Rafael Azagra

An increased rate of falling leads to a rise in fracture risk in postmenopausal women with self-reported osteoarthritis: a prospective multinational cohort study (GLOW)

Objectives Patients with osteoarthritis have increased bone mass but no decrease in fractures. The association between self-reported osteoarthritis and incident falls and fractures was studied in postmenopausal women. Methods The Global Longitudinal Study of Osteoporosis in Women is a prospective multinational cohort of 60 393 non-institutionalised women aged ≥55 years who had visited primary care practices within the previous 2 years. Questionnaires were mailed at yearly intervals. Patients were classified as having osteoarthritis if they answered yes to the question, ‘Has a doctor or other health provider ever said that you had osteoarthritis or degenerative joint disease?’, and this was validated against primary care records in a subsample. Information on incident falls, fractures and covariates was self-reported. Cox and Poisson models were used for incident fractures and number of falls, respectively, to compute hazard ratios (HRs) and rate ratios (RRs) for baseline osteoarthritis status. Results Of 51 386 women followed for a median of 2.9 years (interquartile range 2.1–3.0), 20 409 (40%) reported osteoarthritis. The adjusted HR for osteoarthritis predicting fracture was 1.21 (95% CI 1.13 to 1.30; p<0.0001) and the adjusted RR for falls was 1.24 (95% CI 1.22 to 1.26; p<0.0001). However, the association between osteoarthritis and fracture was not significant after adjustment for incident falls (HR 1.06 (95% CI 0.98 to 1.15; p=0.13)). Conclusions Postmenopausal women with self-reported osteoarthritis have a 20% increased risk of fracture and experience 25% more falls than those without osteoarthritis. These data suggest that increased falls are the causal pathway of the association between osteoarthritis and fractures.

Prediction of absolute risk of fragility fracture at 10 years in a Spanish population: validation of the WHO FRAX ™ tool in Spain.

BackgroundAge-related bone loss is asymptomatic, and the morbidity of osteoporosis is secondary to the fractures that occur. Common sites of fracture include the spine, hip, forearm and proximal humerus. Fractures at the hip incur the greatest morbidity and mortality and give rise to the highest direct costs for health services. Their incidence increases exponentially with age.Independently changes in population demography, the age - and sex- specific incidence of osteoporotic fractures appears to be increasing in developing and developed countries. This could mean more than double the expected burden of osteoporotic fractures in the next 50 years.Methods/DesignTo assess the predictive power of the WHO FRAX™ tool to identify the subjects with the highest absolute risk of fragility fracture at 10 years in a Spanish population, a predictive validation study of the tool will be carried out. For this purpose, the participants recruited by 1999 will be assessed. These were referred to scan-DXA Department from primary healthcare centres, non hospital and hospital consultations. Study population: Patients attended in the national health services integrated into a FRIDEX cohort with at least one Dual-energy X-ray absorptiometry (DXA) measurement and one extensive questionnaire related to fracture risk factors. Measurements: At baseline bone mineral density measurement using DXA, clinical fracture risk factors questionnaire, dietary calcium intake assessment, history of previous fractures, and related drugs. Follow up by telephone interview to know fragility fractures in the 10 years with verification in electronic medical records and also to know the number of falls in the last year. The absolute risk of fracture will be estimated using the FRAX™ tool from the official web site.DiscussionSince more than 10 years ago numerous publications have recognised the importance of other risk factors for new osteoporotic fractures in addition to low BMD. The extension of a method for calculating the risk (probability) of fractures using the FRAX™ tool is foreseeable in Spain and this would justify a study such as this to allow the necessary adjustments in calibration of the parameters included in the logarithmic formula constituted by FRAX™.

FRAX® tool, the WHO algorithm to predict osteoporotic fractures: the first analysis of its discriminative and predictive ability in the Spanish FRIDEX cohort.

