Closing the Osteoporotic-Fracture Care Gap for Frail Older Persons.

Aim To implement standardised fracture risk assessment in the frail older person. Methods Frail older patients underwent opportunistic screening for fracture risk. Roadblocks to standardised assessment were identified. An Integrated Care Team for older persons (ICT) trained in fracture risk assessment using FRAX. Clinical assessment was via a locally agreed algorithm. Data was entered onto Excel. The SQUIRE guidelines for quality improvement programmes were used to report the results. Results Of 96 patients opportunistically screened, the average age was 84 years. FRAX was completed for 19% (n=18). 89% (n=16) met the pharmacotherapy threshold. Nine were recommended pharmacotherapy. Of sixteen patients recommended for DXA, just 31% (n=5) were booked. Following implementation of a quality improvement project, 100 patients were assessed, and average age was 80 years. FRAX was completed for 62% (n=63) and 95% (n=60) required pharmacotherapy. 24% (n=14) had untreated prior fracture. All had pharmacotherapy prescribed. 59% (n=59) required DXA scanning. 70% (n=41) had DXA ordered. Conclusion ICT ownership increased FRAX assessment 3-fold and point of contact prescribing to 100%.

Fracture liaison service in a non-regional orthopaedic clinic--a cost-effective service.

Fracture liaison services (FLS) aim to provide cost-effective targeting of secondary fracture prevention. It is proposed that a dedicated FLS be available in any hospital to which a patient presents with a fracture. An existing orthopaedic clinic nurse was retrained to deliver a FLS. Proformas were used so that different nurses could assume the fracture liaison nurse (FLN) role, as required. Screening consisted of fracture risk estimation, phlebotomy and DXA scanning. 124 (11%) of all patients attending the orthopaedic fracture clinic were reviewed in the FLS. Upper limb fractures accounted for the majority of fragility fractures screened n=69 (55.6%). Two-thirds of patients (n=69) had reduced bone mineral density (BMD). An evidence based approach to both non-pharmacological and pharmacotherapy was used and most patients (76.6%) receiving pharmacotherapy received an oral bisphosphonate (n=46). The FLS has proven to be an effective way of delivering secondary prevention for osteoporotic fracture in a non-regional fracture clinic, without increasing staff costs.

How do patients in a rural setting respond to receiving a copy of their general practitioners letter?

The practice of sending copies of General Practitioners (GPs) letters to patients is not new. As a team in Geriatric and general internal medicine in a rural secondary referral hospital, we asked patients for feedback on how they felt about copies of their GPs letters being sent to them. 126 (96%) of patients were not frightened by the letter. 110(85%) would prefer to continue receiving these letters. Patients in a rural setting want to receive letters about their own medical care.

The use of fingernails as a means of assessing bone health: a pilot study.

BACKGROUND: Anecdotally, patients volunteer reports of increasing hardness of their fingernails within months of starting diverse treatments for osteoporosis. The properties of both nail and bone may be linked in a comparable, measurable way. METHODS: We examined the fingernails of two groups of patients, with (n = 9) and without (n = 13) osteoporosis at either the hip or lumbosacral spine. We performed nanoindentation to assess the degree of nail brittleness and Raman spectroscopy to assess the disulfide bond content of nail. RESULTS: The mean moduli of fingernails of patients with low bone mineral density (BMD) are lower than those of patients with normal BMD. The mean difference in mean modulus between the groups was found to be 0.996 (p = 0.15 between groups). The spectroscopy data also showed differences between the two sets of nails. The disulfide bond content of the nails sourced from osteoporotic patients was lower than that from healthy patients (p = 0.06 between groups). CONCLUSIONS: Bone collagen and nail keratin are two distinct structural proteins, and both require protein sulfation and disulfide bond formation, via cysteine, for structural integrity. A disorder of either process may lead to disordered collagen and keratin synthesis. This is reflected in the structural abnormalities seen in clinical syndromes in which there is either protein deficiency, disorders of sulfur metabolism, or cystathione beta-synthase deficiency. The relationship between nail and bone may exist in a measurable way. This pilot study should lead to further work to explore this relationship. Could nail prove to be a valuable adjunct to diagnosis or provide a means of more rapid follow-up after commencement of therapy?

Diffuse stromal Leydig cell hyperplasia: a unique cause of postmenopausal hyperandrogenism and virilization.

A 60-year-old woman presented with diffuse scalp alopecia, hirsutism, and clitorimegaly, and the mean serum testosterone levels were greater than 200 ng/dL. Findings on computed tomography of both adrenal glands were normal. After bilateral oophorectomy, a unique histological picture consisting of diffuse stromal Leydig cell hyperplasia was found. Reinke crystals were present, but neither hilus cell hyperplasia nor stromal hyperthecosis was noted. Sequencing of the 11 exons of the gene for the luteinizing hormone receptor revealed no abnormality. Relevant data suggest that treatment of the postmenopausal woman with hyperandrogenism and virilization is bilateral laparoscopic oophorectomy if she has no pronounced ovarian enlargement or adrenal tumor on imaging. In this setting, an intensive endocrine evaluation or a search for metastatic disease seems to be unnecessary.

