Hospitalizations for hip and non-hip osteoporotic fractures in Belgium: nationwide trends between 2010 and 2021.

This study aimed to describe the incidence of hospitalizations for osteoporotic fractures in patients aged 50 years and over in Belgium between 2010 and 2021. A declining trend in crude and age-adjusted hospitalization incidence was observed, however, the absolute number of hospitalisations for osteoporotic fractures increased due to demographic changes. PURPOSE: The secular trends of hospitalizations for hip and other osteoporotic fractures between 2010 and 2021 in patients aged 50 years and over in Belgium are unknown. This study aimed to describe the incidence of hospitalizations for osteoporotic fractures in patients aged 50 years and over in Belgium between 2010 and 2021. METHODS: Population-based, retrospective study based on hospitalization data extracted by the national database NIHDI and demographical data retrieved from the Belgian Federal Bureau for Statistics. Data were combined to determine the crude and age-standardized hospitalization incidence of fractures of the hip, distal femur, pelvis, humerus, wrist, and spine (2010 as the reference year). RESULTS: A total of 445,234 hospitalizations for osteoporotic fractures were reported between 2010 and 2021 (excluding 2015). Hospitalizations increased by 5.8% between 2010 and 2021 (p = 0.013) with a higher increase in men (12.1%; p = 0.001) compared to women (4.1%; p = 0.041). The crude incidence of hospitalizations for all fractures per 100,000 persons per year decreased from 990 to 910 between 2010 and 2021 (p = 0.572). The age-standardized incidence for hospitalizations of any osteoporotic fracture in men declined from 5.30/1,000 to 4.42/1,000 (p = 0.010). In women, a similar decrease was observed (13.84/1,000 to 11.62/1,000; p = 0.003). Both age-standardized hospitalizations for hip and non-hip fractures showed a decrease in both sexes. CONCLUSION: Although a declining trend in the crude incidence per 100,000 and in the age-adjusted incidence of hospitalizations for osteoporotic fractures was observed, the absolute number of hospitalizations for osteoporotic fractures increased due to the demographic change of an ageing population.

Predictors of mortality one year after pelvic fractures in an older population: a retrospective cohort study.

The goal was to investigate if patient characteristics can be used to predict 1-year post-fracture mortality after pelvic fracture. Multivariate logistic regression identified male gender, comorbidities and presence of in-hospital complications as predictors of 1-year mortality. PURPOSE: Osteoporotic pelvic fractures have significant mortality and morbidity in the older population. The aim of this study was to investigate the factors predicting one-year mortality of patients sustaining a low-impact pelvic fracture (pelvic ring and acetabulum). METHODS: A total of 282 patients aged ≥ 65 years presenting with a low-energy pelvic ring (n =254) or acetabular (n =28) fracture to the emergency department at the University Hospitals Leuven were included. Demographic and clinical data were retrospectively collected and predictors for mortality one year after pelvic ring fractures were evaluated. RESULTS: The one-year mortality after osteoporotic pelvic ring fractures and acetabular fractures was respectively 20.4% (95% CI 15.7-26.0) and 14% (95% CI 4.0-32.7). Multivariate logistic regression adjusted for confounders identified male gender (OR 3.18; 95% CI (1.06-9.49), p =0.038), a higher number of comorbidities (OR 1.5; 95% CI (1.16-1.95), p =0.002) and in-hospital complications (OR 5.00; 95% CI (1.39-17.97), p =0.014) as independent predictors of one-year mortality after pelvic ring fractures. CONCLUSION: The one-year mortality after low-energy pelvic is high and can be predicted by different patient characteristics. These findings can guide pelvis fracture treatment decisions in the older population.

From research to daily clinical practice: implementation of orthogeriatric co-management in the trauma ward.