BackgroundThe WHO has recently published the FRAX® tool to determine the absolute risk of osteoporotic fracture at 10 years. This tool has not yet been validated in Spain.Methods/designA prospective observational study was undertaken in women in the FRIDEX cohort (Barcelona) not receiving bone active drugs at baseline. Baseline measurements: known risk factors including those of FRAX® and a DXA. Follow up data on self-reported incident major fractures (hip, spine, humerus and wrist) and verified against patient records. The calculation of absolute risk of major fracture and hip fracture was by FRAX® website. This work follows the guidelines of the STROBE initiative for cohort studies. The discriminative capacity of FRAX® was analyzed by the Area Under Curve (AUC), Receiver Operating Characteristics (ROC) and the Hosmer-Lemeshow goodness-of-fit test. The predictive capacity was determined using the ratio of observed fractures/expected fractures by FRAX® (ObsFx/ExpFx).ResultsThe study subjects were 770 women from 40 to 90 years of age in the FRIDEX cohort. The mean age was 56.8 ± 8 years. The fractures were determined by structured telephone questionnaire and subsequent testing in medical records at 10 years. Sixty-five (8.4%) women presented major fractures (17 hip fractures). Women with fractures were older, had more previous fractures, more cases of rheumatoid arthritis and also more osteoporosis on the baseline DXA. The AUC ROC of FRAX® for major fracture without bone mineral density (BMD) was 0.693 (CI 95%; 0.622-0.763), with T-score of femoral neck (FN) 0.716 (CI 95%; 0.646-0.786), being 0.888 (CI 95%; 0.824-0.952) and 0.849 (CI 95%; 0.737-0.962), respectively for hip fracture. In the model with BMD alone was 0.661 (CI 95%; 0.583-0.739) and 0.779 (CI 95%; 0.631-0.929). In the model with age alone was 0.668 (CI 95%; 0.603-0.733) and 0.882 (CI 95%; 0.832-0.936). In both cases there are not significant differences against FRAX® model. The overall predictive value for major fracture by ObsFx/ExpFx ratio was 2.4 and 2.8 for hip fracture without BMD. With BMD was 2.2 and 2.3 respectively. Sensitivity of the four was always less than 50%. The Hosmer-Lemeshow test showed a good correlation only after calibration with ObsFx/ExpFx ratio.ConclusionsThe current version of FRAX® for Spanish women without BMD analzsed by the AUC ROC demonstrate a poor discriminative capacity to predict major fractures but a good discriminative capacity for hip fractures. Its predictive capacity does not adjust well because leading to underdiagnosis for both predictions major and hip fractures. Simple models based only on age or BMD alone similarly predicted that more complex FRAX® models.

Umbrales de FRAX ® para identificar personas con alto o bajo riesgo de fractura osteoporótica en población femenina española

BACKGROUND AND OBJECTIVE To detect FRAX(®) threshold levels that identify groups of the population that are at high/low risk of osteoporotic fracture in the Spanish female population using a cost-effective assessment. PATIENTS AND METHODS This is a cohort study. Eight hundred and sixteen women 40-90 years old selected from the FRIDEX cohort with densitometry and risk factors for fracture at baseline who received no treatment for osteoporosis during the 10 year follow-up period and were stratified into 3 groups/levels of fracture risk (low<10%, 10-20% intermediate and high>20%) according to the real fracture incidence. RESULTS The thresholds of FRAX(®) baseline for major osteoporotic fracture were: low risk<5; intermediate ≥ 5 to <7.5 and high ≥ 7.5. The incidence of fracture with these values was: low risk (3.6%; 95% CI 2.2-5.9), intermediate risk (13.7%; 95% CI 7.1-24.2) and high risk (21.4%; 95% CI12.9-33.2). The most cost-effective option was to refer to dual energy X-ray absorptiometry (DXA-scan) for FRAX(®)≥ 5 (Intermediate and high risk) to reclassify by FRAX(®) with DXA-scan at high/low risk. These thresholds select 17.5% of women for DXA-scan and 10% for treatment. With these thresholds of FRAX(®), compared with the strategy of opportunistic case finding isolated risk factors, would improve the predictive parameters and reduce 82.5% the DXA-scan, 35.4% osteoporosis prescriptions and 28.7% cost to detect the same number of women who suffer fractures. CONCLUSIONS The use of FRAX ® thresholds identified as high/low risk of osteoporotic fracture in this calibration (FRIDEX model) improve predictive parameters in Spanish women and in a more cost-effective than the traditional model based on the T-score ≤ -2.5 of DXA scan.

Análise de demanda em Medicina de Família no Brasil utilizando a Classificação Internacional de Atenção Primária

In various countries, motives for contact of patients with Primary Health Care (PHC) is classified by the International Classification of Primary Care (ICPC-2). This instrument enables the assessment of why people seek care, thereby assisting in planning strategies to attend the populations health needs. The scope of this study was to identify the main reasons for same-day appointments in PHC units of a medium-sized Brazilian city. The methodology used was to examine all records of a typical month of three family practice residents. Data were extracted from a secondary database of same-day appointments during the spring of 2010, classified with ICPC and then statistically analyzed. 1222 records were considered; 32 motives accounted for 50% of contacts. Most common motives were related to the General and Unspecific chapter of the ICPC. About 20% of visits occurred for administrative reasons. Female sex and greater age were determinants of greater motives for consultation. Knowing the motives for appointments by gender and age may help PHC teams in tackling health problems at the critical point of access to PHC.

