El papel de la determinación de un marcador de resorción, el telopéptido carboxiterminal del colágeno I, en la valoración del cumplimiento terapéutico en pacientes tratadas con bifosfonatos orales / The determining role of a resorption marker,carboxyterminal telopeptide of collagen I,in assessing therapeutic compliance inpatients treated with oral bisphosphonates

Objetivo: Se estima que al año entre el 50-60% de los pacientes tratados con fármacos para la osteoporosis son incumplidores. Disponemos de diferentes métodos indirectos de valoración del cumplimiento. Nuestro objetivo es testar una única determinación del telopéptido carboxiterminal del colágeno tipo I (CTX) para valorar el cumplimiento en pacientes tratadas con bifosfonatos, de forma aislada o junto al cuestionario de Morinsky-Green. Material y método: Estudio de validación diagnóstica realizado en 10 centros de Cataluña. Mediante muestreo consecutivo se seleccionaron mujeres postmenopáusicas con osteoporosis y tratadas con un mismo fármaco antirresortivo en el último año; se excluyeron aquellas tratadas con un fármaco diferente a bifosfonato, con deterioro cognitivo, enfermedad terminal, o insuficiencia renal avanzada, o fractura en el año previo. Se recogieron datos sobre el diagnóstico de osteoporosis y tipo de tratamiento. Se solicitó analítica con determinación del CTX. Como gold-standard se utilizó la tasa de posesión de medicación (Medication Possession Ratio, MPR). Mediante metodología de la curva ROC se estableció el punto de corte teórico del CTX. Se calculó la sensibilidad, la especificidad y los valores predictivos positivos para estimar el cumplimiento terapéutico. Resultados: Se incluyeron 100 pacientes, de las cuales más de la mitad recibían alendronato. Según la MPR, un 70% eran cumplidoras. El valor medio del CTX fue de 0,193±0,146 ng/ml, siendo inferior en las pacientes cumplidoras. Se estableció como punto de corte para valorar el cumplimiento un valor de 0,196 ng/ml. La valoración conjunta del CTX junto al cuestionario de Morinsky-Green presentó mayor capacidad discriminativa. Conclusiones: La realización de una única determinación del CTX (<0,196 ng/ml) junto al cuestionario de Morinsky-Green permite valorar mejor el cumplimiento terapéutico en pacientes tratadas con bifosfonatos

Objective:It is estimated that in one year between 50‐60% of patients treated with osteoporosis drugs are non‐com‐pliant. There are different indirect methods of assessing compliance. Our objective is to test a single determination ofthe carboxyterminal telopeptide of type I collagen (CTX) to assess compliance in patients treated with bisphosphonates,either on its own or together with the Morinsky‐Green questionnaire.Material and method:A diagnostic assessment study was carried out in 10 centers in Catalonia. Through consecutivesampling, postmenopausal women with osteoporosis were selected and treated with the same antiresorptive drug inthe last year. Those treated with a drug other than bisphosphonate, with cognitive impairment, terminal illness, advancedrenal failure or fracture in the previous year, were excluded. Data were collected on the diagnosis of osteoporosis andtype of treatment. Analysis was requested with CTX determination. As a gold standard, the medication possession rate(MPR) was used. Using the ROC curve methodology, the theoretical CTX cut‐off point was established. Sensitivity, spe‐cificity and positive predictive values were calculated to estimate therapeutic compliance.Results:100 patients were included, of which more than half were being treated with alendronate. According to theMPR, 70% were compliant. The mean CTX value was 0.193±0.146 ng/ml. It was lower in the compliant patients. A valueof 0.196 ng/ml was established as a cut‐off point to assess compliance. The joint assessment of the CTX together withthe Morinsky‐Green questionnaire showed greater discriminatory capacity.Conclusions:Carrying out a single determination of CTX (<0.196 ng/ml) along with the Morinsky‐Green questionnaireallows us to more accurately assess the therapeutic compliance in patients treated with bisphosphonates

[Prediction of the total calcium intake from consumption of milk products in Spain adult population. INDICAD Study 2001]. / Predicción de la ingesta total de calcio a través del consumo de lácteos en la población adulta de España. Estudio INDICAD 2001.

