuries. Such programmes also reduce the rate of falls leading to medical care.

Risk factors for fractures of the proximal humerus: results from the EPIDOS prospective study.

Fracture of the proximal humerus is one of the most frequent fractures attributable to osteoporosis; yet, it has seldom been studied. Two types of factors (related to bone fragility and falls) were evaluated to identify risk factors for proximal humerus fractures as well as to examine possible interactions between them. Subjects were 6901 white women aged ≥75 years and all participated in the EPIDOS study of risk factors for osteoporotic fractures (France, 1992‐1998). The baseline examination included measurements of femoral neck bone mineral density (BMD) and calcaneal ultrasound parameters (speed of sound [SOS] and broadband ultrasound attenuation [BUA]), a functional clinical examination, and completing a questionnaire on health status and lifestyle. During a mean of 3.6 (0.8) years of follow‐up, 165 women had a humeral fracture. Using multivariate Cox regression models, we identified three predictors related to bone fragility—low BMD (relative risk [RR] = 1.4; 95% CI, 1.1‐1.7), low SOS (RR = 1.3; 95% CI, 1.0‐1.6), and maternal history of hip fracture (RR = 1.8; 95% CI, 1.0‐3.0)—and four fall‐related predictors—a previous fall (RR = 3.0; 95% CI, 1.5‐6.1), a low level of physical activity (RR = 2.2; 95% CI, 1.1‐4.4), impaired balance (RR = 1.8; 95% CI, 1.1‐2.9), and pain in lower limb extremity (RR = 1.4; 95% CI, 1.0‐2.1). The effect of these fall‐related predictors varied according to the BMD level; they were significantly associated with proximal humerus fractures in women with osteoporosis (BMD T score < −2.5) but not in nonosteoporotic women. The incidence of proximal humerus fracture in women with osteoporosis and a low fall risk score (5.1 per 1000 woman‐years) was only slightly higher than in nonosteoporotic women (4.6 per 1000 woman‐years) and similar to the incidence in women without osteoporosis but a high fall risk score (5.3 per 1000 woman‐years). On the other hand, the incidence in women who had both types of risk factors was more than two times higher (12.1 per 1000 woman‐years) than in women with only one of the two risk factors. These results suggest that women who have both types of risk factors should receive the highest priority for prevention.

Effect of Hip Fracture on Mortality in Elderly Women: The EPIDOS Prospective Study

Objectives: To assess whether the occurrence of a hip fracture is associated with an increased risk of mortality even after taking into account age and prefracture health status and whether this increased risk of mortality persists beyond the first 6 months after the fracture.

Fracture risk prediction using BMD and clinical risk factors in early postmenopausal women: sensitivity of the WHO FRAX tool.

The aim of this prospective study was (1) to identify significant and independent clinical risk factors (CRFs) for major osteoporotic (OP) fracture among peri‐ and early postmenopausal women, (2) to assess, in this population, the discriminatory capacity of FRAX and bone mineral density (BMD) for the identification of women at high risk of fracture, and (3) to assess whether adding risk factors to either FRAX or BMD would improve discriminatory capacity. The study population included 2651 peri‐ and early postmenopausal women [mean age (± SD): 54 ± 4 years] with a mean follow‐up period of 13.4 years (±1.4 years). At baseline, a large set of CRFs was recorded, and vertebral BMD was measured (Lunar, DPX) in all women. Femoral neck BMD also was measured in 1399 women in addition to spine BMD. Women with current or past OP treatment for more than 3 months at baseline (n = 454) were excluded from the analyses. Over the follow‐up period, 415 women sustained a first low‐energy fracture, including 145 major OP fractures (108 wrist, 44 spine, 20 proximal humerus, and 13 hip). In Cox multivariate regression models, only 3 CRFs were significant predictors of a major OP fracture independent of BMD and age: a personal history of fracture, three or more pregnancies, and current postmenopausal hormone therapy. In the subsample of women who had a hip BMD measurement and who were not receiving OP therapy (including hormone‐replacement therapy) at baseline, mean FRAX value was 3.8% (±2.4%). The overall discriminative value for fracture, as measured by the area under the Receiver Operating Characteristic (ROC) curve (AUC), was equal to 0.63 [95% confidence interval (CI) 0.56–0.69] and 0.66 (95% CI 0.60–0.73), respectively, for FRAX and hip BMD. Sensitivity of both tools was low (ie, around 50% for 30% of the women classified as the highest risk). Adding parity to the predictive model including FRAX or using a simple risk score based on the best predictive model in our population did not significantly improve the discriminatory capacity over BMD alone. Only a limited number of clinical risk factors were found associated with the risk of major OP fracture in peri‐ and early postmenopausal women. In this population, the FRAX tool, like other risk scores combining CRFs to either BMD or FRAX, had a poor sensitivity for fracture prediction and did not significantly improve the discriminatory value of hip BMD alone.

