Development and validation of a one year predictive model for secondary fractures in osteoporosis

The number of osteoporosis-related fractures in the United States is no longer declining. Existing risk-based assessment tools focus on long-term risk. Payers and prescribers need additional tools to identify patients at risk for imminent fracture. We developed and validated a predictive model for secondary osteoporosis fractures in the year following an index fracture using administrative medical and pharmacy claims from the Optum Research Database and Symphony Health, PatientSource. Patients ≥50 years with a case-qualifying fracture identified using a validated claims-based algorithm were included. Logistic regression models were created with binary outcome of a second fracture versus no second fracture within a year of index fracture, with the goal of predicting second fracture occurrence. In the Optum Research Database, 197,104 patients were identified with a case-qualifying fracture (43% commercial, 57% Medicare Advantage). Using Symphony data, 1,852,818 met the inclusion/exclusion criteria. Average patient age was 70.09 (SD = 11.09) and 71.28 (SD = 14.24) years in the Optum Research Database and Symphony data, respectively. With the exception of history of falls (41.26% vs 18.74%) and opioid use (62.80% vs 46.78%), which were both higher in the Optum Research Database, the two populations were mostly comparable. A history of falls and steroid use, which were previously associated with increased fracture risk, continue to play an important role in secondary fractures. Conditions associated with bone health (liver disease), or those requiring medications that impact bone health (respiratory disease), and cardiovascular disease and stroke—which may share etiology or risk factors with osteoporosis fractures—were also predictors of imminent fractures. The model highlights the importance of assessment of patient characteristics beyond bone density, including patient comorbidities and concomitant medications associated with increased fall and fracture risk, in alignment with recently issued clinical guidelines for osteoporosis treatment.

Adherence to Anti-Osteoporotic Treatment and Clinical Implications after Hip Fracture: A Systematic Review

The role of anti-osteoporotic treatment as part of the secondary prevention after hip fracture in terms of mortality and re-fracture risk has been studied, and the results are promising. Decreased treatment adherence and compliance is a problem that needs to be addressed by healthcare professionals. A systematic review of the literature was performed using the PubMed database with terms that included hip fracture, mortality, second fracture, and specific anti-osteoporotic treatment. We included 28 articles, 21 regarding mortality and 20 re-fracture rates in hip fracture patients. All studies showed lower mortality after hip fracture associated with anti-osteoporotic treatment, mostly bisphosphonate agents. The re-fracture risk is still debatable, since conflicting data were found. Although most of the studies showed notable effects on mortality and re-fracture rates associated with anti-osteoporotic treatment, we still need more data to validate the actual results.

Fragility fracture identifies patients at imminent risk for subsequent fracture: real-world retrospective database study in Ontario, Canada

Background The secondary fracture prevention gap in the osteoporosis field has been previously described as a ‘crisis’. Closing this gap is increasingly important in the context of accumulating evidence showing that an incident fragility fracture is associated with an increased risk of subsequent fracture within 1–2 years, known as imminent fracture risk. The objective of this study was to use health services data to characterize the time between index fragility fractures occurring at different osteoporotic sites and subsequent fractures. Methods This retrospective observational study used de-identified health services data from the publicly funded healthcare system in Ontario, the largest province of Canada. Patients aged > 65 with an index fragility fracture occurring between 2011 and 2015 were identified from the ICES Data Repository using International Classification of Diseases (ICD)-10 codes. We examined median time to subsequent fragility fractures for osteoporotic fracture sites until the end of follow-up (2017). BMD assessment and use of osteoporosis therapies following index fracture were also characterized. Results Among 115,776 patients with an index fragility fracture, 17.8% incurred a second fragility fracture. Median time between index and second fracture occurring at any site was 555 days (interquartile range: 236–955). For each index fracture site examined, median time from index to second fracture was < 2 years. The proportion of patients with BMD assessment was 10.3% ≤1 year prior to and 16.4% ≤1 year post index fracture. The proportion of patients receiving osteoporosis therapy was 29.8% ≤1 year prior, 34.6% ≤1 year post, and 25.9% > 3 years post index fracture. Conclusions This cohort of Canadian patients aged > 65 years who experienced a fragility fracture at any site are at imminent risk of experiencing subsequent fracture within the next 2 years and should be proactively assessed and treated.

