Stuart G. Silverman

Adherence to Bisphosphonate Therapy and Fracture Rates in Osteoporotic Women: Relationship to Vertebral and Nonvertebral Fractures From 2 US Claims Databases

OBJECTIVE To characterize the relationships between adherence (complance and persistence) to bisphosphonate therapy and risk of specific fracture types in postmenopausal women. PATIENTS AND METHODS Data were collected from 45 employers and 100 health plans in the continental United States from 2 claims databases during a 5-year period (January 1, 1999, through December 31, 2003). Claims from patients receiving a bisphosphonate prescription (alendronate or risedronate) were evaluated for 6 months before the Index prescription and during 24 months of follow-up to determine total, vertebral, and nonvertebral osteoporotic fractures, persistence (no gap in refills for >30 days during 24 months), and refill compliance (medication possession ratio > or = 0.80). RESULTS The eligible cohort included 35,537 women (age, > or = 45 years) who received a bisphosphonate prescription. A subgroup with a specified diagnosis of postmenopausal osteoporosis was also evaluated. Forty-three percent were refill compliant, and 20% persisted with bisphosphonate therapy during the 24-month study period. Total, vertebral, nonvertebral, and hip fractures were significantly lower in refill-compliant and persistent patients, with relative risk reductions of 20% to 45%. The relationship between adherence and fracture risk remained significant after adjustment for baseline age, concomitant medications, and fracture history. There was a progressive relationship between refill compliance and fracture risk reduction, commencing at refill compliance rates of approximately 50% and becoming more pronounced at compliance rates of 75% and higher. CONCLUSIONS Adherence to bisphosphonate therapy was associated with significantly fewer fractures at 24 months. Increasing refill compliance levels were associated with progressively lower fracture rates. These findings suggest that incremental changes in medication-taking habits could improve clinical outcomes of osteoporosis treatment.

International Society for Clinical Densitometry 2007 Adult and Pediatric Official Positions

The International Society for Clinical Densitometry (ISCD) periodically convenes Position Development Conferences (PDCs) in order to establish standards and guidelines for the assessment of skeletal health. The most recent Adult PDC was held July 20-22, 2007, in Lansdowne, Virginia, USA; the first Pediatric PDC was June 20-21, 2007 in Montreal, Quebec, Canada. PDC topics were selected according to clinical relevancy, perceived need for standardization, and likelihood of achieving agreement. Each topic area was assigned to a task force for a comprehensive review of the scientific literature. The findings of the review and recommendations were presented to adult and pediatric international panels of experts. The panels voted on the appropriateness, necessity, quality of the evidence, strength, and applicability (worldwide or variable according to local requirements) of each recommendation. Those recommendations that were approved by the ISCD Board of Directors become Official Positions. This is a review of the methodology of the PDCs and selected ISCD Official Positions.

A prospective follow-up study of 570 patients with oral lichen planus: persistence, remission, and malignant association.

Five hundred seventy patients with oral lichen planus were followed for periods ranging from 6 months to more than 10 years (mean, 5.6 years). The mean age was 52 years, and 67% of the patients were women. Erosive lichen planus was the most frequent clinical form, and the buccal mucosa was the most common site. Of the 75% patients treated with corticosteroids, 29% experienced complete remission and 63% had partial remission while maintained on medication. Fewer than 3% experienced spontaneous remission. Malignant transformation occurred in 7 patients (1.2%) in a mean time of 3.4 years after the onset of lichen planus. The onset of lichen planus could not be associated with any evident factors, such as family history, Candida albicans, glucose intolerance, and smoking.

Image-guided tumor ablation: standardization of terminology and reporting criteria.

The field of interventional oncology with use of image-guided tumor ablation requires standardization of terminology and reporting criteria to facilitate effective communication of ideas and appropriate comparison between treatments that use different technologies, such as chemical (ethanol or acetic acid) ablation, and thermal therapies, such as radiofrequency (RF), laser, microwave, ultrasound, and cryoablation. This document provides a framework that will hopefully facilitate the clearest communication between investigators and will provide the greatest flexibility in comparison between the many new, exciting, and emerging technologies. An appropriate vehicle for reporting the various aspects of image-guided ablation therapy, including classification of therapies and procedure terms, appropriate descriptors of imaging guidance, and terminology to define imaging and pathologic findings, are outlined. Methods for standardizing the reporting of follow-up findings and complications and other important aspects that require attention when reporting clinical results are addressed. It is the groups intention that adherence to the recommendations will facilitate achievement of the groups main objective: improved precision and communication in this field that lead to more accurate comparison of technologies and results and, ultimately, to improved patient outcomes. The intent of this standardization of terminology is to provide an appropriate vehicle for reporting the various aspects of image-guided ablation therapy.