OBJECTIVE: To assess the predictive value of calcium intake from milk products and its effect of this on the total contribution of food calcium. DESIGN: Cross-sectional study. SETTING: Urban and rural health centres in Spain. PARTICIPANTS: Patients aged 20 or over who attended for consultation for whatever reason in the time-period set. Criterion for exclusion: terminal illness. 1546 questionnaires were included in the study. MAIN MEASUREMENTS: Consumption of calcium from milk products and from other sources. RESULTS: The intake of milk products accounted for 66.8% of the total intake of calcium (0%-93%). The consumption of < or =2 rations of milk products per day supposed a total calcium intake of under 1000 mg/day; of >3 rations, a total intake of 1000-1500 mg/day; and of >4 rations, 1500 mg/day. In subjects with low milk product intake (< or =2 rations per day), the predictive value of this for total calcium was low (10%-30%); and in those with >4 rations, its predictive value was 70%. CONCLUSIONS: Calculation of the total intake of calcium in milk products is useful in the consultation, but undervalues the real contribution, as it takes no notice of calcium from other food sources. Only the intake of >4 rations of milk products a day is sufficiently predictive.

Management of osteoporosis in general practice: a cross-sectional survey of primary care practitioners in Spain.

A cross-sectional survey was conducted to determine the current situation in Spain regarding diagnosis and care of patients with osteoporosis in the primary care setting. A total of 2,500 primary care physicians who were homogeneously grouped in autonomous communities throughout the country received a postal 30-item anonymous self-administered questionnaire. The questionnaire covered demographics and personal characteristics of the physicians, conditions in everyday consultation, and degree of knowledge with regard to risk factors, diagnosis, treatment, and follow-up of the disease. The overall response was 850 (34%). The mean age of physicians surveyed was 43 years (range 23-66 years). The percentage of physicians specialized in community and family medicine was 46.7%. In 55.2% of cases, years of practice ranged between 11 and 20, and 55.7% of physicians visited between 31 and 50 patients per day. Age and years of practice were not associated with daily number of visits. Only 4% of physicians stated that there were specific programs for osteoporosis implemented in their primary care center. Diagnostic complementary investigations that could be ordered included plain radiographs in 96.2% of cases and bone densitometry in 27.8%. Laboratory tests included serum hormones in 61.6% of cases, PTH in 50.2%, and bone alkaline phosphatase in 33.4%. The diagnosis of osteoporosis was made always personally in 25.2% of cases. Personal diagnosis and follow-up, as well as actions directed to detection of osteoporosis were significantly higher among physicians working in centers with specific programs for osteoporosis. With regard to knowledge about osteoporosis, the mean percentage of correct responses was 63%. The percentage of correct responses was inversely associated with age and years of practice, and positively associated with speciality of community and family medicine. Primary care providers are in a good position to assess risk factors and recommend prevention strategies, as well as to play an active role in the diagnosis, care, and follow-up of patients with osteoporosis. Practitioners of younger age and relatively few years of practice were those with more up-to-date information regarding the disease, and the existence of a specific program for osteoporosis seems to improve the management of this condition.

Prevención de la osteoporosis en pacientes con fractura de cadera / Osteoporosis prevention in patients with hip fracture

