Nutrition in Bone Fracture Prevention & Healing: Part 3

X-ray image of hip, with top of femur broken (source)

 Today, three more resources on bone healing:

1. A systematic review of nutrition support's effect on hip fracture healing;
2. A special article on how to conduct a systematic review. Though it was done on hip fracture, the findings and conclusion can be applied to other search topics;
3. One of the research articles included in the Cochrane Systematic Review.

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Review:

Source - Cochrane Database of Systematic Reviews. 3, 2009.

Title - Nutritional supplementation for hip fracture aftercare in older people.

Authors - Avenell, Alison;  Handoll, Helen HG

Abstract -

  Background - Older people with hip fractures are often malnourished at the time of fracture, and have poor food intake subsequently.

  Objective - To review the effects of nutritional interventions in older people recovering from hip fracture.

  Search Strategy - We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2005), the Cochrane Central Register of Controlled Trials
(2006, Issue 1), MEDLINE, six other databases and reference lists. We contacted investigators and handsearched journals.

 Selection Criteria -  Randomised and quasi-randomised controlled trials of nutritional interventions for people aged over 65 years with hip fracture.

 Data Collection & Analysis - Both authors independently selected trials, extracted data and assessed trial quality. We sought additional information from trialists, and pooled data for primary outcomes.

 Main Results -

• Twenty-one randomised trials involving 1727 participants were included.
• Overall trial quality was poor, specifically regarding allocation concealment, assessor blinding and intention-to-treat analysis, and limited availability of outcome data.
• Eight trials evaluated oral multinutrient feeds: providing non-protein energy, protein, some vitamins and minerals. Oral feeds had no statistically significant effect on mortality (15/161 versus 17/176; relative risk (RR) 0.89, 95% confidence interval (CI) 0.47 to 1.68) but may reduce 'unfavourable outcome' (combined outcome of mortality and survivors with medical complications) (14/66 versus 26/73; RR 0.52, 95% CI 0.32 to 0.84).
• Four trials examining nasogastric multinutrient feeding showed no evidence of an effect on mortality (RR 0.99, 95% CI 0.50 to 1.97) but the studies were heterogeneous regarding case mix. Nasogastric feeding was poorly tolerated. There was insufficient information for other outcomes.
• Increasing protein intake in an oral feed was tested in four trials. There was no evidence for an effect on mortality (RR 1.42, 95% CI 0.85 to 2.37). Protein supplementation may have reduced the number of long term medical complications.
• Two trials, testing intravenous vitamin B1 and other water soluble vitamins, or 1-alpha-hydroxycholecalciferol (an active form of vitamin D) respectively, produced no evidence of effect for either supplement.
• One trial, evaluating dietetic assistants to help with feeding, showed a trend for a reduction in mortality (RR 0.57, 99% CI 0.29 to 1.11).

 Conclusion -

• Some evidence exists for the effectiveness of oral protein and energy feeds, but overall the evidence for the effectiveness of nutritional supplementation remains weak.
• Adequately sized trials are required which overcome the methodological defects of the reviewed studies.
• In particular, the role of dietetic assistants requires further evaluation.

Links:
Abstract
Full article (PDF, 740 KB)

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Special article:

Source - American Journal of Clinical Nutrition, Vol. 73, No. 3, 505-510, March 2001

Title - Lessons for search strategies from a systematic review, in The Cochrane Library, of nutritional supplementation trials in patients after hip fracture.

Authors - Avenell, Alison;  Handoll, Helen HG, Grant AM

Abstract -

  Background - A key aim when conducting systematic reviews of randomized controlled trials (RCTs) is to include all of the evidence, if possible. Serious bias may result if trials are missed through inadequate search strategies.

 Objective - The objective was to evaluate the search plan for identifying RCTs in nutrition as part of a systematic review, in The Cochrane Library, of nutritional supplementation trials in patients after hip fracture.