Introduction: Evidence strongly suggests that orthogeriatric co-management improves patient outcomes in frail older patients with a fracture, but evidence regarding how to implement this model of care in daily clinical practice is scarce. In this paper, we first describe the implementation process and selection of implementation strategies for an orthogeriatric co-management program in the traumatology ward of the University Hospitals Leuven in Belgium. Second, we report the results of a multi-method feasibility study. This study (1) measures the fidelity towards the program's core components, (2) quantifies the perceived feasibility and acceptability by the healthcare professionals, and (3) defines implementation determinants. Methods: Implementation strategies were operationalized based on the Expert Recommendations for Implementing Change (ERIC) guidelines. In the feasibility study, fidelity towards the core components of the program was measured in a group of 15 patients aged 75 years and over by using electronic health records. Feasibility and acceptability as perceived by the involved healthcare professionals was measured using a 15-question survey with a 5-point Likert scale. Implementation determinants were mapped thematically based on seven focus group discussions and two semi-structured interviews by focusing on the healthcare professionals' experiences. Results: We observed low fidelity towards completion of a screening questionnaire to map the premorbid situation (13%), but high fidelity towards the other program core components: multidimensional evaluation (100%), development of an individual care plan (100%), and systematic follow-up (80%). Of the 50 survey respondents, 94% accepted the program and 62% perceived it as feasible. Important implementation determinants were feasibility, awareness and familiarity, and improved communication between healthcare professionals that positively influenced program adherence. Conclusions: Fidelity, acceptability, and feasibility of an orthogeriatric co-management program were high as a result of an iterative process of selecting implementation strategies with intensive stakeholder involvement from the beginning. Clinical trial registration: [https://www.isrctn.com/ISRCTN20491828], International Standard Randomised Controlled Trial Number (ISRCTN) Registry: [ISRCTN20491828]. Registered on October 11, 2021.

Skeletal response to teriparatide in real-life setting: effects of age, baseline bone density and prior denosumab use.

OBJECTIVES: Teriparatide (TPD) is an osteoanabolic agent used in patients with high osteoporotic fracture risk. Predictors of therapeutic response to TPD in real-life setting are not well characterised. This study investigated the influence of previous antiresorptive therapy, age and other patient characteristics on the skeletal response to TPD. METHODS: Retrospective study at the metabolic bone clinic, University Hospitals Leuven, Belgium. Patients with osteoporosis and a high fracture burden received TPD for 9-18 months. Bone mineral density (BMD) was measured at baseline, 9 and 18 months at lumbar spine (LS), femoral neck (FN) and total hip (TH). RESULTS: BMD at LS increased at 9 months (change mean (standard error) 6.8 % (0.7) p < 0.001) and at 18 months (8.0 % (0.9) p < 0.001), while BMD at FN and TH did not change significantly. Non-response in BMD change at the LS was seen with prior denosumab use (odds ratio 0.21, 95% confidence interval (CI) 0.049-0.912, p = 0.037). Changes in BMD at TH were significantly greater in younger patients and in patients with a lower baseline BMD. CONCLUSION: TPD-induced changes in BMD at TH might depend on age and baseline BMD and at LS on prior denosumab use. The results suggest that these factors may be relevant for clinical decision making when initiating TPD treatment, although larger studies are needed to confirm these findings.

Sarcopenia, osteoporosis and frailty.

Muscles and bones are intricately connected tissues displaying marked co-variation during development, growth, aging, and in many diseases. While the diagnosis and treatment of osteoporosis are well established in clinical practice, sarcopenia has only been classified internationally as a disease in 2016. Both conditions are associated with an increased risk of adverse health outcomes such as fractures, dysmobility and mortality. Rather than focusing on one dimension of bone or muscle mass or weakness, the concept of musculoskeletal frailty captures the overall loss of physiological reserves in the locomotor system with age. The term osteosarcopenia in particular refers to the double jeopardy of osteoporosis and sarcopenia. Muscle-bone interactions at the biomechanical, cellular, paracrine, endocrine, neuronal or nutritional level may contribute to the pathophysiology of osteosarcopenia. The paradigm wherein muscle force controls bone strength is increasingly facing competition from a model centering on the exchange of myokines, osteokines and adipokines. The most promising results have been obtained in preclinical models where common drug targets have been identified to treat these conditions simultaneously. In this narrative review, we critically summarize the current understanding of the definitions, epidemiology, pathophysiology, and treatment of osteosarcopenia as part of an integrative approach to musculoskeletal frailty.

Prognostic factors and prediction model for 1-year mortality after proximal humeral fracture.

The goal was to investigate if patient characteristics can be used to predict 1-year post-fracture mortality after proximal humeral fracture (PHF). A clinical prediction model showed that the combination of 6 pre-fracture characteristics demonstrated good predictive properties for mortality within 1 year of PHF. INTRODUCTION: Proximal humeral fractures (PFH) are the third most common major non-vertebral osteoporotic fractures in older persons and result in an increased mortality risk. The aim of this study was to investigate if patient characteristics can be used to predict 1-year post-fracture mortality. METHODS: Retrospective study with 261 patients aged 65 and older who were treated for a PHF in University Hospitals Leuven between 2016 and 2018. Baseline variables including demographics, residential status, and comorbidities were collected. The primary outcome was 1-year mortality. A clinical prediction model was developed using LASSO regression and validated using split sample and bootstrapping methods. The discrimination and calibration were evaluated. RESULTS: Twenty-seven (10.3%) participants died within 1-year post-PHF. Pre-fracture independent ambulation (p < 0.001), living at home at time of fracture (p < 0.001), younger age (p = 0.006), higher BMI (p = 0.012), female gender (p = 0.014), and low number of comorbidities (p < 0.001) were predictors for 1-year survival. LASSO regression identified 6 stable predictors for a prediction model: age, gender, Charlson comorbidity score, BMI, cognitive impairment, and pre-fracture nursing home residency. The discrimination was 0.891 (95% CI, 0.833 to 0.949) in the training sample, 0.878 (0.792 to 0.963) in the validation sample and 0.756 (0.636 to 0.876) in the bootstrapping samples. A similar performance was observed for patients with and without surgery. The developed model demonstrated good calibration. CONCLUSIONS: The combination of 6 pre-fracture characteristics demonstrated good predictive properties for mortality within 1 year of PHF. These findings can guide PHF treatment decisions.