Objetivo. Conocer si hubo medidas preventivas para la osteoporosis (Op) en pacientes que sufrieron una fractura de la extremidad proximal del fémur (FEPF). Sujetos y mediciones. Estudio observacional retrospectivo. Se trataba de pacientes mayores de 50 años procedentes de los hospitales de referencia, residentes en nuestra comarca, con FEPF de baja energía y dados de alta durante el año 2000. Mediante una encuesta telefónica con el paciente o con su cuidador principal recogimos: factores de riesgo para la osteoporosis y caídas, existencia de densitometría previa a la fractura, tratamiento previo con fármacos para la Op (profilaxis o tratamiento) y recepción de consejos relacionados con la Op en los dos años anteriores a la fractura. Resultados. Estudiamos 194 pacientes, 40 (20,6 por ciento) hombres, y 154 (79,4 por ciento) mujeres, con una media de edad de 83 años (DE 8 años). El 93,8 por ciento tenían algún factor de riesgo de osteoporosis, siendo la media 2,2. Tenían realizada una densitometría previa a la fractura 10 (5,2 por ciento). Habían tomado fármacos 37 (19,2 por ciento); nunca realizaron tratamiento 157 (80,8 por ciento). Recordaban consejos para incrementar el ejercicio 67 pacientes (35 por ciento); relacionados con aumentar la ingesta de calcio 50 (27 por ciento) y 36 (19,2 por ciento) recordaban consejos respecto a la mejora del mobiliario y la arquitectura de la casa. Conclusiones. No existen, salvo casos aislados, maniobras diagnósticas, tratamiento o actividades preventivas para la Op en los pacientes que posteriormente sufrieron una FEPF en nuestro medio (AU)

[Diagnosing osteoporosis in primary care in Spain (ABOPAP 2000 study)]. / Abordaje de la osteoporosis en la atención primaria en España (estudio ABOPAP-2000).

OBJECTIVE: To discover how osteoporosis is tackled in Spanish primary care before the publication of the semFYC osteoporosis guide. DESIGN: Self-filled questionnaire for primary care doctors sent out by commercial mail (in blocks per province). SETTING: Five thousand family medicine clinics in Spain.Participants. Doctors working in primary care.Measurements. Level of activity relating to osteoporosis in daily consultations (identification of risk factors, screening, who conducts diagnosis and follow-up, level of access to densitometry and specialist) and identification data (province, type of work centre and number of consultations per day). MAIN RESULTS: 414 replies embracing reformed and non-reformed centres from the entire country, with different case overloads. 32.3% stated that osteoporosis treatment was viewed as a preventive activity in their centre and only 35.5% systematically asked for family history of osteoporosis. Osteoporosis screening was high in determined situations (82.9% in vertebral compression, 78.3% in hip fracture) and deficient in others (59.6% in glucocorticoid treatment, 46.6% in colles fractures, 36% in chronic nephropathy, 29.2% in thinness, 17.1% in chronic hepatopathy and 11.8% in treatment for epilepsy or with lithium). 73.9% could not request bone densitometry and 64.3% thought that access to other care levels was complicated. 51.9% said they continued to monitor osteoporosis. The impossibility of requesting densitometry or difficult access conditioned the screening level. There were differences in access according to autonomous communities, with Catalonia having best access to Densitometry (75%), followed by the communities of Madrid, Valencia and Euskadi (30%). CONCLUSIONS: Diagnosis of osteoporosis in primary care is deficient and is partly conditioned by difficulty in access to diagnostic tests and the lack of systematic screening.

Abordaje de la osteoporosis en la atención primaria en España (estudio ABOPAP-2000) / Diagnosing osteoporosis in primary care in Spain (ABOPAP 2000 study)

