Vertebral Scheuermann's disease in Europe: prevalence, geographic variation and radiological correlates in men and women aged 50 and over.

UNLABELLED: In 27 centres across Europe, the prevalence of deforming spinal Scheuermann's disease in age-stratified population-based samples of over 10,000 men and women aged 50+ averaged 8% in each sex, but was highly variable between centres. Low DXA BMD was un-associated with Scheuermann's, helping the differential diagnosis from osteoporosis. INTRODUCTION: This study aims to assess the prevalence of Scheuermann's disease of the spine across Europe in men and women over 50 years of age, to quantitate its association with bone mineral density (BMD) and to assess its role as a confounder for the radiographic diagnosis of osteoporotic fracture. METHODS: In 27 centres participating in the population-based European Vertebral Osteoporosis Study (EVOS), standardised lateral radiographs of the lumbar and of the thoracic spine from T4 to L4 were assessed in all those of adequate quality. The presence of Scheuermann's disease, a confounder for prevalent fracture in later life, was defined by the presence of at least one Schmorl's node or irregular endplate together with kyphosis (sagittal Cobb angle >40° between T4 and T12) or a wedged-shaped vertebral body. Alternatively, the (rare) Edgren-Vaino sign was taken as diagnostic. The 6-point-per-vertebral-body (13 vertebrae) method was used to assess osteoporotic vertebral shape and fracture caseness. DXA BMD of the L2-L4 and femoral neck regions was measured in subsets. We also assessed the presence of Scheuermann's by alternative published algorithms when these used the radiographic signs we assessed. RESULTS: Vertebral radiographic images from 4486 men and 5655 women passed all quality checks. Prevalence of Scheuermann's varied considerably between centres, and based on random effect modelling, the overall European prevalence using our method was 8% with no significant difference between sexes. The highest prevalences were seen in Germany, Sweden, the UK and France and low prevalences were seen in Hungary, Poland and Slovakia. Centre-level prevalences in men and women were highly correlated. Scheuermann's was not associated with BMD of the spine or hip. CONCLUSIONS: Since most of the variation in population impact of Scheuermann's was unaccounted for by the radiological and anthropometric data, the search for new genetic and environmental determinants of this disease is encouraged.

Prevention of Falls Network Europe: a thematic network aimed at introducing good practice in effective falls prevention across Europe. Four years on.

ProFaNE, Prevention of Falls Network Europe, is a four-year thematic network co-ordinated by the University of Manchester, UK, with 25 partners across Europe and funded by the European Community Framework 5. There are also Network Associates from a number of EU and non-EU countries who give their advice and experience at steering meetings, seminars and conferences. There are four main themes (taxonomy and co-ordination of trials; clinical assessment and management of falls; assessment of balance function; psychological aspects of falling). The work of ProFaNE is practical, in terms of developing the evidence base for implementation of effective interventions, standardising the health processes for people with a history of falls and encouraging best practice across Europe. Over the four years of the Network many key publications by the members have been regularly cited, the web membership has increased to over 2,000 members from 30 countries, there is an active discussion board and there are nearly 1,000 resources available to download. The success of the networking and relationship building in these four years has meant that many countries have adopted new national strategies to prevent falls and injuries.

Low BMD is less predictive than reported falls for future limb fractures in women across Europe: results from the European Prospective Osteoporosis Study.

