Post-Fracture Care Program: Pharmacological Treatment of Osteoporosis in Older Adults with Fragility Fractures.

PURPOSE OF REVIEW: To present and discuss the recently published scientific evidence on the approach, mode of action, and timing of osteoporosis therapy initiation after fragility fractures. RECENT FINDINGS: A comprehensive management approach is required to reduce mortality and morbidity associated with fragility fractures. This will help to reduce the risk of missing the diagnosis of osteoporosis as the underlying disorder while at the same time promoting the timely treatment of osteoporosis. The target is to minimize the incidence of post-traumatic disability and to reduce the imminent fracture risk. This article will present a Bone-Care algorithm for the diagnosis and management of fragility fractures in patients presenting for trauma surgery. This algorithm has been developed based on recently published national as well as international guidelines for implementation in standard clinical practice. International figures revealed that only a small proportion of those patients at high risk of sustaining a fragility fracture receive osteoporosis therapy. Based on the best currently available evidence, it is safe to start osteoporosis therapy in the acute post-fracture period (the optimal therapeutic window of romosozumab is the late endochondral phase/throughout bone remodeling). The right Bone-Care pathway ensures the delivery of a comprehensive management approach that meets the global call to action. All parameters including risk, benefit, compliance, and cost should be considered on an individual base for all kinds of therapy.

FRAX: re-adjust or re-think.

Since its development in 2008, FRAX has booked its place in the standard day to day management of osteoporosis. The FRAX tool has been appreciated for its simplicity and applicability for use in primary care, but criticised for the same reason, as it does not take into account exposure response. To address some of these limitations, relatively simple arithmetic procedures have been proposed to be applied to the conventional FRAX estimates of hip and major fracture probabilities aiming at adjustment of the probability assessment. However, as the list of these adjustments got longer, this has reflected on its implementation in the standard practice and gave FRAX a patchy look. Consequently, raises the need to re-think of the current FRAX and whether a second generation of the tool is required to address the perceived limitations of the original FRAX. This article will discuss both point of views of re-adjustment and re-thinking.

Development and initial validation of a composite disease activity score for systemic juvenile idiopathic arthritis.

OBJECTIVE: To develop a composite disease activity score for systemic JIA (sJIA) and to provide preliminary evidence of its validity. METHODS: The systemic Juvenile Arthritis Disease Activity Score (sJADAS) was constructed by adding to the four items of the original JADAS a fifth item that aimed to quantify the activity of systemic features. Validation analyses were conducted on patients with definite or probable/possible sJIA enrolled at first visit or at the time of a flare, who had active systemic manifestations, which should include fever. Patients were reassessed 2 weeks to 3 months after baseline. Three versions were examined, including ESR, CRP or no acute-phase reactant. RESULTS: A total of 163 patients were included at 30 centres in 10 countries. The sJADAS was found to be feasible and to possess face and content validity, good construct validity, satisfactory internal consistency (Cronbach's alpha 0.64-0.65), fair ability to discriminate between patients with different disease activity states and between those whose parents were satisfied or not satisfied with illness outcome (P < 0.0001 for both), and strong responsiveness to change over time (standardized response mean 2.04-2.58). Overall, these properties were found to be better than those of the original JADAS and of DAS for RA and of Puchot score for adult-onset Still's disease. CONCLUSION: The sJADAS showed good measurement properties and is therefore a valid instrument for the assessment of disease activity in children with sJIA. The performance of the new tool should be further examined in other patient cohorts that are evaluated prospectively.

Tackling comorbidity associated with rheumatic diseases in standard practice.

In spite of the dramatic improvement of the long-term prognosis of inflammatory arthritic conditions, patients living with arthritis remain more likely to have a shorter lifespan in contrast to the age-matched population without arthritis. This high incidence of morbidity-mortality has been attributed to an increased prevalence of comorbidities, particularly cardiovascular disease, infections, and the development of malignant space-occupying lesions. In spite of the published guidelines highlighting the importance of comorbidity assessment and management, implementing these recommendations in standard clinical practice remains a challenge for the treating rheumatologists and rheumatology nurse specialists. This article will review the challenge of comorbidity in inflammatory arthritic conditions and its dynamic nature, the impact on patient management, as well as recent trends in the screening and assessment of comorbidity risk in standard clinical practice.

Towards Tailored Patient's Management Approach: Integrating the Modified 2010 ACR Criteria for Fibromyalgia in Multidimensional Patient Reported Outcome Measures Questionnaire.