Objetivo. Conocer el abordaje de la osteoporosis en atención primaria en España antes de la edición de la Guía de Osteoporosis de la semFYC. Diseño. Encuesta autoadministrada a médicos de atención primaria remitida por correo comercial (agrupados por provincias). Emplazamiento. Cinco mil consultas de medicina de familia de España. Participantes. Médicos que trabajaban en atención primaria. Mediciones. Nivel de actuación ante la osteoporosis en la consulta diaria (identificación de factores de riesgo, cribado, quién realiza el diagnóstico y seguimiento, nivel de acceso a densitometría y especialista) y datos identificativos (provincia, tipo de centro de trabajo y número de visitas al día). Resultados principales. Se obtuvieron 414 respuestas que abarcaban centros reformados y no reformados de todo el país, con diferente sobrecarga asistencial. El 32,3 per cent manifestó que la osteoporosis era considerada como una actividad preventiva en su centro y tan sólo el 35,5 per cent interrogaba sistemáticamente por el antecedente familiar de osteoporosis. El cribado de osteoporosis era elevado en determinadas situaciones (el 82,9 per cent en aplastamiento vertebral, el 78,3 per cent en fractura de cadera) y deficiente en otras (el 59,6 per cent en tratamiento con glucocorticoides, el 46,6 per cent en fractura de Colles, el 36 per cent en nefropatía crónica, el 29,2 per cent en delgadez, el 17,1 per cent en hepatopatía crónica y el 11,8 per cent en tratamiento con antiepilépticos o litio). El 73,9 per cent no podía solicitar densitometrías óseas y el 64,3 per cent consideraba que el acceso a otros ámbitos asistenciales era complicado, pero el 51,9 per cent manifestaba proseguir el estudio de la osteoporosis. La imposibilidad de solicitar densitometría o el acceso dificultoso condicionaba el grado de cribado. Se observaron diferencias en el acceso según las comunidades autónomas, siendo Cataluña la que tenía un mejor acceso a la densitometría (75 per cent), seguida de las comunidades de Madrid, Valencia y el País Vasco (30 per cent). Conclusiones. El abordaje de la osteoporosis en atención primaria es deficiente y en parte viene condicionado por la dificultad en el acceso a pruebas diagnósticas y a la falta de sistematización de su cribado (AU)

[Are food intake and life styles related with bone mass in fertile women?]. / Hay relación entre los hábitos alimenticios y estilo de vida con la masa ósea en mujeres fértiles?

BACKGROUND: To study the relationship between current and adolescent calcium intake and bone mineral density (BMD) in 76 premenopausal women of 42 y. with regular menses and without pathologies associated with body weight, body morphology or BMD. METHODS: Was measured: the lumbar and femoral BMD by dual energy X-Ray absorptiometer, calcium and protein intake by a week frequencies questionnaire, and calciuria. Obesity, exercise, alcohol, tobacco and family history of osteoporosis were considered. Levels of BMD < -1SD was considered as osteopenia. RESULTS: Calcium intake average was 989 mg/day, 62% by dairy. Twenty-five percent presented osteopenia in some bone site. BMD was not correlated with calcium or protein intake, calcium/protein nor calciuria. No differences was found between normal and osteopenic group for any of the studied variables, except lower body mass index in the femoral osteopenic group. Those women who decreased the calcium intake from adolescence had 8.2% less femoral BMD tha those who increased the consumption (p = 0.05). CONCLUSION: Current and adolescent calcium intake, family history of osteoporosi calciuria, and exercise have not found useful as screening of osteopenia in premenopausal women with moderated exercise level and low consumption of alcohol and tobacco.

[Factors that influence primary care physicians' level of tiredness at work]. / Factores que influyen en el nivel cansancio laboral de los médicos de atención primaria.

OBJECTIVE: To relate the characteristics of working activity to the level of tiredness at work (low, medium and high). DESIGN: A crossover, observational and random study. SETTING: Primary Care Centres in Spain, belonging to the new sanitary model. PARTICIPANTS: 116 doctors (75% General Practitioners, 19% paediatricians and 6% Interns in their third year of Family Medicine (R-3)). An anonymous survey sent by mail over five consecutive days, during a period without any epidemics. Tiredness at work was measured on a scale of 0 to 10 (nil to maximum) by means of 7 questions covering quantitative working activity (the number of patients seen, of discussions between nurse and doctor, of emergencies and home visits), its quality (the type of patient, the bureaucracy involved) and the doctor's length of experience. RESULTS: The tiredness at work found was 4.7 +/- 1.6. Those who showed high levels of tiredness had greater working activity in both the quantitative and qualitative senses than those with medium tiredness; and these, in their turn, greater working activity than those with low tiredness. Doctors' length of experience did not affect the level of tiredness. General Practitioners were more tired than paediatricians and R-3. CONCLUSIONS: A doctor's tiredness at work is determined by the number of patients seen, the type of patient and the amount of bureaucracy and organisation. All these factors should be borne in mind when the doctor's working activities are organised.