Epidemiological transition to mortality and refracture following an initial fracture

This study sought to redefine the concept of fracture risk that includes refracture and mortality, and to transform the risk into "skeletal age". We analysed data obtained from 3521 women and men aged 60 years and older, whose fracture incidence, mortality, and bone mineral density (BMD) have been monitored since 1989. During the 20-year follow-up period, among 632 women and 184 men with a first incident fracture, the risk of sustaining a second fracture was higher in women (36%) than in men (22%), but mortality risk was higher in men (41%) than in women (25%). The increased risk of mortality was not only present with an initial fracture, but was accelerated with refractures. Key predictors of post-fracture mortality were male gender (hazard ratio [HR] 2.4; 95% CI, 1.79–3.21), advancing age (HR 1.67; 1.53–1.83), and lower femoral neck BMD (HR 1.16; 1.01–1.33). A 70-year-old man with a fracture is predicted to have a skeletal age of 75. These results were incorporated into a prediction model to aid patient-doctor discussion about fracture vulnerability and treatment decisions.

The Ongoing Democratic Experiment

This chapter describes the present day as an age of democratic anxiety. It talks about the palpable fear in the “advanced industrialized” world in which the anti-democratic reflexes not felt for many decades have suddenly reawakened. It also mentions comments by John Taylor and John Dunn, who pointed out that citizen participation is the first fracture point of modern democracy: citizen participation is very broad. The chapter looks at the second fracture point of modern democracy that concerns executive power. It clarifies that an elected leader at the helm of a modern democratic state can sometimes behave just as despotically as an autocrat.

MON-394 Vitamin D Levels and Functional Recovery Following Hip Fracture

Background: Vitamin D deficiency is common in patients presenting with low energy hip fractures. The relationship between Vitamin D levels at the time of a fracture with long term functional outcomes has not been studied. Identifying a benefit to recovery with adequate vitamin D would support supplementation in elderly patients at risk for hip fracture. Methods: A retrospective cohort of patients &gt;/= 50 years, who were treated surgically for low energy hip fracture between July 1 2016 and June 30 2018 were identified. The correlation between Vitamin D levels and functional recovery, assessed using the time up and go (TUG) test, survival at 3 months and 1 year, and readmission within 3 months was examined. The Charlson comorbidity index (CCI) at baseline was also assessed. Results: A total of 216 patients were treated for a hip fracture of which 174 were included with measured baseline Vitamin D levels. A majority were female (112, 64.4%), mean age 79.6 years (+/-11.9), mean Vitamin D level 28.2 ng/ml (+/- 12.4) and mean CCI 5.9 (+/- 2.5). Vitamin D &lt;20 ng/ml was seen in 39 (22.4%) patients and all received appropriate supplementation. 39 (22.4%) individuals died within a year of surgery, among whom 17 (43.6% of 39) passed away within 3 months. 36 (20.7%) were readmitted within 3 months of surgery and 14 (8%) sustained a second fracture within a year. The correlation of Vitamin D levels, taken as a continuous variable, to outcomes, was analyzed using logistic regression. Although not significant, higher Vitamin D was found to be protective against death within 3 months (OR=0.995, p=0.8), but actually increased the odds of death within 1 year (OR=1.008, p=0.62), readmission within 3 months (OR=1.001, p=0.96), second fracture within 1 year (OR=1.017, p=0.33) and failure to recover (OR=1.002, 0.86). After adjusting for age, gender and CCI, Vitamin D levels were non-significantly inversely associated with both TUG 1 and TUG2, with every 1 unit higher Vitamin D associated with a TUG lowered by 0.15 seconds, p=0.42 and 0.44. Vitamin D was poorly correlated to CCI with correlation coefficient of 0.02, p = 0.71. Conclusions: Our results indicate that Vitamin D levels at the time of a hip fracture do not correlate with patients’ functional outcomes. It is possible that replacing vitamin D eliminated the possible negative impact on functional recovery.