We have previously shown that center- and sex-specific fall rates explained one-third of between-center variation in upper limb fractures across Europe. In this current analysis, our aim was to determine how much of the between-center variation in fractures could be attributed to repeated falling, bone mineral density (BMD), and other risk factors in individuals, and to compare the relative contributions of center-specific BMD vs. center-specific fall rates. A clinical history of fracture was assessed prospectively in 2451 men and 2919 women aged 50-80 from 20 centers participating in the European Prospective Osteoporosis Study (EPOS) using standardized questionnaires (mean follow-up = 3 years). Bone mineral density (BMD, femoral neck, trochanter, and/or spine) was measured in 2103 men and 2565 women at these centers. Cox regression was used to model the risk of incident fracture as a function of the person-specific covariates: age, BMD, personal fracture history (PFH), family hip fracture history (FAMHIP), time spent walking/cycling, number of 'all falls' and falls not causing fracture ('fracture-free') during follow-up, alcohol consumption, and body mass index. Center effects were modeled by inclusion of multiplicative gamma-distributed random effects, termed center-shared frailty (CSF), with mean 1 and finite variance theta (theta) acting on the hazard rate. The relative contributions of center-specific fall risk and center-specific BMD on the incidence of limb fractures were evaluated as components of CSF. In women, the risk of any incident nonspine fracture (n = 190) increased with age, PFH, FAMHIP, > or =1 h/day walking/cycling, and number of 'all falls' during follow-up (all P < 0.074). 'Fracture-free' falls (P = 0.726) and femoral neck BMD did not have a significant effect at the individual level, but there was a significant center-shared frailty effect (theta = 0.271, P = 0.001) that was reduced by 4% after adjusting for mean center BMD and reduced by 19% when adjusted for mean center fall rate. Femoral trochanter BMD was a significant determinant of lower limb fractures (n = 53, P = 0.014) and the center-shared frailty effect was significant for upper limb fractures (theta = 0.271, P = 0.011). This upper limb fracture center effect was unchanged after adjusting for mean center BMD but was reduced by 36% after adjusting for center mean fall rates. In men, risk of any nonspine fracture (n = 75) increased with PFH, fall during follow-up (P < 0.026), and with a decrease in trochanteric BMD [RR 1.38 (1.08, 1.79) per 1 SD decrease]. There was no center effect evident (theta = 0.081, P = 0.096). We conclude that BMD alone cannot be validly used to discriminate between the risk of upper limb fractures across populations without taking account of population-specific variations in fall risk and other factors. These variations might reflect shared environmental or possibly genetic factors that contribute quite substantially to the risk of upper limb fractures in women.

Determinants of the size of incident vertebral deformities in European men and women in the sixth to ninth decades of age: the European Prospective Osteoporosis Study (EPOS).

UNLABELLED: More severe vertebral fractures have more personal impact. In the European Prospective Osteoporosis Study, more severe vertebral collapse was predictable from prior fracture characteristics. Subjects with bi-concave or crush fractures at baseline had a 2-fold increase in incident fracture size and thus increased risk of a disabling future fracture. INTRODUCTION: According to Euler's buckling theory, loss of horizontal trabeculae in vertebrae increases the risk of fracture and suggests that the extent of vertebral collapse will be increased in proportion. We tested the hypothesis that the characteristics of a baseline deformity would influence the size of a subsequent deformity. METHODS: In 207 subjects participating in the European Prospective Osteoporosis Study who suffered an incident spine fracture in a previously normal vertebra, we estimated loss of volume (fracture size) from plane film images of all vertebral bodies that were classified as having a new fracture. The sum of the three vertebral heights (anterior, mid-body, and posterior) obtained at follow-up was subtracted from the sum of the same measures at baseline. Each of the summed height loss for vertebrae with a McCloskey-Kanis deformity on the second film was expressed as a percentage. RESULTS AND CONCLUSIONS: In univariate models, the numbers of baseline deformities and the clinical category of the most severe baseline deformity were each significantly associated with the size of the most severe incident fracture and with the cumulated sum of all vertebral height losses. In multivariate modeling, age and the clinical category of the baseline deformity (crush > bi-concave > uni-concave > wedge) were the strongest determinants of both more severe and cumulative height loss. Baseline biconcave and crush fractures were associated at follow-up with new fractures that were approximately twice as large as those seen with other types of deformity or who previously had undeformed spines. In conclusion, the characteristics of a baseline vertebral deformity determines statistically the magnitude of vertebral body volume lost when a subsequent fracture occurs. Because severity of fracture and number of fractures are determinants of impact, the results should improve prediction of the future personal impact of osteoporosis once a baseline prevalent deformity has been identified.

Incidence of vertebral fracture in europe: results from the European Prospective Osteoporosis Study (EPOS).