Manejo de la infección por Helicobacter pylori en atención primaria en España

Resumen Introduccion Las indicaciones sobre cuando y como diagnosticar y tratar la enfermedad ulcerosa y la infeccion por Helicobacter pylori son razonablemente claras en la actualidad. El objetivo fue analizar el manejo de la infeccion por H. pylori y el acceso a las pruebas diagnosticas de la infeccion en atencion primaria. Material y metodos Estudio observacional, transversal, realizado mediante cuestionario anonimo administrado a medicos de atencion primaria de todo el territorio espanol.Las indicaciones y los tratamientos se analizaron evaluando su adecuacion a las recomendaciones de consenso sobre lainfeccion por H. pylori . Resultados Se recogieron 991 encuestas. El 87,7% de los medicos realizo uno o mas tratamientos erradicadores en el ultimo ano, el 79,9% en ulcera duodenal, el 75,3% en ulcera gastrica y el 18,3% en enfermedad por reflujo. El 74,7% indico una pauta de tratamiento erradicador cuya composicion fue correcta. El 29% la indico con una duracion superior a la recomendada (14 dias). El 67% no indico tratamiento erradicador en el paciente ulceroso bien controlado con antisecretores y continua el tratamiento antisecretor de mantenimiento. El 64,7% de los medicos tiene acceso a la endoscopia, el 67,4% al test del aliento, el 59,6% a la serologia y el 11,9% a la prueba de deteccion de antigeno de H. pylori en heces. Se detectaron variaciones importantes entre las diversas comunidades autonomas en el acceso a las pruebas diagnosticas. Conclusiones El porcentaje de adecuacion a las recomendaciones es razonable. Sin embargo, se observa una notable variabilidad geografica e importantes restricciones en el acceso a pruebas diagnosticas, lo que dificulta la aplicacion de las recomendaciones.

Measuring health-related quality of life in men with osteoporosis or osteoporotic fracture

BackgroundOsteoporosis is a serious health problem that worsens the quality of life and the survival rate of individuals with this disease on account the osteoporotic fractures. Studies have long focused on women, and its presence in men has been underestimated. While many studies conducted in different countries mainly assess health-related quality of life and identify fracture risks factors in women, few data are available on a Spanish male population.Methods/DesignObservational study.Study populationMen ≥ 40 years of age with/without diagnosed osteoporosis and with/without osteoporotic fracture included by their family doctor.MeasurementsThe relationship between customary clinical risk factors for osteoporotic fracture and health-related quality of life in a Spanish male population. A telephone questionnaire on health-related quality of life is made.Statistical analysisThe association between qualitative variables will be assessed by the Chi-square test. The distribution of quantitative variables by Students t-test. If the conditions for using this test are not met, the non-parametric Mann-Whitneys U test will be used.The validation of the results obtained by the FRAX™ tool will be performed by way of the Hosmer-Lemeshow test and by calculating the area under the Receiver Operating Characteristic (ROC) curve (AUC). All tests will be performed with a confidence intervals set at 95%.DiscussionThe applicability and usefulness of Health-related quality of life (HRQOL) studies are well documented in many countries. These studies allow implementing cost-effective measures in cases of a given disease and reducing the costly consequences derived therefrom. This study attempts to provide objective data on how quality of life is affected by the clinical aspects involved in osteoporosis in a Spanish male population and can be useful as well in cost utility analyses conducted by health authorities.The sample selected is not based on a high fracture risk group. Rather, it is composed of men in the general population, and accordingly comparisons should not lead to erroneous interpretations.A possible bias correction will be ensured by checking reported fractures against healthcare reports and X-rays, or by consulting health care centers as applicable.

Manejo de la dispepsia, la enfermedad ulcerosa y la infección por Helicobacter pylori en atención primaria

