To assess the ability of distal forearm fractures to predict future fractures, we conducted a population-based retrospective cohort study among the 1288 residents (243 men, 1045 women) of Rochester, Minnesota age 35 years or older who experienced their first distal forearm fracture in 1975-94. During 9664 person-years of follow-up, 548 patients experienced 1109 subsequent fractures, excluding 195 that occurred on the same day as the index forearm fracture. The cumulative incidence of any subsequent fracture was 55% by 10 years and 80% by 20 years following the initial distal forearm fracture. Compared to expected fracture rates in the community, the risk of a hip fracture following the index forearm fracture was increased 1.4-fold in women (95% CI, 1.1-1.8) and 2.7-fold in men (95% CI, 0.98-5.8). In women, the risk of hip fracture differed by age, as we had found in a previous study. Women over age 70 had a 1.6-fold increase (95% CI, 1.2-2.0) in subsequent hip fracture risk whereas women who sustained their first forearm fracture before age 70 years did not have significantly increase risk. By contrast, vertebral fractures were significantly increased at all ages, with a 5.2-fold increase (95% CI, 4.5-5.9) in risk among women and a 10.7-fold increase (95% CI, 6.7-16.3) among men following a first distal forearm fracture. The increased risk in men suggests that a sentinel forearm fracture should not be ignored. Among the women, we also found a missed opportunity for intervention as hormone replacement therapy was underutilized.

No abstract

Despite the availability of medications that reduce fracture risk, most women who sustain a hip fracture are not evaluated or treated for osteoporosis. While a number of studies have attributed this to a lack of physician awareness, no studies have evaluated this problem from the patient's perspective. To explore the process a woman negotiates when deciding to accept pharmacologic treatment for osteoporosis after hip fracture, we used a stage-of-change model to characterize a consecutive series of 70 postmenopausal women (mean age 85 years) admitted to a tertiary care hospital with an acute low-impact hip fracture between May 2000 and August 2000. We measured stage-of-change using a modified form of the Weinstein Precaution Adoption Process Model (PAPM). The majority of patients (65%) were ineligible because of dementia or delirium; only 29 were eligible and 21 were enrolled. Most women (62%) were in stages 1 or 2 of the PAPM, indicating that they were unaware of osteoporosis or had never considered pharmacologic treatment for it. The only factors associated with a more advanced PAPM stage (indicating active consideration or currently taking treatment) were a previous bone mineral density (BMD) evaluation ( p = 0.007) and a diagnosis of osteoporosis ( p = 0.001). Although 48% of women had a previous fragility fracture and osteoporosis knowledge was poor overall (mean score 52% correct), neither was associated with a more advanced PAPM stage in this sample. In conclusion, women evaluated after hip fracture were not ready to accept pharmacologic treatment for osteoporosis; they were unaware that they had osteoporosis or had never considered treatment for it. For a woman to advance through the behavior change process, she must first be made aware of the problem that requires a change in behavior. Physicians play a crucial role in promoting awareness of the diagnosis of osteoporosis after fracture, which in turn is associated with patient advancement through the behavior change process and the decision to accept pharmacologic intervention. The large number of cognitively impaired patients in this population, however, will certainly make efforts to improve osteoporosis awareness, diagnosis and intervention more challenging.

In subjects with diabetes receiving medical care, women had poorer control of blood pressure and a significantly higher mean SBP compared with men. These findings might partially explain the excess CHD mortality in women with diabetes.

A 71-year-old woman presented to the outpatient clinic with a chief complaint of having low back pain for 6 months. The back pain was insidious at onset, nonradiating, moderate in intensity, worse at night, and partially relieved with acetaminophen or aspirin. The patient described the pain as a constant, dull, aching sensation and recalled no trauma. She experienced anorexia and reported a 6.8-kg weight loss and decreased energy over the past several months. She also described occasional night sweats. The patient's history was remarkable for bilateral stage I breast cancer, for which she had a bilateral modified radical mastectomy 7 years previously. She also underwent left carotid artery to left subclavian artery bypass surgery for symptomatic left subclavian artery stenosis 4 years previously. Total hysterectomy was performed many years previously for reasons unrelated to cancer. The patient had hyperlipidemia but was not taking a lipid-lowering agent. Several years previously, microscopic hematuria was detected, and findings on cystoscopy and excretory urography were normal. She denied having gross hematuria. The patient was a current smoker with a 30-pack-year history of cigarette smoking. Her current medications were acetaminophen and aspirin on an as-needed basis. Physical examination disclosed a pulse rate of 88/min with a regular rhythm and a blood pressure level of 140/88 mm Hg. Examination of the patient's spine showed no deformity, tenderness, or restriction of joint movements. Findings on the neurologic examination, including gait assessment, motor strength, and reflexes, were unremarkable. Examination of her abdomen revealed a midline, pulsatile mass (5 × 10 cm) extending from the epigastric area to the umbilical area. The mass was nontender and fixed. No bruit was audible over the abdominal mass. The patient had been aware of this mass for several months but had not sought medical attention. She denied recent change in the size of the abdominal mass, abdominal pain, change in bowel habits,