Vertebral fracture is one of the major adverse clinical consequences of osteoporosis; however, there are few data concerning the incidence of vertebral fracture in population samples of men and women. The aim of this study was to determine the incidence of vertebral fracture in European men and women. A total of 14,011 men and women aged 50 years and over were recruited from population-based registers in 29 European centers and had an interviewer-administered questionnaire and lateral spinal radiographs performed. The response rate for participation in the study was approximately 50%. Repeat spinal radiographs were performed a mean of 3.8 years following the baseline film. All films were evaluated morphometrically. The definition of a morphometric fracture was a vertebra in which there was evidence of a 20% (+4 mm) or more reduction in anterior, middle, or posterior vertebral height between films--plus the additional requirement that a vertebra satisfy criteria for a prevalent deformity (using the McCloskey-Kanis method) in the follow-up film. There were 3174 men, mean age 63.1 years, and 3,614 women, mean age 62.2 years, with paired duplicate spinal radiographs (48% of those originally recruited to the baseline survey). The age standardized incidence of morphometric fracture was 10.7/1,000 person years (pyr) in women and 5.7/1,000 pyr in men. The age-standardized incidence of vertebral fracture as assessed qualitatively by the radiologist was broadly similar-12.1/1,000 pyr and 6.8/1,000 pyr, respectively. The incidence increased markedly with age in both men and women. There was some evidence of geographic variation in fracture occurrence; rates were higher in Sweden than elsewhere in Europe. This is the first large population-based study to ascertain the incidence of vertebral fracture in men and women over 50 years of age across Europe. The data confirm the frequent occurrence of the disorder in men as well as in women and the rise in incidence with age.

Cerebral dysfunction after cardiac operations in elderly patients.

BACKGROUND: Cerebral injury remains a significant complication of cardiac operations. We determined the incidence of cerebral dysfunction in a population of elderly patients undergoing open chamber cardiac operations (group 1) as compared with a younger population (group 2) and an age-matched group of elderly patients undergoing major noncardiac operations (group 3). METHODS: Sixty-eight patients (55 for open chamber cardiac operations and 13 for noncardiac operations) were prospectively studied. Patients were evaluated preoperatively and postoperatively before hospital discharge using a complete neurologic examination and a battery of standard neuropsychometric tests, and at surgical follow-up with neuropsychometric tests only. RESULTS: Postoperative changes detected by neurologic examination consisted of the appearance of new primitive reflexes in all groups. No statistically significant differences in incidence were found. The neuropsychometric performance of group 1 patients was statistically different from that of patients in groups 2 and 3 only in the early follow-up period. CONCLUSIONS: Elderly patients having open chamber cardiac operations exhibit significantly more cerebral dysfunction in the early postoperative period than those undergoing major noncardiac operations and younger patients after open chamber procedures. These changes do not persist into the late follow-up period.

Reduction in the incidence of suicide: a health gain objective for the NHS.

Much emphasis is currently being placed on the identification of possible areas of improvement concerning the health of individuals, and therefore, the general population. One health-gain objective under consideration for severe mental illness is the reduction of mortality from suicide. During 1990, 3950 people are known to have taken their own lives in England and Wales and a further 1996 deaths are likely to have been suicides. Although suicide accounts for < 1% of all deaths in the general population, in the 15-44 age group about 10% of deaths are from suicide. It is envisaged that reducing suicide rates will be achieved through the setting of specific national and local targets. This type of approach dictates explicit requirements in outcome, which clearly has implications for the shape of the National Health Service. One problem with using recorded rates of suicide is that suicide is a medico-legal verdict and its use by coroners is influenced by a number of factors. Thus, before rates of suicide can be accepted as indicators of the effectiveness of health services, the validity of the statistics being gathered must be scrutinized. Moreover, the relatively small number of cases that occur each year means that statistical analysis of the data obtained from small areas, such as district health authorities, may be problematic.

Role ambiguity in general practice: the care of patients dying at home.

Semi-structured interviews were given to 22 GPs to investigate their perceptions and strategies when dealing with dying patients. There seemed no clear division in practice between policies of telling and not telling patients about their illness. Most patients find out eventually, but GPs differ in the extent to which they aim for open discussions of the matter. Over half perceived care of the dying as a demanding but satisfying fulfillment of their professional skills, but nearly a quarter found it difficult and with few compensating rewards. We conclude that while there is a well established ideal type corresponding to the curative role, there is another which is still in the process of development. This type generates a role for doctors which parallels the patient's dying role, as distinct from the sick role.