Orthogeriatric co-management for older patients with a major osteoporotic fracture: Protocol of an observational pre-post study.

BACKGROUND: Osteoporotic fractures are associated with postoperative complications, increased mortality, reduced quality of life, and excessive costs. The care for older patients with a fracture is often complex due to multimorbidity, polypharmacy, and presence of geriatric syndromes requiring a holistic multidisciplinary approach based on a comprehensive geriatric assessment. Nurse-led geriatric co-management has proven to prevent functional decline and complications, and improve quality of life. The aim of this study is to prove that nurse-led orthogeriatric co-management in patients with a major osteoporotic fracture is more effective than inpatient geriatric consultation to prevent in-hospital complications and several secondary outcomes in at least a cost-neutral manner. METHODS: An observational pre-post study will be performed on the traumatology ward of the University Hospitals Leuven in Belgium including 108 patients aged 75 years and older hospitalized with a major osteoporotic fracture in each cohort. A feasibility study was conducted after the usual care cohort and prior to the intervention cohort to measure fidelity to the intervention components. The intervention includes proactive geriatric care based on automated protocols for the prevention of common geriatric syndromes, a comprehensive geriatric evaluation followed by multidisciplinary interventions, and systematic follow-up. The primary outcome is the proportion of patients having one or more in-hospital complications. Secondary outcomes include functional status, instrumental activities of daily living status, mobility status, nutritional status, in-hospital cognitive decline, quality of life, return to pre-fracture living situation, unplanned hospital readmissions, incidence of new falls, and mortality. A process evaluation and cost-benefit analysis will also be conducted. DISCUSSION: This study wants to prove the beneficial impact of orthogeriatric co-management in improving patient outcomes and costs in a heterogenous population in daily clinical practice with the ambition of long-term sustainability of the intervention. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number (ISRCTN) Registry: ISRCTN20491828. Registered on October 11, 2021, https://www.isrctn.com/ISRCTN20491828.

Rebound-associated vertebral fractures after denosumab discontinuation in a lung cancer patient with bone metastases.

Denosumab is a commonly used antiresorptive treatment in patients with osteoporosis or solid tumours with bone metastases. Upon denosumab discontinuation, a rebound phenomenon can occur that results in an increased (vertebral) fracture risk. This phenomenon is well-known in the setting of osteoporosis but rarely reported in cancer patients with bone metastases discontinuing denosumab. We present the case of a 43-year old women with lung cancer and bone metastases who suffered multiple vertebral fractures after discontinuation of denosumab.

Erectile dysfunction predicts mortality in middle-aged and older men independent of their sex steroid status.

BACKGROUND: erectile dysfunction is associated with mortality, whereas the association between low testosterone (T) and higher mortality remains controversial. Sexual dysfunction and low T often coexist, but the relative importance of sexual symptoms versus low T in predicting mortality is not known. We studied the interrelationships between sex steroids and sexual symptoms with all-cause mortality in a large prospective cohort of European men. DESIGN: survival status was assessed in 1,788 community-dwelling men, aged 40-79, who participated in the European Male Ageing Study (EMAS). Sexual symptoms were evaluated via a validated questionnaire (EMAS-SFQ). Sex steroids were measured by mass spectrometry. Cox proportional hazard models were used to study the association between hormones, sexual symptoms and mortality. RESULTS: about 420 (25.3%) men died during a mean follow-up of 12.6 ± 3.1 years. Total T levels were similar in both groups, but free T was lower in those who died. Men with three sexual symptoms (erectile dysfunction, reduced morning erections and lower libido) had a higher mortality risk compared with men with none of these symptoms (adjusted hazard ratio (HR) and 95% confidence intervals: 1.75 (1.28-2.40, P = 0.001)). Particularly, erectile dysfunction and poor morning erections, but not lower libido, were associated with increased mortality (HR 1.40 (1.13-1.74, P = 0.002), 1.28 (1.04-1.59, P = 0.023) and 1.12 (0.90-1.39, P = 0.312), respectively). Further adjusting for total T, free T or oestradiol did not influence the observed risk. CONCLUSIONS: sexual symptoms, in particular erectile dysfunction, predict all-cause mortality independently of sex steroids and can be an early warning sign of a poor health status.