Objectives. To assess the validity, reliability, and responsiveness to change of a patient self-reported questionnaire combining the Widespread Pain Index and the Symptom Severity Score as well as construct outcome measures and comorbidities assessment in fibromyalgia patients. Methods. The PROMs-FM was conceptualized based on frameworks used by the WHO Quality of Life tool and the PROMIS. Initially, cognitive interviews were conducted to identify item pool of questions. Item selection and reduction were achieved based on patients as well as an interdisciplinary group of specialists. Rasch and internal consistency reliability analyses were implemented. The questionnaire included the modified ACR criteria main items (Symptom Severity Score and Widespread Pain Index), in addition to assessment of functional disability, quality of life (QoL), review of the systems, and comorbidities. Every patient completed HAQ and EQ-5D questionnaires. Results. A total of 146 fibromyalgia patients completed the questionnaire. The PROMs-FM questionnaire was reliable as demonstrated by a high standardized alpha (0.886-0.982). Content construct assessment of the functional disability and QoL revealed significant correlation (p < 0.01) with both HAQ and EQ-5D. Changes in functional disability and QoL showed significant (p < 0.01) variation with diseases activity status in response to therapy. There was higher prevalence of autonomic symptoms, CVS risk, sexual dysfunction, and falling. Conclusions. The developed PROMs-FM questionnaire is a reliable and valid instrument for assessment of fibromyalgia patients. A phased treatment regimen depending on the severity of FMS as well as preferences and comorbidities of the patient is the best approach to tailored patient management.

Widespread lytic lesions-A metastatic or vasculitic process?

INTRODUCTION: This case highlights the complexities in the initial diagnosis and investigations of widespread lytic lesions initially perceived to be a widespread metastatic process and the consideration of alternative diagnosis. PRESENTATION OF CASE: A 57 year-old man with a background of psoriatic arthritis presented to the rheumatology department with lumbar back pain and sensory disturbance over L4/5. Magnetic resonance imaging (MRI) and bone scan identified lesions consistent with bony metastases at L5. The patient previously had a raised prostate specific antigen (PSA) of 10.8µg/L (normal<4) but prostate biopsy was benign. Multiple metastatic deposits in the liver and kidneys (confirmed necrotic tissue on biopsy) were identified through further investigations. The initial diagnosis of malignancy was challenged after a positron emission tomography (PET) scan showed lesions highly suggestive of polyarteritis nodosa (PAN) and subsequent magnetic resonance angiogram (MRA) revealed stenosis and aneurysm in the renal artery in keeping with PAN. Therefore what was initially thought to be a widespread metastatic disease process was in fact the manifestation of a systemic vasculitic disease. DISCUSSION: PAN is a vasculitis that predominantly involves small to medium-sized vessels. The disease can affect any site in the body, but holds a predisposition for organs such as kidneys, heart and the gastrointestinal tract. Differential diagnosis of PAN should be considered in patients with widespread lytic lesions. CONCLUSION: Due to the pathological nature of PAN and its variable clinical manifestations that add to the challenges of its diagnosis, one must hold a high clinical suspicion, even in urological conditions.

Ultrasound assessment of the median nerve: a biomarker that can help in setting a treat to target approach tailored for carpal tunnel syndrome patients.

Ultrasonography (US) is a valuable tool for confirming the diagnosis of carpal tunnel syndrome (CTS) as it enables the detection of changes in the median nerve shape and rule out anatomic variants as well as space-occupying lesions such as ganglion cysts or tenosynovitis. This work was carried out aiming at: 1. Ultrasonography assessment of the median nerve and its neurovascular blood-flow in CTS patients before and after management. 2. Verify the possibility of using baseline US parameters as a biomarker to predict likely outcomes and frame a treatment plan for CTS patients. 233 CTS subjects diagnosed based on clinical and electrophysiological (NCS) testing were included in this work. US measures at the tunnel inlet included: cross sectional area, flattening ratio and neural Power Doppler (PD) signals. Patients who had severe NCS outcomes or neurological deficit were referred for open surgical decompression; the remaining patients were given the choice of either conservative or surgical management. The main outcome variable was improvement >70% in CTS symptoms. Assessments were carried out at baseline, 1-week, 1-month and 6-months post treatment. Results revealed an inverse relation between the neural vasculature and CTS severity defined by NCS (r = - 0.648). In CTS cases treated conservatively, the US measures started to improve within 1-week, whereas in the surgically treated cohort there was an initial phase of post-operative nerve measures increase, before settling at 1-month time of follow-up. The risk of poor outcomes was significantly higher (RR 3.3) in patients with high median nerve flattening ratio. This risk was most marked in the cohort with nerve flattening associated with longer duration of illness (RR 4.3) and low PD signal (RR 4.1). The results revealed that in addition to the diagnostic value of US in CTS, the detection of increased median nerve neuro-vasculature has a good prognostic value as an indicator of early median nerve affection.