KIE: Twenty-two British general practitioners were given semi-structured interviews to investigate their perceptions and strategies when dealing with dying patients. On the question of telling patients about the nature of their illnesses, there appeared to be a continuum, rather than a dichotomy, of practice--most patients learn the information eventually, but physicians differ in the extent to which they aim for open discussion of the issue. Over half of the physicians perceived terminal care to be a demanding but satisfying fulfillment of their professional skills. Nearly a quarter, however, found it both difficult and unrewarding. The authors suggest that such physicians are guided by only a curative role model and have not yet succeeded in internalizing a developing role model for dealing with dying patients.

Communication between general practitioners and patients dying at home.

Semi-structured interviews were carried out with four general practitioners and some of their terminally ill patients in order to investigate how doctors solve the problem of communication with these patients about the outcome of the illness. Three of the doctors preferred not to give explicit information, or to talk about the outcome, even when they knew that the patient realised that he or she was dying. Within this constraint they developed different ways of coping with the problem of how to talk to the patient. We interpret this behaviour as an attempt to remain within the framework of rules and expectations provided by the traditional roles of doctor and patient, a framework that would be threatened by the doctor's acknowledgement of helplessness. The fourth doctor did tell his patients, and treated the problem as one of counselling patients to help them cope with their predicament. His role of healer was thus extended to include terminally ill patients.

KIE: Two psychologists present excerpts from and discuss semi-structured interviews they conducted with four Durham, England, general practitioners and several of their terminally ill patients. The object of the study was to investigate the ways in which physicians perceive and express the problems of communicating with their dying patients, and how their patients perceive these communications. Three of the doctors prefer not to reveal diagnosis and prognosis explicitly in terminal illness even in cases where they are aware that the patients realize their condition. Each has developed a strategy of relationship that conceals physician helplessness and supports hope. The fourth doctor actively elicits questions and assumes a counseling role in helping his patients deal with impending death.

Place of death and access to home care services: are certain patient groups at a disadvantage?

Research indicates that fewer people are able to die at home than would wish to do so. Furthermore the ability to die at home is unequally distributed depending on patient characteristics. Unless factors associated with home deaths are identified and interventions are targeted accordingly, further general improvements in care support may only help those already at an advantage. This paper reviews research investigating the relation between patient characteristics and home deaths and considers whether these variables influence place of death because they are associated with differential access to services, focusing on access to palliative home care. Patients with informal carer support were both more likely to die at home and to access palliative home care. Provision of home care did not remove the dependence on informal carers in achieving home death, however. An important target in improving home death rates is therefore better support for informal carers overall. Older patients were both less likely to die at home and to access home care. Once in home care they no longer were less likely to die at home. Although age related needs require consideration, improved access to home care is therefore likely to increase home deaths for older people. Women were less likely to die at home than men, yet younger women may be more likely to access home care. There is some evidence to suggest that men were less efficient as carers, which may help explain why women were less likely to achieve home deaths, while making their referral to home care more likely. While home care may help redress the gender imbalance, men may also need to be encouraged and enabled to take on the carer role. Cancer patients in higher socioeconomic groups were both more likely to die at home and to access home care. Hence home deaths may increase by improving access for lower socioeconomic groups to the services available.

Epidemiology of duodenal ulcer perforation: a study on hospital admissions in Norfolk, United Kingdom.