Obesity is not protective against fracture in postmenopausal women: GLOW

OBJECTIVE To investigate the prevalence and incidence of clinical fractures in obese, postmenopausal women enrolled in the Global Longitudinal study of Osteoporosis in Women (GLOW). METHODS This was a multinational, prospective, observational, population-based study carried out by 723 physician practices at 17 sites in 10 countries. A total of 60,393 women aged ≥ 55 years were included. Data were collected using self-administered questionnaires that covered domains that included patient characteristics, fracture history, risk factors for fracture, and anti-osteoporosis medications. RESULTS Body mass index (BMI) and fracture history were available at baseline and at 1 and 2 years in 44,534 women, 23.4% of whom were obese (BMI ≥ 30 kg/m(2)). Fracture prevalence in obese women at baseline was 222 per 1000 and incidence at 2 years was 61.7 per 1000, similar to rates in nonobese women (227 and 66.0 per 1000, respectively). Fractures in obese women accounted for 23% and 22% of all previous and incident fractures, respectively. The risk of incident ankle and upper leg fractures was significantly higher in obese than in nonobese women, while the risk of wrist fracture was significantly lower. Obese women with fracture were more likely to have experienced early menopause and to report 2 or more falls in the past year. Self-reported asthma, emphysema, and type 1 diabetes were all significantly more common in obese than nonobese women with incident fracture. At 2 years, 27% of obese women with incident fracture were receiving bone protective therapy, compared with 41% of nonobese and 57% of underweight women. CONCLUSIONS Our results demonstrate that obesity is not protective against fracture in postmenopausal women and is associated with increased risk of ankle and upper leg fractures.

Management of the Incidental Renal Mass

Despite substantial advances in the imaging-based diagnosis of renal masses, the increased detection of incidental renal masses with cross-sectional imaging poses problems to the radiologist and referring physician. Most incidental renal masses can be diagnosed with confidence and either ignored or treated without further testing. However, some renal masses, particularly small ones, remain indeterminate and require a management strategy that is both medically appropriate and practical. In this article, the literature will be reviewed and an approach to the diagnosis and management of the incidental renal mass will be suggested. Management recommendations, derived from data regarding the probability of malignancy in cystic and solid renal masses, are provided for two types of patients, those in the general population and those with limited life expectancy or co-morbidity. The Bosniak classification is used to guide the management of cystic masses, with observation reserved for selected patients, and the presumption of benignity recommended for simple-appearing cystic masses smaller than 1 cm. Among solid renal masses, a more aggressive overall approach is taken. However, additional imaging, and in selected patients, percutaneous biopsy, is recommended to diagnose benign neoplasms. Although additional studies are needed to establish risks and benefits, observation of solid masses may be considered in selected patients. Minimally invasive treatments of renal cancer (including percutaneous ablation) show promise but at the same time challenge the radiologist to review the approach to the incidental renal mass.

Making the first fracture the last fracture: ASBMR task force report on secondary fracture prevention.

Fragility fractures are common, affecting almost one in two older women and one in three older men. Every fragility fracture signals increased risk of future fractures as well as risk of premature mortality. Despite the major health care impact worldwide, currently there are few systems in place to identify and “capture” individuals after a fragility fracture to ensure appropriate assessment and treatment (according to national guidelines) to reduce future fracture risk and adverse health outcomes. The Task Force reviewed the current evidence about different systematic interventional approaches, their logical background, as well as the medical and ethical rationale. This included reviewing the evidence supporting cost‐effective interventions and developing a toolkit for reducing secondary fracture incidence. This report presents this evidence for cost‐effective interventions versus the human and health care costs associated with the failure to address further fractures. In particular, it summarizes the evidence for various forms of Fracture Liaison Service as the most effective intervention for secondary fracture prevention. It also summarizes the evidence that certain interventions, particularly those based on patient and/or community‐focused educational approaches, are consistently, if unexpectedly, ineffective. As an international group, representing 36 countries throughout Asia‐Pacific, South America, Europe, and North America, the Task Force reviewed and summarized the international data on barriers encountered in implementing risk‐reduction strategies. It presents the ethical imperatives for providing quality of care in osteoporosis management. As part of an implementation strategy, it describes both the quality improvement methods best suited to transforming care and the research questions that remain outstanding. The overarching outcome of the Task Forces work has been the provision of a rational background and the scientific evidence underpinning secondary fracture prevention and stresses the utility of one form or another of a Fracture Liaison Service in achieving those quality outcomes worldwide.

An algorithm recommendation for the management of knee osteoarthritis in Europe and internationally: a report from a task force of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO).