MABS: targeted therapy tailored to the patient's need.

Monoclonal antibodies (MABs) represent the window of opportunity in modern medicine. As immunology plays a vital role both in our survival and in disease development, MABs were found to be of great help in diagnosing, prognosticating and managing certain malignancies, inflammatory conditions, autoimmune as well as infectious diseases. Technological advances have enabled the production of MABs that target specific antigens linked with several disease processes. These drugs are now a component of therapy, not only for many common malignancies, including breast, colorectal, lung and pancreatic cancers, as well as lymphoma, leukaemia and multiple myeloma, but also for several inflammatory conditions such as rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis and inflammatory bowel disease. Targeted therapy has raised new questions about tailoring treatment, including cancer management, to the individual patient's needs. This would have a positive impact on the drug's effectiveness and toxicity as well as the economics of care. While targeted MABs are generally better tolerated than traditional chemotherapy, they are associated with several adverse effects, which vary from one patient to another.

Musculoskeletal US: examining the joints.

Musculoskeletal ultrasound (US) is an excellent tool to diagnose muscle, tendon and ligament injuries, cystic structures and peripheral nerve compression, as well as soft tissue masses, without the risk of ionizing radiation. Musculoskeletal US is now routinely used by a growing number of rheumatology and sports medicine centres throughout UK. In standard clinical practice, US has an extremely useful application in differentiating fluid from soft tissue and identifying the severity of joint inflammation. The work described in this article was carried out to assess patients' feedback regarding the use of US guidance for intra-articular injections and/or the removal of fluid from their inflamed knee joints in a nurse-led clinic. Nineteen patients who had US-guided knee joint injection/aspiration in the clinic were asked to complete a questionnaire regarding their satisfaction with the procedure, and to rate their joint pain and patient global assessment (using numerical visual analogue scale) before the US-guided procedure, and 1 month after. Results revealed a significant improvement (p<0.001) of the joint injection outcome measures and the patients' satisfaction of the US-guided procedure. Therefore, musculoskeletal US can improve two fundamental clinical skills: the clinical diagnosis of joint inflammation, and the accuracy of joint injection/aspiration. This study supports the concept that incorporating musculoskeletal US into clinical practice leads to significant improvements in patient care. It also reveals that US-guided procedures are appreciated by patients.

Biological nurse specialist: goodwill to good practice.

The extensive use of biological agents in recent years for the treatment of rheumatological diseases has required a steep learning curve for the specialist nurses who manage and work in this specialty. Safe prescribing of biological therapies requires good infrastructure and specialist nursing personnel. With additional training, the specialist nurse may take responsibility for a number of tasks in the patient pathway including screening, treatment administration, patient education, prescription coordination for home drug delivery, patient support, monitoring and data collection. Biological treatment is becoming more widely used in several specialities, in particular gastroenterology, dermatology and ophthalmology. Since 2002, rheumatology specialist nurses have taken the lead in assessment and providing biologic therapy, not only for patients suffering from rheumatic diseases but also for those with immune-mediated inflammatory disorders. The unique nature and variable safety profiles of these agents led to the development of immune-mediated inflammatory disease infusion (IMID) centres and highlighted the importance of having biological specialist nurses. This article will discuss the evolution of the IMID/biologic specialist nurse role and how IMID services started with goodwill from the rheumatology nurse specialists to develop into a main component of the holistic approach to care.

Osteoporosis: not only in women, but in men too.

Osteoporosis is a chronic disease where the nurse specialist can make a significant impact. The osteoporosis nurse specialist has an important role, not only in the prevention and management of osteoporosis but also in the promotion of skeletal health across the public health and social care arenas and in the continuing development of services across primary and secondary care. The scale of the problem in women and the potential role of hormone replacement therapy in the prevention and treatment of osteoporosis has played down the problem of osteoporosis and osteoporotic fractures in men, thus facilitating a negligent attitude. This article summarizes the outcome of a dedicated male osteoporosis clinic, which was started by the lead clinicians in metabolic bone disease and falls and subsequently was run by the osteoporosis nurse specialist. A clinic proforma which can be used as a standard in clinical practice is presented. In addition, an algorithm for the management of men with osteoporosis is discussed.

Short-term outcome after anti-tumor necrosis factor-alpha therapy in rheumatoid arthritis: do we need to revise our assessment criteria?