BACKGROUND: Studies on the incidence of perforated duodenal ulcer are limited and in the United Kingdom, data are largely based on findings observed over two decades ago. To provide updated epidemiological data on duodenal ulcer perforation, the incidence of the disease in Norfolk, United Kingdom was determined. METHODOLOGY: Medical records of patients with duodenal ulcer perforation were reviewed to confirm the diagnosis and obtain information on possible risk factors, namely, Helicobacter pylori infection, smoking and intake of non-steroidal anti-inflammatory drugs. The patients were admitted between 1 January 1996 and 31 December 1998, and were residents of Norfolk, United Kingdom. RESULTS: Sixty-eight cases of duodenal ulcer perforation were identified, 36 (52.9%) were males and 32 (47.1%) were females. The age-standardised incidence rate was 3.77 per 100,000 population per year (95% confidence interval 3.72-3.83). The mean age upon admission for all cases was 72.3 years (standard deviation: 17.8). The mean age for males was 67.7 years (standard deviation: 19.4) and for females 77.6 years (standard deviation: 15.7), which differed significantly (difference in means: 9.9, 95% confidence interval 1.5-18.3). There were 29 deaths (42.7%), of which 19 were females. After adjustment for covariates, the odds ratio of mortality in women was 4.57 (95% confidence interval 1.28-16.29). There were 25 (36.8%) smokers and 22 (32.4%) patients were non-steroidal anti-inflammatory drug users. Helicobacter pylori infection was assessed in only 14 (20.6%) patients; 2 were positive, 3 were negative, and in the rest the results were unrecorded. CONCLUSIONS: The incidence rates were lower compared to previous studies in the United Kingdom conducted in the 1960's and 1980's, which could reflect either improved health care or decreasing exposure to known risk factors. Furthermore, the difference in age distribution of incident cases between males and females may explain the higher mortality in females.

Developing the Cambridge palliative audit schedule (CAMPAS): a palliative care audit for primary health care teams.

BACKGROUND: Problems with the provision of palliative care have been reported. Audit is one means of improving care. Earlier audits of primary care palliative care have been initiated by general practitioners (GPs) and are predominantly retrospective record reviews. Widely applicable methods for the audit of primary care palliative care do not exist. AIM: To develop relevant palliative care standards and to devise an audit schedule (the Cambridge palliative audit schedule, CAMPAS) suitable for monitoring palliative care in diverse primary care settings. METHOD: Primary health care team (PHCT) members collaborated at all stages. Reasonable outcomes and acceptable interventions for PHCTs were identified and standards developed. Each standard was constructed to ensure uniform interpretation, and CAMPAS was structured to collect data necessary for determining whether the standards were met. RESULTS: Over 50% of PHCTs (n = 20) in the health district were recruited and trained to use CAMPAS. A total of 876 contacts with 29 patients was recorded by PHCTs using CAMPAS. Considerable inter- and intra-PHCT variation was found in the achievement of the standards. CONCLUSIONS: The favourable participation rate suggests commitment to audit and improvement in patient care. Overall, the standards were reported to be suitable. Although 100% achievement of some standards may be unrealistic, the level of attainment for many suggests that it is possible. CAMPAS has been reported to be a useful structure for recording assessments and monitoring care, as well as a usable audit schedule. As an audit tool, it identified areas in need of improvement and facilitated feed-back to participants. Future audit is required to determine whether improvements in care have been effected.

Team midwifery: the views and job satisfaction of midwives.

OBJECTIVE: As part of an evaluation of a team midwifery scheme we assessed the satisfaction of community and hospital midwives and their views about working practices and care provided. DESIGN: Survey of complete enumeration of community midwives (most working in teams) and hospital midwives providing antenatal, intrapartum and postnatal care to a population of women. SETTING: Community and district general hospital, in the UK. MEASUREMENTS: Socio-demographic data about midwives, ratings on Likert-type scales of job satisfaction, quality of care variables, relationships with other professionals and women; Glasgow Midwifery Process Questionnaire. FINDINGS: 80 out of 92 midwives (87%) responded. Community midwives were younger, more recently qualified, employed on lower grades, less likely to be married and have children than hospital midwives. The Glasgow Midwifery Process Questionnaire revealed that midwives, particularly hospital midwives, had low morale. Community midwives were more likely to report that their job was satisfying, offered a variety of work, enabled them to use skills and knowledge fully, and offered opportunities for professional development. Hospital midwives were more likely to report following strict guidelines. Community midwives, however, disliked the long on call and unsociable hours, and reported disruption to family/social life. Forty-one per cent of hospital midwives (12) and 28% of community midwives (14) reported regularly working beyond their shift. Whilst midwives thought that team midwifery was, in theory, a good idea, in practice it was not working well because of the size of teams and caseload. About half the community midwives felt that teams had detrimentally affected the quality and continuity of care. CONCLUSIONS: Whilst team midwifery aims to improve continuity of maternity care, in this instance, it does not appear to achieve this aim. Many midwives reported it had adversely affected care. Team midwifery is a source of disillusionment for midwives, since the continuity of carer ideal is unachievable in a system based on teams of seven or more. Attendance at the delivery may be a luxury provided at the expense of antenatal and postnatal continuity. IMPLICATIONS: Midwives recommended remedial measures: reducing team sizes, reducing caseloads, ensuring teams were fully staffed, reducing 'on call' and labour ward hours. It remains to be seen whether these will have the desired effects on continuity of care.