Interleukin-1 gene polymorphism disease activity and bone mineral metabolism in rheumatoid arthritis.

OBJECTIVE: To determine whether interleukin-1 alpha and 1 beta gene polymorphism is associated with rheumatoid arthritis disease activity and bone mineral metabolism, and whether there is any relationship between IL-1 beta and rheumatoid arthritis (RA) motif gene. METHODS: IL-1 gene polymorphisms were analyzed in 65 RA patients who met American College of Radiology (ACR) criteria and 60 controls. From genomic DNA, 2 polymorphisms in each gene for IL1 alpha-889 and IL-1 beta + 3953 were typed by PCR-RFLP and HLA-DRB1 allele typing was also undertaken by PCR-SSOP. Some clinical and laboratory parameters were collected. The allelic frequencies and carriage rates were compared between RA patients and controls and between patients with active and quiescent disease. Comparison was also made between IL-1 polymorphism and parameters of bone mineral metabolism and between patients with the HLA-DRB1 RA motif plus IL-1 beta 2 and patients without the two alleles. Fisher test and the analysis of variance was used to analyze the data. RESULTS: There was no significant difference in the frequency and carriage rate of IL-1 alpha polymorphisms between RA patients and the controls. The beta 2/2 genotype of IL-1 beta was more common in female RA patients compared with controls (P = 0.001). A lower carriage rate of IL-1 beta 2 occurred in male RA patients (P = 0.001). A higher carriage rate of IL-1 alpha 2 is associated with a higher ESR (P = 0.008), HAQ score (P = 0.03), and vit-D3 (P < 0.001), but conversely a lower SJC (p = 0.002), a lower RF (P = 0.002) and a lower BMD at the lumbar spine (P = 0.001). A higher frequency of IL-1 alpha 1 is associated with a lower CRP value (P = 0.009). An increased IL-1 beta 2 carriage is associated with active rheumatoid disease as indicated by a higher CRP (P < 0.001), ESR (P < 0.001) and pain score (P = 0.001) and a higher BMD at the lumbar spine (P = 0.007), lower vit-D3 and. Udpd/Crea level The presence of the HLA DRB1 RA motif and IL-1 beta allele 2 at same time did not contribute to disease activity. CONCLUSION: Polymorphisms of the IL-beta gene may affect the RA occurrence. Carriage of IL-1 beta 2 polymorphisms is associated with more active disease in RA and the presence of both the IL-1 alpha 2 and the IL-1 beta 1 allele in RA influences bone resorption.

Telling the truth about cancer: views of elderly patients and their relatives.

The aim of this study was to compare the attitudes of elderly patients and their relatives towards telling the truth about cancer. 120 patients were asked if they would wish to be told about bad news, such as cancer, which might emerge during the admission. Matched relatives were asked if such information should be disclosed to the patient. Of the 120 patients, 99 (83%) wanted to be told the truth; 66 relatives (55%) relatives wanted their next of kin informed. There was agreement in 73 (61%) pairs. The kappa statistic was 0.16 (95% confidence interval -0.03 to 0.35), which indicates poor agreement. We conclude that most elderly people wish to be informed of a diagnosis of cancer. Patient preferences cannot be predicted by talking to relatives.

Preliminary work on the development of a novel detection method for osteoporosis.

Osteoporosis affects both the organic and mineral phases of bone resulting in a decrease in resistance to fracture. Dual x-ray absorptiometry (DEXA) scans are used for diagnosing osteoporosis, which is conventionally characterised by a decrease in mineral density. Unfortunately, some patients who suffer osteoporotic fractures have normal bone density, because both the organic and the mineral phase are affected. However, there are currently no methods of evaluating the health of the organic phase. Patients undergoing treatment for osteoporosis have reported hardening of their fingernails. As the properties of nail and bone may be linked in a comparable, measurable way, this work used both mechanical (nano-indentation) and chemical (Raman spectroscopy) methods to evaluate differences between fingernails sourced from osteoporotic and non-osteoporotic patients. The difference in mean modulus between the nails sourced from the groups was 1.1 GPa. The disulphide bond content of fingernail samples from each group was measured by Raman spectroscopy and disulphide bond content of fingernail was found to be significantly lower in the osteoporotic group. It can be concluded that a relationship between the mechanical and chemical properties of nail and bone may exist in a measurable way. This work has suggested that changes in the organic phase of bone are reflected in similar proteins, such as keratin, from which fingernails are composed. Collagen and keratin are two distinct structural proteins, but they share the need for protein sulphation and disulphide bond formation, via cysteine, for their structural integrity. A disorder of either process should lead to disordered collagen and keratin synthesis.

Diffuse cystic glandular malformation of the stomach associated with adenocarcinoma: Case report and review of the literature.