OBJECTIVE: To evaluate the Disease Activity Score (DAS) using various aggregated dimensions to quantify treatment outcome in patients with rheumatoid arthritis (RA), in order to determine the best instrument to be used as an endpoint that indicates good response in terms of EULAR response criteria and DAS28 remission criteria, and which satisfies the demands of clinical rheumatology. METHODS: Using raw data for each patient subjected to anti-tumor necrosis factor-a therapy (81 patients), before and 6 months after treatment, DAS28 was calculated 4 times using the standard equation, as follows: (1) DAS 1 (the standard DAS28): tender joint count (TJC), swollen joint count (SJC), patient global assessment (PGA), erythrocyte sedimentation rate (ESR); (2) DAS 2: TJC, SJC, PGA, C-reactive protein (CRP); (3) DAS 3: TJC, SJC, physician global assessment (PhGA), ESR; and (4) DAS 4: TJC, SJC, PhGA, CRP. Disease activity was identified if DAS score exceeded 5.1. A clinically significant response was recorded if there had been improvement of > 1.2 of the DAS score. RESULTS: DAS 2, DAS3, and DAS4 were superior to the current DAS score used for assessment of RA activity (effect size differences were -0.35, -0.13, and -0.48, respectively). Assessment of disease activity using TJC, SJC, PhGA, and CRP was the best tool to assess response to therapy. ESR was marginally superior to CRP in its sensitivity to monitor disease activity changes (effect sizes 1.08 and 1.03, respectively). CONCLUSION: These results suggest that self-report indices on their own, such as PGA and pain score, are inadequate indicators of disease activity. The DAS might profitably be amended by one or 2 continuous measures for better quantification of the degree of improvement of patients on a given therapeutic modality. Using PhGA and CRP instead of PGA and ESR, respectively, in the DAS equation discriminated better between different patients' responses than the traditional DAS score.

Quantitative ultrasonography and magnetic resonance imaging of the parotid gland: can they replace the histopathologic studies in patients with Sjogren's syndrome?

OBJECTIVE: To assess the diagnostic value of parotid gland quantitative assessment using ultrasound (US) as well as magnetic resonance imaging (MRI) in patients with Sjogren's syndrome (SS) and to evaluate the possibility of using such modalities as a predictor of the histopathologic score of salivary gland biopsy in this group of patients. METHODS: Sonographic and MRI studies were performed on the parotid glands of 47 patients diagnosed to have primary SS, 20 healthy control subjects of matched sex and age, and 20 subjects with sicca symptoms but without any evidence of SS. The patients and the control subjects were scored according to the structural changes seen in both radiologic modalities. In addition, sialography and labial gland biopsy were done for all patients as well as the control subjects and scored according to the degree of affection. RESULTS: Parenchymal inhomogenity (PIH) was seen in 93.6% of the patients studied by US, while nodular pattern was seen in 97.8% in the MRI study. The US and MRI results correlated significantly with the histopathologic score of the minor salivary glands (r = 0.82, 0.84, respectively) as well as sialography score (r = 0.69, 0.60, respectively). There was good agreement between US and MRI findings (r = 0.87) in both SS cases and control subjects. CONCLUSION: US and MRI are equally sensitive tools for the diagnosis of salivary involvement in patients with SS. Quantitative assessment of US and MRI images seem to represent an advance in the diagnosis of SS as they offer a good prediction of the pathology score of the salivary gland. MRI seems unnecessary as a routine diagnostic tool and should be considered as the second option in case of normal US.

The evolving therapy of rheumatic diseases, the future is now.

There are two main ways in which physicians will be urged to improve the outcome for their patients suffering from rheumatic diseases in the coming era, these are, early diagnosis and timely effective therapy. Current reserch suggests that in rheumatoid arthritis joint damage occurs early, often within the first 2 years and even in the absence of associating severe symptoms, is a call for action for primary care physicians as well as rheumatologists. Similarly in SLE patients, sometimes the treatments are ineffective or too toxic with sepsis or opportunistic infections often limiting their use or resulting in the death of the patient. As primary care physicians are the clinicians most frequently visited by patients with initial symptoms of the disease, they first need to learn when to suspect it as well as its complications, and when to refer the patient appropriately. Rheumatologists need to determine when and how to prescribe the most appropriate treatment, as well as how to incorporate the new drugs which are emerging on the scene. At the same time, earlier initiation of combination therapy with the disease modifying anti-rheumatic therapy holds an area of continued exploration. This new information has modified our approach to patients' management. The age of "wait and see" is over.