Does hospital at home for palliative care facilitate death at home? Randomised controlled trial.

OBJECTIVE: To evaluate the impact on place of death of a hospital at home service for palliative care. DESIGN: Pragmatic randomised controlled trial. SETTING: Former Cambridge health district. PARTICIPANTS: 229 patients referred to the hospital at home service; 43 randomised to control group (standard care), 186 randomised to hospital at home. INTERVENTION: Hospital at home versus standard care. MAIN OUTCOME MEASURES: Place of death. RESULTS: Twenty five (58%) control patients died at home compared with 124 (67%) patients allocated to hospital at home. This difference was not significant; intention to treat analysis did not show that hospital at home increased the number of deaths at home. Seventy three patients randomised to hospital at home were not admitted to the service. Patients admitted to hospital at home were significantly more likely to die at home (88/113; 78%) than control patients. It is not possible to determine whether this was due to hospital at home itself or other characteristics of the patients admitted to the service. The study attained less statistical power than initially planned. CONCLUSION: In a locality with good provision of standard community care we could not show that hospital at home allowed more patients to die at home, although neither does the study refute this. Problems relating to recruitment, attrition, and the vulnerability of the patient group make randomised controlled trials in palliative care difficult. While these difficulties have to be recognised they are not insurmountable with the appropriate resourcing and setting.

Differences in mortality after fracture of hip: the east Anglian audit.

OBJECTIVE: To investigate differences between hospitals in clinical management of patients admitted with fractured hip and to relate these to mortality at 90 days. DESIGN: A prospective audit of process and outcome of care based on interviews with patients, abstraction from records with standard proforma, and follow up at three months. Data were analysed with chi 2 test and forward stepwise regression modelling of mortality. SETTING: All eight hospitals in East Anglia with trauma orthopaedic departments. PATIENTS: 580 consecutive patients admitted for fracture of neck of femur. MAIN OUTCOME MEASURE: Mortality at 90 days. RESULTS: Patients admitted to each hospital were similar with respect to age, sex, pre-existing illnesses, and activities of daily living before fracture. In all, 560 (97%) were treated surgically, by a range of grades of surgeon. Two hundred and sixty one patients (45%; range between hospitals 10-91%) received pharmaceutical thromboembolic prophylaxis, 502 (93%; 81-99%) perioperative antibiotic prophylaxis. The incidence of fatal pulmonary emboli differed between patients who received and those who did not receive prophylaxis against deep vein thrombosis (P = 0.001). Mortality at 90 days was 18%, differing significantly between hospitals (5-24%). One hospital had significantly better survival than the others (odds ratio 0.14; 95% confidence interval 0.04-0.48; P = 0.0016). CONCLUSIONS: No single factor or aspect of practice accounted for this protective effect. Lower mortality may be associated with the cumulative effects of several aspects of the organisation of treatment and the management of fracture of the hip, including thromboembolic pharmaceutical prophylaxis, antibiotic prophylaxis, and early mobilisation.

[The German version of the Falls Efficacy Scale-International Version (FES-I)]. / Die Deutsche Version der Falls Efficacy Scale-International Version (FES-I).

The German version of the Falls Efficacy Scale-International Version (FES-I), which is presented, was developed for the documentation of fall-related selfefficacy in older persons by a EU-funded expert network (Prevention of Falls Network Europe ProFaNE). The FES-I represents a modification of the original Falls Efficacy Scale (FES), including additional items on complex functional performances and social aspects of falls. The FES-I shows high internal reliability (Cronbach's alpha = 0.96) as well as high test-retest reliability (r=0.96). The mean inter-item correlation was: r = 0.55 (Range r = 0.29-0.79). Results of validation studies for the FES-I in community dwelling older persons for different European countries and geriatric patients with cognitive impairment will be published in the near future.