The experiences of early career geriatricians throughout Europe during the COVID-19 pandemic.

The COVID-19 pandemic has severely affected older adults and brought about unprecedented challenges to geriatricians. We aimed to evaluate the experiences of early career geriatricians (residents or consultants with up to 10 years of experience) throughout Europe using an online survey. We obtained 721 responses. Most of the respondents were females (77.8%) and residents in geriatric medicine (54.6%). The majority (91.4%) were directly involved in the care of patients with COVID-19. The respondents reported moderate levels of anxiety and feelings of being overloaded with work. The anxiety levels were higher in women than in men. Most of the respondents experienced a feeling of a strong restriction on their private lives and a change in their work routine. The residents also reported a moderate disruption in their training and research activities. In conclusion, early career geriatricians experienced a major impact of COVID-19 on their professional and private lives.

Effects of Orthogeriatric Care Models on Outcomes of Hip Fracture Patients: A Systematic Review and Meta-Analysis.

Orthogeriatrics is increasingly recommended in the care of hip fracture patients, although evidence for this model is conflicting or at least limited. Furthermore, there is no conclusive evidence on which model [geriatric medicine consultant service (GCS), geriatric medical ward with orthopedic surgeon consultant service (GW), integrated care model (ICM)] is superior. The review summarizes the effect of orthogeriatric care for hip fracture patients on length of stay (LOS), time to surgery (TTS), in-hospital mortality, 1-year mortality, 30-day readmission rate, functional outcome, complication rate, and cost. Two independent reviewers retrieved randomized controlled trials, controlled observational studies, and pre/post analyses. Random-effects meta-analysis was performed. Thirty-seven studies were included, totaling 37.294 patients. Orthogeriatric care significantly reduced LOS [mean difference (MD) - 1.55 days, 95% confidence interval (CI) (- 2.53; - 0.57)], but heterogeneity warrants caution in interpreting this finding. Orthogeriatrics also resulted in a 28% lower risk of in-hospital mortality [95%CI (0.56; 0.92)], a 14% lower risk of 1-year mortality [95%CI (0.76; 0.97)], and a 19% lower risk of delirium [95%CI (0.71; 0.92)]. No significant effect was observed on TTS and 30-day readmission rate. No consistent effect was found on functional outcome. Numerically lower numbers of complications were observed in orthogeriatric care, yet some complications occurred more frequently in GW and ICM. Limited data suggest orthogeriatrics is cost-effective. There is moderate quality evidence that orthogeriatrics reduces LOS, in-hospital mortality, 1-year mortality, and delirium of hip fracture patients and may reduce complications and cost, while the effect on functional outcome is inconsistent. There is currently insufficient evidence to recommend one or the other type of orthogeriatric care model.

Aging Men With Insufficient Vitamin D Have a Higher Mortality Risk: No Added Value of its Free Fractions or Active Form.

CONTEXT: Low total 25-hydroxyvitamin D (25(OH)D) has been associated with mortality. Whether vitamin D in its free form or 1,25-dihydroxyvitamin D (1,25(OH)2D), provide any additional information is unclear. OBJECTIVE: To determine what level of 25(OH)D is predictive for mortality and if free 25(OH)D or 1,25(OH) 2 D concentrations have any added value. METHODS: This prospective cohort comprised 1915 community-dwelling men, aged 40 to 79 years. Intervention included determination of association of total and free 25(OH)D and 1,25(OH) 2 D concentrations with survival status. Vitamin D results were grouped into quintiles. For total 25(OH)D, specific cutoff values were also applied. Cox proportional hazard models were used adjusted for center, body mass index, smoking, alcohol, physical activity, season of blood sample, kidney function, and number of comorbidities. RESULTS: A total of 469 (23.5%) men died during a mean follow-up of 12.3 ±â€…3.4 years. Compared to those with normal vitamin D values (> 30 µg/L), men with a total 25(OH)D of less than 20 µg/L had an increased mortality (hazard ratio [HR] 2.03 [95% CI, 1.39-2.96]; P < .001). Likewise, men in the lowest 3 free 25(OH)D quintiles (< 4.43 ng/L) had a higher mortality risk compared to the highest quintile (HR 2.09 [95% CI, 1.34-3.25]; P < .01). Mortality risks were similar across all 1,25(OH)2D and vitamin D binding protein quintiles. CONCLUSION: Aging men with vitamin D deficiency have a 2-fold increased mortality risk. Determinations of either the free fractions of vitamin D or measurement of its active form offer no additional information on mortality risks.