The DESIR cohort: A 10-year follow-up of early inflammatory back pain in France: Study design and baseline characteristics of the 708 recruited patients

OBJECTIVES The French Society of Rheumatology has initiated a large national multicenter, longitudinal, prospective follow-up of patients presenting with early inflammatory back pain in order to set up a database to facilitate several investigations on diagnosis, prognosis, epidemiology, pathogenesis and medico-economics in the field of early inflammatory back pain and spondyloarthritis. METHODS Patients were recruited if they had inflammatory back pain of more than 3 months and less than 3 years. Patients will be followed every 6 months during the first 2 years then every year during at least 5years. Apart from information collected on a Case Report Form (demographics, disease activity, severity, co-morbidities, socio-economics, treatments, radiological and MRI evaluation of the spine and the pelvis according to the local investigators, and for some centers bone densitometry and ultrasonography of entheses), the digital X-rays and MRI of the spine and pelvis are stored using a specific software (Carestream) and the biological samples (DNA, RNA, sera, urines) are centralized at the Biological Resources Center (Bichat Hospital). RESULTS The recruitment period of the 708 patients (mean age: 34±9years, female 54%, HLA-B27 positive: 57%) in the 25 centers was 26 months (from December 2007 to April 2010). The modified New York criteria, Amor criteria, ESSG criteria and axial ASAS criteria were fulfilled by 26%, 77%, 76% and 67% of the patients at entry, respectively. A history or current symptoms suggestive of peripheral arthritis, acute anterior uveitis and inflammatory bowel disease were observed in 21%, 9% and 4% of the patients, respectively. The disease was active (BASDAI: 45±20) despite an NSAID intake in 66% of the patients. CONCLUSION This large cohort should facilitate the conduct of researches in different areas (clinical, medico-economics, translational) in order to improve our knowledge on the pathogenesis and natural history of axial spondyloarthritis.

Do Markers of Bone Resorption Add to Bone Mineral Density and Ultrasonographic Heel Measurement for the Prediction of Hip Fracture in Elderly Women? The EPIDOS Prospective Study

Abstract: We have previously shown that hip bone mineral density (BMD), heel broadband ultrasound attenuation (BUA) and bone resorption markers are independent predictors of hip fracture in elderly women. We investigated whether a combination of these three parameters could improve the predictive value of a single test in a nested case–control analysis (75 hip fractures and 228 age-matched controls) of the EPIDOS prospective study comprising 7598 healthy women 75 years of age and older followed prospectively for a mean 22 months. At baseline, prior fracture, femoral neck BMD by dual-energy X-ray absorptiometry (DXA), heel BUA and urinary type I collagen C-telopeptide breakdown products (CTX) were assessed. The area under the receiver operating characteristic curve was significant for the three diagnostic tests, heel BUA being the best single predictor. The added value of urinary CTX to either BMD or BUA depends on the cutoff point chosen to define patients at risk and on the therapeutic strategy that is considered. Defining patients at risk as those with low BMD (or low BUA) or high CTX resulted in a significant increase in the sensitivity compared with BMD or BUA alone – a strategy that could be applied when a broad treatment is considered. However, this increased sensitivity was also obtained simply by increasing the BMD and BUA cutoffs, suggesting that a combination of CTX with BMD/BUA is not useful for that type of treatment strategy. Conversely, defining patients at risk as those with both low BMD and high CTX increases the specificity (88% vs 78%) with a similar number of hip fracture patients being identified (30% vs 32%) – a combination that could be useful when the strategy is to target treatment to a subset of high-risk patients. This strategy appears to be more cost-effective than bone mass measurement alone as indicated by the 37% fewer patients who need to be treated to avoid one fracture per year. If DXA or ultrasound is not available, the combination of a bone resorption marker with a history of any type of fracture after the age of 50 years gave a predictive value similar to that obtained with femoral neck BMD or heel BUA alone, for both types of treatment strategy. We conclude that the combination of urinary CTX with hip BMD could be useful for the identification of elderly women at high risk for hip fracture, resulting in higher specificity for a given sensitivity threshold than BMD measurement alone. If DXA is not available, the combination of history of fracture and urinary CTX performs as well as hip BMD to assess hip fracture risk in elderly women.