A 60-year-old man was found to have diffuse cystic glandular malformation and adenocarcinoma of the stomach. Review of the literature revealed one similar reported case and five others with diffuse heterotopic cystic malformation only. Clinically, the lesion is associated with gastrointestinal symptoms, and radiologically, it can mimic diffuse gastric carcinoma, lymphoma, and polyposis.

Delirium in newly admitted elderly patients: a prospective study.

The prevalence, associated conditions and outcome of delirium were studied in a consecutive series of 184 patients admitted with acute illness to a department of health care of the elderly. Forty of these elderly subjects (22 per cent) met Diagnostic and Statistical Manual version 3 (revised) criteria for delirium. Screening for delirious patients using the abbreviated mental test on admission gave a high sensitivity (92 per cent). The conditions most commonly associated with delirium were infection and stroke. Onset of acute illness of less than 15 days, a reported history of dementia or recent confusion, and presence of a definite site of infection were much more likely in those with delirium. Serial use of the abbreviated mental test was a sensitive means of distinguishing delirious from other patients and may be useful in both the clinical and research setting. Delirious patients had more serious pre-existing disease than non-delirious patients. They had a higher number of admissions during the 2 years prior to the index admission, a higher mortality rate and a higher rate of transfer to long-stay care than other patients, but no difference in duration of admission. All acutely ill elderly people should undergo an abbreviated mental test on admission, and if abnormal, this should be repeated as it will aid detection of delirium.

In vivo and in vitro serine/threonine phosphorylations of epidermal growth factor receptor upon entry into the cell cycle.

Protein phosphorylation and dephosphorylation is one of the main mechanisms of cell cycle regulation. This study examines the modulation of epidermal growth factor receptor phosphorylation as cells emerge from quiescence and enter the S phase of the cell cycle. The epidermal growth factor receptor is phosphorylated primarily on serine and threonine, but not on tyrosine residues, in an S phase-dependent fashion, as determined by phosphoamino acid analysis and anti-phosphotyrosine immunoblotting. These phosphorylations occur both in vitro and in vivo and are ligand independent. Some of the sites that are phosphorylated in vitro also appear to be phosphorylated in vivo, as determined by two-dimensional tryptic phosphopeptide analysis. At least one of the in vivo phosphorylation sites is phosphorylated by mitogen-activated protein kinase. Although the mechanism for this ligand-independent phosphorylation is not known, its correlation with emergence from quiescence and entry into the cell cycle suggests that the phosphorylation of epidermal growth factor receptor on serine and threonine residues may have heretofore unknown role(s) in cell cycle entry and progression.

The abbreviated mental test: its use and validity.

The validity of the Abbreviated Mental Test was demonstrated by comparison with final clinical diagnoses in a consecutive sample of 168 patients admitted with acute illness to a department of health care of the elderly. Fifty-eight (34%) had abnormal cognition. The best cut-off point was 8, with less than 8 suggesting abnormal cognitive function. A short version (the AMT7) of the AMT was developed. Its validity, internal consistency and coverage of domains was equivalent to the AMT but it had a slightly higher sensitivity (with acceptable specificity) than the original. This new short version may improve performance of junior doctors in clinical practice who appear to have difficulty remembering all 10 items of the AMT.

Complete Release of Axillary Buds from Apical Dominance in Intact, Light-Grown Seedlings of Pisum sativum L. following a Single Application of Cytokinin.

Single applications of either 6-benzyladenine or zeatin to inhibited axillary buds of intact, light-grown seedlings of Pisum sativum L. cv Black-eyed Susan, resulted in the formation of rapidly elongating, leafy shoots. Similar treatment with kinetin or isopentenyladenine caused only limited but outgrowth which stopped 6 days after application.

Radicicol inhibits tyrosine phosphorylation of the mitotic Src substrate Sam68 and retards subsequent exit from mitosis of Src-transformed cells.

Sam68 (Src-associated in mitosis 68 kDa) is a protein that associates with and is tyrosine phosphorylated by Src in a mitosis-specific manner, thereby raising the possibility of a role for Src in the regulation of the cell cycle. This study examines the effects of radicicol, a Src tyrosine kinase inhibitor, upon both the phosphorylation of Sam68 and mitotic progression in Src-transformed mouse fibroblasts. Radicicol reversibly inhibits the mitosis-specific tyrosine phosphorylation of Sam68 in vivo, as determined by antiphosphotyrosine immunoblotting. Radicicol inhibits the tyrosine phosphorylation of both free and Src-associated Sam68, suggesting the presence of two intracellular pools of tyrosine phosphorylated Sam68 in mitotic cells. In addition, radicicol treatment has no effect on the ability of cells to enter mitosis, indicating that tyrosine phosphorylation of Sam68 is probably not important for cells to enter mitosis. However, radicicol reversibly retards the exit of cells from mitosis, as determined by flow cytometric analyses. Radicicol mediated inhibition of Sam68 tyrosine phosphorylation, and its concurrent ability to block mitotic exit suggests the possibility of a significant role for Src kinase and this unique mitotic substrate, Sam68, in cell cycle regulation.