 Design - We identified potential studies by searching the electronic databases BIOSIS, CABNAR, CINAHL, EMBASE, HEALTHSTAR, and MEDLINE; reference lists in trial reports; and other relevant articles. We also contacted investigators and other experts for information and searched 4 nutrition journals by hand.

 Results - We identified 15 RCTs that met the predefined inclusion criteria. The search plan identified 8 trials each in EMBASE, HEALTHSTAR, and MEDLINE and 7 in BIOSIS and CABNAR. BIOSIS was the only electronic database source of 2 trials. Eleven trials were identified by searching electronic databases and 2 unpublished trials were identified via experts in the field. We found one trial, published only as a conference abstract, by searching nutrition journals by hand. After publication of the protocol for the review in The Cochrane Library, we were informed of another unpublished trial.

  Conclusions - We found that a limited search plan based on only MEDLINE or one of the other commonly available databases would have failed to locate nearly one-half of the studies. To protect against bias, the search plan for a systematic review of nutritional interventions should be comprehensive.

Links:
Abstract
Full article (PDF, 59 KB)

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Research:

Source - Age and Ageing 2006 35(2):148-153; doi:10.1093/ageing/afj011

Title - Using dietetic assistants to improve the outcome of hip fracture: a randomised controlled trial of nutritional support in an acute trauma ward.

Authors - Duncan DG,  Beck SJ,  Hood K and Johansen A

Abstract -

 Objective - to examine how improved attention to nutritional status and dietary intake, achieved through the employment of dietetic assistants (DAs), will affect postoperative clinical outcome among elderly women with hip fracture.

 Design - open prospective randomised controlled trial, comparing conventional nursing care with the additional nutritional support provided by DA.

 Setting - thirty-eight bedded acute trauma ward in a teaching hospital.

 Participants - all but 11 of 344 consecutive admissions with acute nonpathological hip fracture were approached. Three hundred and eighteen (93%) agreed to inclusion. Sixteen were ineligible as they were immediately transferred to another acute ward, were managed conservatively or died preoperatively.

 Primary outcome measure - postoperative mortality in the acute trauma unit.

 Secondary outcome measures - postoperative mortality at 4 months after fracture, length of stay, energy intake and nutritional status.

 Results -  DA-supported participants were less likely to die in the acute ward (4.1 versus 10.1%, P = 0.048). This effect was still apparent at 4 month follow-up (13.1 versus 22.9%, P = 0.036). DA-supported subjects had significantly better mean daily energy intake (1,105 kcal versus 756 kcal/24 h, 95% CI 259–440 kcal/24 h, P<0.001), significantly smaller reduction in mid-arm circumference during their inpatient stay (0.39 cm, P = 0.002) and nonsignificantly favourable results for other anthropometric and laboratory measurements.

 Conclusion - Dietetic or nutrition assistants are being introduced in units across the UK. This, the largest ever study of nutritional support after hip fracture, shows that their employment significantly reduced patients’ risk of dying in the acute trauma unit; an effect that persisted at 4 month follow-up.

Links:

Abstract
Full article (PDF 108 KB)

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Note: Lack of time prevents me from "cutting and pasting" abstracts from and links to all 21 randomised controlled trials included in the Cochrane review, yet I don't want to write a biased post and present only one article (resource #3) with promising results.  Also, as the Cochrane reviewers noted:

"The quality of trial methodology, as reported, was disappointing. Many of the trials failed to report trial methodology in sufficient detail to give top scores on individual items. The impression that the scores for these studies more reflect the quality of reporting rather than trial methodology was strengthened by the changed, generally increased, scores of some items of eight studies upon gaining additional information from the trialists (Brown 1992; Bruce 2003; Day 1988; Espaulella 2000; Hankins 1996; Hartgrink 1998; Houwing 2003; Sullivan 1998)" (page 10).

So for now, I've added the review to my library and as time permits, will look at more of the individual studies, particularly those with high scores for methodology.