Whom to treat? The contribution of vertebral X-rays to risk-based algorithms for fracture prediction. Results from the European Prospective Osteoporosis Study.

INTRODUCTION: Vertebral fracture is a strong risk factor for future spine and hip fractures; yet recent data suggest that only 5-20% of subjects with a spine fracture are identified in primary care. We aimed to develop easily applicable algorithms predicting a high risk of future spine fracture in men and women over 50 years of age. METHODS: Data was analysed from 5,561 men and women aged 50+ years participating in the European Prospective Osteoporosis Study (EPOS). Lateral thoracic and lumbar spine radiographs were taken at baseline and at an average of 3.8 years later. These were evaluated by an experienced radiologist. The risk of a new (incident) vertebral fracture was modelled as a function of age, number of prevalent vertebral fractures, height loss, sex and other fracture history reported by the subject, including limb fractures occurring between X-rays. Receiver Operating Characteristic (ROC) curves were used to compare the predictive ability of models. RESULTS: In a negative binomial regression model without baseline X-ray data, the risk of incident vertebral fracture significantly increased with age [RR 1.74, 95% CI (1.44, 2.10) per decade], height loss [1.08 (1.04, 1.12) per cm decrease], female sex [1.48 (1.05, 2.09)], and recalled fracture history; [1.65 (1.15, 2.38) to 3.03 (1.66, 5.54)] according to fracture site. Baseline radiological assessment of prevalent vertebral fracture significantly improved the areas subtended by ROC curves from 0.71 (0.67, 0.74) to 0.74 (0.70, 0.77) P=0.013 for predicting 1+ incident fracture; and from 0.74 (0.67, 0.81) to 0.83 (0.76, 0.90) P=0.001 for 2+ incident fractures. Age, sex and height loss remained independently predictive. The relative risk of a new vertebral fracture increased with the number of prevalent vertebral fractures present from 3.08 (2.10, 4.52) for 1 fracture to 9.36 (5.72, 15.32) for 3+. At a specificity of 90%, the model including X-ray data improved the sensitivity for predicting 2+ and 1+ incident fractures by 6 and 4 fold respectively compared with random guessing. At 75% specificity the improvements were 3.2 and 2.4 fold respectively. With the modelling restricted to the subjects who had BMD measurements (n=2,409), the AUC for predicting 1+ vs. 0 incident vertebral fractures improved from 0.72 (0.66, 0.79) to 0.76 (0.71, 0.82) upon adding femoral neck BMD (P=0.010). CONCLUSION: We conclude that for those with existing vertebral fractures, an accurately read spine X-ray will form a central component in future algorithms for targeting treatment, especially to the most vulnerable. The sensitivity of this approach to identifying vertebral fracture cases requiring anti-osteoporosis treatment, even when X-rays are ordered highly selectively, exceeds by a large margin the current standard of practice as recorded anywhere in the world.

The 'right kind' of pain: talking about symptoms in outpatient oncology consultations.

Despite improvements in cancer management over the past 25 years, unrelieved symptoms continue to be reported. Little is known about how patients' problems and concerns are communicated to professionals during oncology treatment. This qualitative study investigates the process of communication between cancer patients and oncologists during consultations in outpatient clinics of a regional teaching hospital. Data were collected by nonparticipant observation and audiotaping consultations. Analyses were by qualitative content analysis and conversation analysis. An objectives, strategies and tactics model was applied to organize the findings. Seventy-four consultations between cancer patients and 15 doctors were observed and audiotaped. Pain talk is defined and identified as a substantial topic, occurring in 39 out of 74 consultations. Doctor-initiated questions are the predominant discourse feature and are prominent not only in initiating discussions but also in directing further talk (e.g. over three-quarters of doctor-initiated questions are in a closed form which focus narrowly on limited physical aspects of patients' pain). This limited information exchange is used alongside other communication tactics to identify the 'right kind' of pain that may benefit from cancer therapy and to truncate talk of problems perceived to be outside of this specialist remit. Although individualized, holistic care is the expressed philosophy of the clinic, our data show that doctors tightly control the agenda to focus narrowly on pain which was amenable to radiotherapy, chemotherapy, surgery or hormone manipulation. Inadequate exploration of patients' pain is likely to be detrimental to symptom control.