Objetivo Analizar el manejo de la dispepsia, la ulcera peptica y la infeccion por Helicobacter pylori (Hp) en atencion primaria. Diseno Estudio observacional, transversal, realizado mediante cuestionario anonimo entre enero y octubre de 2000. Emplazamiento Atencion primaria. Participantes Medicos de 17 centros de atencion primaria (CAP). Mediciones Encuesta de 19 preguntas remitida por correo. Resultados principales Respondieron un 64,8% de los medicos (107/165). El 94,3% habia realizado uno o mas tratamientos erradicadores en el ultimo ano. El 89,7% indica erradicacion de forma habitual en la ulcera duodenal y el 70,1% en la ulcera gastrica. El 79,4% no ha indicado nunca tratamiento erradicador sin documentar la infeccion por Hp. La endoscopia asociada a histologia y/o ureasa es la tecnica mas utilizada para el diagnostico. La pauta terapeutica mas utilizada (77,6%) es omeprazol, claritromicina y amoxicilina durante 7 dias, cada 12 h. El 44,9% comprueba siempre la erradicacion despues del tratamiento, mientras que el 36,4% solo lo hace si recidiva la sintomatologia. El test del aliento (72,7%) es la prueba mas utilizada para comprobar la erradicacion. No se observaron diferencias en las respuestas en funcion de la antiguedad ni la titularidad de la plaza. Por el contrario, los especialistas en medicina familiar y comunitaria (MFyC) remiten menos a menudo pacientes al digestologo, utilizan menos el transito gastroesofagico, utilizan mas el test del aliento y realizan mas tratamientos en duodenitis erosiva en comparacion con el resto de facultativos de atencion primaria. Conclusiones Las actitudes observadas se adecuan razonablemente a lo establecido en las reuniones de consenso y varian entre los medicos MFyC y el resto de facultativos de atencion primaria.

¿Siete o diez días? Estudio de coste-efectividad sobre la duración del tratamiento de la infección por H. pylori en atención primaria

Objetivo Determinar si resulta coste-efectivo prolongar el tratamiento de 7 a 10 dias en pacientes dispepticos y diferenciar entre dispepsia funcional, dispepsia no investigada y enfermedad ulcerosa. Diseno Estudio de coste-efectividad mediante arbol de decision con la comparacion de los costes directos por paciente curado con ambas estrategias.Horizonte temporal: 2 anos; perspectiva:Sistema Nacional de Salud. Emplazamiento Atencion primaria. Participantes Simulacion de 100 pacientes con ulcera peptica, dispepsia funcional o dispepsia no investigada que reciben tratamiento para la infeccion por Helicobacter pylori. Intervenciones Tratamiento erradicador de H. pylori con un inhibidor de la bomba de protones, claritromicina y amoxicilina durante 7 o 10 dias. Se midio el coste incremental por paciente curado. Resultados En pacientes con ulcera peptica,el coste incremental por paciente curado al prolongar el tratamiento erradicador de 7 a 10 dias es de 147 € (intervalo de confianza [IC] del 95%, 121,3-162,7), mientras que en los pacientes con dispepsia funcional o dispepsia no investigada, es de -39,8 € (IC del 95%, -28,5 a -60,7) y -27,3 € (IC del 95%, -14,92 a -52,72), respectivamente. El analisis de sensibilidad demostro que la eficacia del tratamiento erradicador (7 frente a 10) fue la variable que mas influyo en la estabilidad de los resultados. Conclusiones Siete dias es la duracion mas coste-efectiva de las terapias triples para realizar tratamiento erradicador en pacientes ulcerosos. Sin embargo, las pautas de 10 dias son mas coste-efectivas en pacientes con dispepsia funcional o para el tratamiento de pacientes sin diagnostico endoscopico previo.

La coordinacion entre atencion primaria y especializada de digestivo es insuficiente. Resultados de una encuesta realizada a gastroenterologos y medicos de familia

BACKGROUND AND OBJECTIVES Collaboration between general practitioners (GPs) and specialists is considered crucial to provide high-quality healthcare. The objective of this study was to analyze the relationship between gastroenterologists and GPs in regional hospitals and their referring primary care centers in Catalonia (Spain). MATERIALS AND METHODS A descriptive, observational, cross-sectional study was carried out using anonymous questionnaires between January and April 2008. RESULTS A total of 314 surveys were administered (261 GPs and 53 gastroenterologists). The overall relationship was considered highly deficient or insufficient by 62.3% of gastroenterologists (95% CI, 47.9-74.9) and by 55.6% of GPs (95% CI, 49.3-61.7). More than half (56.6%) of the gastroenterologists did not know any GPs, or only a very few, and the situation was the same for 80.4% of GPs. Sixty-four percent of gastroenterologists considered that the quality of care for digestive diseases in primary care was highly deficient or insufficient while 21.1% of GPs considered that the care provided by gastroenterologists was highly deficient or insufficient. The perception of healthcare in both primary and specialized settings was substantially better when there was good interaction between gastroenterologists and GPs. CONCLUSIONS Practitioners acknowledge that the degree of interaction between different levels of healthcare is insufficient. Moreover, gastroenterologists consider that the management of digestive diseases in primary care is deficient. Establishing a personal relationship between the two types of practitioners substantially improves mutual assessment.