OBJECTIVES Existing practice guidelines for osteoarthritis (OA) analyze the evidence behind each proposed treatment but do not prioritize the interventions in a given sequence. The objective was to develop a treatment algorithm recommendation that is easier to interpret for the prescribing physician based on the available evidence and that is applicable in Europe and internationally. The knee was used as the model OA joint. METHODS ESCEO assembled a task force of 13 international experts (rheumatologists, clinical epidemiologists, and clinical scientists). Existing guidelines were reviewed; all interventions listed and recent evidence were retrieved using established databases. A first schematic flow chart with treatment prioritization was discussed in a 1-day meeting and shaped to the treatment algorithm. Fine-tuning occurred by electronic communication and three consultation rounds until consensus. RESULTS Basic principles consist of the need for a combined pharmacological and non-pharmacological treatment with a core set of initial measures, including information access/education, weight loss if overweight, and an appropriate exercise program. Four multimodal steps are then established. Step 1 consists of background therapy, either non-pharmacological (referral to a physical therapist for re-alignment treatment if needed and sequential introduction of further physical interventions initially and at any time thereafter) or pharmacological. The latter consists of chronic Symptomatic Slow-Acting Drugs for OA (e.g., prescription glucosamine sulfate and/or chondroitin sulfate) with paracetamol at-need; topical NSAIDs are added in the still symptomatic patient. Step 2 consists of the advanced pharmacological management in the persistent symptomatic patient and is centered on the use of oral COX-2 selective or non-selective NSAIDs, chosen based on concomitant risk factors, with intra-articular corticosteroids or hyaluronate for further symptom relief if insufficient. In Step 3, the last pharmacological attempts before surgery are represented by weak opioids and other central analgesics. Finally, Step 4 consists of end-stage disease management and surgery, with classical opioids as a difficult-to-manage alternative when surgery is contraindicated. CONCLUSIONS The proposed treatment algorithm may represent a new framework for the development of future guidelines for the management of OA, more easily accessible to physicians.

What Is the Current Role of CT Urography and MR Urography in the Evaluation of the Urinary Tract

Technologic advances in both computed tomography (CT) and magnetic resonance (MR) imaging have resulted in the ability to image the urinary tract in ways that surpass the prior mainstay of urinary tract imaging, the intravenous urogram. In adults, for most, if not all, historical indications for intravenous urography, CT urography or MR urography is now the preferred examination. Although a variety of techniques for both examinations have been described, each test provides more diagnostic information than does intravenous urography. With the introduction of multidetector technology, CT urography, to date, has emerged as the initial heir apparent to intravenous urography; many years of experience have now clearly demonstrated that CT is the test of choice for many urologic problems, including urolithiasis, renal masses, urinary tract infection, trauma, and obstructive uropathy. CT urography provides a detailed anatomic depiction of each of the major portions of the urinary tract--the kidneys, intrarenal collecting systems, ureters, and bladder--and thus allows patients with hematuria to be evaluated comprehensively. MR urography can be used also to evaluate the urinary tract and has the advantage of not using ionizing radiation and the potential to provide more functional information than CT. However, MR urography is less established and less reliably results in diagnostic image quality relative to CT urography. Although both tests can be used to evaluate the urinary tract, several issues remain and include reaching a consensus on the optimal protocols and appropriate utilization in an era of cost containment and heightened concerns about radiation exposure.

CT-guided aspiration of suspected pancreatic infection

SummaryWe have performed CT-guided percutaneous needle aspiration in 104 patients with severe pancreatitis strongly suspected of harboring pancreatic infection on the basis of systemic toxicity and CT findings (Balthazar CT grade D or E). Of these 104 patients, 51 (49%) were documented with pancreatic infection. Gram stain was positive in 54 of 58 infected aspirates, and culture was positive in all 58. Klebsiella,Escherichia coli, andStaphylococcus aureus were the most frequent organisms. Eighty-six percent of infected processes contained only one organism. Overall, pancreatic infection was documented by GPA within the first 2 wk in approx one-half of patients. There were no complications. The overall rate of infection decreased from 60 (1980–1987) to 34% (1988–1995) (p=0.01). This change was caused by a reduction in the rate of infected necrosis from 67 to 32% (p=0.015). The overall mortality rate remained at 20%. The mortality of sterile pancreatitis was not different from infected pancreatitis (p=0.14). We conclude that GPA is a safe, accurate method of diagnosis of pancreatic infection. The rate of pancreatic infectoon appears to be decreasing. The overall mortality of severe pancreatitis among patients suspected of harboring pancreatic infection has remained unchanged because of the high mortality associated with both infected necrosis and severe sterile necrosis.