Epidemiology and secular trends of pelvic fractures in Belgium: A retrospective, population-based, nationwide observational study.

INTRODUCTION: Fractures of the pelvis and acetabulum are associated with osteoporosis, and their incidence is rising in older adults. In the last decade an increasing number of these fractures are being operated in older patients in certain regions. The goal of this study was to describe the incidence of pelvic and acetabular fractures in Belgium between 1988 and 2018. MATERIALS & METHODS: This retrospective, nationwide, population-based study was conducted with the help of the national health insurance database from the Belgian National Institute for Health and Disability Insurance (NIHDI-RIZIV-INAMI). Multiple codes for the reimbursement of the diagnosis and treatment of pelvic and acetabular fractures were collated and (since 2006) linked to the patients' age group, sex and region. RESULTS: Between 1988 and 2018, 91.317 pelvic and acetabular fractures were diagnosed. The overall incidence increased from 15,8/100.000 persons per year in 1988 to 29,7/100.000 persons per year in 2006 and to 37,6/100.000 persons per year in 2018. These fractures showed a bimodal incidence, with a small peak in children (particularly boys), and an increasing incidence in older adults, particularly in women. Between 2006 and 2018, 5.957 (12,4%) patients underwent surgical treatment for their pelvic fracture. 2.088 patients underwent an osteosynthesis of the acetabulum and 3869 patients underwent an osteosynthesis of the pelvic ring. There were 3622 osteosynthesises (60.8%) in patients younger than 60 years old and 2335 (39,1%) in patients over 60 years old. CONCLUSION: There is an increasing incidence of pelvic and acetabular fractures in Belgium with the majority of these fractures occurring in older people. Younger adults have the highest proportion of surgical treatment, but given the much higher incidence in older adults, there is a considerable amount of operations in older adults too.

Case report: an aortic aneurysm as cause of pseudoachalasia.

BACKGROUND: Pseudoachalasia is a rare disorder which has clinical, radiographic, and manometric findings that are often indistinguishable from primary achalasia. It is usually associated with malignancy. Few reports describe vascular compression as a cause of pseudoachalasia. CASE PRESENTATION: Here we present a case of a 84-year-old woman with anorexia, dysphagia and unintentional weight loss initially diagnosed as achalasia. Upon further investigation a rare cause of pseudoachalasia due to vascular compression of the esophagus was found. It could have been overlooked due to the fact that the initial work-out with a barium swallow, manometry and endoscopy was suggestive for primary achalasia. CONCLUSION: Particularly in older patients with a manometric diagnosis of achalasia, additional investigation to rule out pseudoachalasia is warranted. Although malignant involvement of the esophagus is the most common cause of pseudoachalasia, benign origins have also been described.

Age-related bone loss and sarcopenia in men.

Bone and muscle are required for mobility but they also have endocrine and metabolic functions. In ageing as well as in many chronic diseases, bone loss and muscle atrophy occur simultaneously, leading to concomitant osteoporosis and sarcopenia. This occurs in both genders but compared with postmenopausal women, men appear to be better protected against age-related bone and muscle decay. Sex steroids (both androgens like testosterone and oestrogens like estradiol) are mainly responsible for musculoskeletal sexual dimorphism. They stimulate peak bone and muscle mass accretion during puberty and midlife, and prevent subsequent loss in ageing men but not post-menopausal women. Still, recent studies have highlighted the importance of intrinsic ageing mechanisms such as cellular senescence and oxidative stress in both genders. Sarcopenia may predispose to dysmobility, frailty, falls and fractures, but whether so-called osteosarcopenia qualifies as a distinct entity remains debated. Although randomized clinical trials in male osteoporosis are smaller and therefore underpowered for some outcomes like hip fractures, the available evidence suggests that the clinical diagnostic and therapeutic approach to male osteoporosis is largely similar to that in postmenopausal women. There is a clear unmet medical need for effective and safe anabolic drugs to rebuild the ageing skeleton, muscle, and preferably both tissues simultaneously. The Wnt/sclerostin and myostatin/activin receptor signalling pathways appear particularly promising in this regard. In this narrative review, we aim to provide an overview of our current understanding of the pathophysiology and treatment of male osteoporosis and sarcopenia, and interactions between these two diseases.