The significance and tectonic evolution of Huatung basin

&lt;p&gt;The Huatung basin (HB), located between the Philippine Sea plate (PSP) and the South China Sea (SCS), has likely existed near tectonically-active plate boundaries since the early Cenozoic. It may record SCS evolution from the SCS rifting phase to today, and is a key region to understand the broad geodynamic interactions between the SCS and PSP. A left-lateral shear plate boundary between the SCS and PSP followed the Gagua ridge and was active before 56 Ma. A slight compressive component along the Gagua ridge might have occurred from 40 to 30 Ma, giving rise to the topographic uplift of Gagua ridge and adjacent ridges with possibly some underthrusting of the PSP below the HB. A significant compressive episode also occurred along a second fracture zone around 23 Ma ago. The Manila trench inception occurred along the PSP-SCS plate boundary before the end of SCS spreading, involving the subduction of the younger SCS beneath the older HB. Later the intra-oceanic Luzon arc formed and collided in a sub-parallel fashion with the Eurasian continent around 5-6 Ma ago to form Taiwan. The PSP/EU motion was oblique with respect to this plate boundary during SCS opening. However, we have no direct evidence of the HB age (early Cenozoic or early Cretaceous) and if the PSP underthrusted below the HB. We propose to carry a deep seismic refraction survey and dredge sampling of basement units to clarify this problem. This work is supported by the Chinese National Natural Science Foundation (contracts 91958212, 41730532, 41576070 and 41676043).&lt;/p&gt;

Short-term risk factors for a second hip fracture in a UK population

Introduction A hip fracture carries significant morbidity and mortality—a second fracture of the contralateral hip carries even higher complications. Most second hip fractures occur within 48 months of the first. The aim of this study was to comprehensively analyse all identifiable variables that may increase the risk of a contralateral hip fracture within this time period. Methods We retrospectively analysed 1242 consecutive patients with hip fractures presenting to our institution. All patient-related, surgery-related and inpatient variables were collected from the index admission. We then identified patients with a subsequent contralateral hip fracture in the following 2 years. Univariate and multivariate analyses were performed to identify risk factors associated with a second fracture. Results A total of 66 patients (5.3%) had a contralateral hip fracture in the 2 years following initial hip fracture. Mean age at first presentation was 81 years, and mean time to second fracture was 305 days. Following multivariate analysis, the patients at highest risk of a second fracture were those with dementia, acute inpatient chest infection, urinary tract infection and multiple comorbidities as measured by the Charlson score. Discharge destination after initial fracture was not associated with the risk of a second fracture. Conclusions We have identified a number of discrete risk factors that are associated with a short- to medium-term risk of contralateral hip fracture that may be useful in screening for patients at risk and provide them with focused medical rehabilitation.

Mathematical Modeling of Fluid Flow to Unconventional Oil Wells With Radial Fractures and Its Testing With Field Data

Radial fractures are created in unconventional gas and oil reservoirs in modern well stimulation operations such as hydraulic refracturing (HRF), explosive fracturing (EF), and high energy gas fracturing (HEGF). This paper presents a mathematical model to describe fluid flow from reservoir through radial fractures to wellbore. The model can be applied to analyzing angles between radial fractures. Field case studies were carried out with the model using pressure transient data from three typical HRF wells in a lower-permeability reservoir. The studies show a good correlation between observed well performance and model-interpreted fracture angle. The well with the highest productivity improvement by the HRF corresponds to the interpreted perpendicular fractures, while the well with the lowest productivity improvement corresponds to the interpreted conditions where the second fracture is much shorter than the first one or where there created two merged/parallel fractures. Result of the case studies of a tight sand reservoir supports the analytical model.