Fracture liaison services in Ireland-how do we compare to international standards?

In this first na tional survey of public hospitals in The Republic of Ireland, we found fracture liaison services (FLS) to be heterogeneous, limited in many cases and poorly supported. A national strategy is urgently needed to support the implementation and operation of an FLS, and thus help reduce the burden of fragility fractures for patients and the healthcare system. INTRODUCTION: Fragility/low-trauma fractures are a global concern, whose incidence is rising as the population ages. Many are preventable, and people with a prior fragility fracture are at particularly high risk of further fractures. This patient group is the target of the International Osteoporosis Foundation (IOF) Capture the Fracture campaign, advocating global adoption of fracture liaison services (FLS), with the aim of preventing secondary fragility fractures. We wished to determine the current availability and standards of an FLS in Ireland, ahead of the launch of a National FLS database. METHODS: We devised a questionnaire encompassing the thirteen IOF standards for an FLS and asked all 16 public hospitals with an orthopaedic trauma unit in Ireland, to complete for the calendar year 2019 in patients aged ≥ 50 years. RESULTS: All sites returned the questionnaire, i.e. 100% response rate. Nine hospitals stated that they have an FLS, additionally one non-trauma hospital running a FLS responded, and were included. These 10 FLS had identified and managed 3444 non-hip fractures in the year 2019. This figure represents 19% of the expected non-hip fragility fracture numbers occurring annually in Ireland. Implementation of the IOF standards was very variable. All sites reported being inadequately resourced to provide a high-quality service necessary to be effective. CONCLUSION: The existence and functioning of FLS in Ireland are heterogeneous and suboptimal. A national policy to support the implementation of this programme in line with international standards of patient care is urgently needed.

The Impact of Delirium on Recovery in Geriatric Rehabilitation after Acute Infection.

OBJECTIVES: Delirium is common during acute infection in older patients and is associated with functional decline. Geriatric rehabilitation (GR) can help older patients to return to their premorbid functional level. It is unknown whether delirium affects GR outcomes in patients with acute infection. We evaluated whether delirium affects trajectories of activities of daily living (ADL) and quality of life (QoL) recovery in GR after COVID-19 infection. DESIGN: This study was part of the EU-COGER study, a multicenter cohort study conducted between October 2020 and October 2021. SETTING AND PARTICIPANTS: Participants were recruited after COVID-19 infection from 59 GR centers in 10 European countries. METHODS: Data were collected at GR admission, discharge, and at the 6-week and 6-month follow-ups. Trajectories of ADL [using the Barthel index (BI)] and QoL [using the EuroQol-5 Dimensions-5 Level (EQ-5D-5L)] recovery were examined using linear mixed models. RESULTS: Of the 723 patients included (mean age 75.5 ± 9.9 years; 52.4% male), 28.9% had delirium before or during GR admission. Participants with delirium recovered in ADL at approximately the same rate as those without (linear slope effect = -0.13, SE 0.16, P = .427) up to an estimated BI score of 16.1 at 6 months. Similarly, participants with delirium recovered in QoL at approximately the same rate as those without (linear slope effect = -0.017, SE 0.015, P = .248), up to an estimated EQ-5D-5L score of 0.8 at 6 months. CONCLUSIONS AND IMPLICATIONS: Presence of delirium during the acute phase of infection or subsequent GR did not influence the recovery trajectory of ADL functioning and QoL.

Prevalence of vitamin K deficiency in older people with hip fracture.

Introduction: Vitamin K plays an important role in blood coagulation. Diet is the main source of vitamin K and body stores are depleted in days, hence deficiency is common in malnourished older people. A high proportion of people who sustain a hip fracture are already malnourished, compounded by fasting for surgery which might further increase deficiency. We wanted to explore the prevalence of vitamin K deficiency in hip fracture patients and the impact of a short period of fasting.Methods: In consecutive patients hospitalised with a hip fracture, we measured vitamin K and PIVKA-II (undercarboxylated factor II - a marker of subclinical vitamin K status) on admission and on first post-operative day. We excluded those on anticoagulants.Results: N = 62 participated; 4 had missing pre-op vitamin K samples and n = 3 had no surgery leaving n = 55 with paired samples. Mean age was 80.0 ± 9.6 years, 33% males. Prevalence of subclinical vitamin K deficiency on admission was 36% (20/55) based on reference range of > 0.15µg/L. The proportion with subclinical K deficiency after surgery rose to 64% (35/55), p < 0.05. 13% had detectable PIVKA-II concentrations pre-operatively, 15% did post-operatively. None had abnormal prothrombin time. Vitamin K status was not associated with post-operative haemoglobin drop or transfusion requirements.Conclusion: Prevalence of vitamin K deficiency in hip fracture patients is high and increases further following a short period of fasting. Though no significant impact was noted on peri-operative blood loss, larger studies are warranted to explore this, and the potential role of vitamin K supplements peri-operatively.

Androgen deprivation in males is associated with decreased central arterial compliance and reduced central systolic blood pressure.

The higher incidence of coronary artery disease in men is often attributed to androgens. Arterial compliance or 'stiffness' is increasingly regarded as a modifiable risk factor for cardiovascular disease. We wanted to look at the effects of complete androgen withdrawal, on arterial compliance in men. We performed arterial compliance studies on 12 men with complete androgen deprivation as treatment for prostate cancer, and on 12 age-matched healthy controls. Central pulse wave velocities were significantly higher in the androgen-deprived men (14.2 +/- 2.7 vs 11.8 +/- 1.6 m/sec, P = 0. 02). The cases tended to have higher brachial systolic pressures than controls though this difference was not significant (P = 0.2). We conclude that androgen withdrawal is associated with a reduction in central arterial compliance. Conversely androgen withdrawal does not affect peripheral arterial compliance. It is unlikely that the presence of normal concentrations of androgens can explain the sex difference in mortality rates. Longitudinal studies are needed for further evaluation. Journal of Human Hypertension (2000) 14, 395-397

Takayasu's arteritis: a cause of prolonged arterial stiffness.

OBJECTIVES: Cardiovascular disease is a major cause of mortality and morbidity in patients with Takayasu's arteritis (TA). Increased arterial stiffness is an independent risk factor and predictor of cardiovascular mortality in a variety of diseases. Pulse wave velocity (PWV) and the augmentation index (AI) are used as clinical measurements of arterial stiffness. METHODS: Data are presented from 10 patients with TA and 11 normal controls obtained between 2000 and 2004. Arterial compliance was assessed non-invasively by measurement of PWV, using the Complior system, and calculation of the aortic AI. RESULTS: TA patients (mean age 40.8+/-13.2 yr) were compared with a control group of healthy women from a parallel study (mean age 32.3+/-5.5 yr). The mean carotid-femoral PWV (PWV-CF) was higher in TA patients (P = 0.03). In addition, both aortic AI derived from the radial artery (P = 0.002) and carotid AI (P = 0.03) were higher in TA patients compared with controls. PWV-CF did not correlate with CRP (r = - 0.23, P = 0.23) or ESR (r = - 0.19, P = 0.27). Similar results were obtained for the correlation of carotid-radial PWV with CRP (r = 0.15, P = 0.32) and ESR (r = 0.33, P = 0.14). CONCLUSIONS: Our data show that TA is associated with elevated arterial stiffness in the central aorta, which may persist when the disease is quiescent. These data suggest that PWV represents a means by which cardiovascular risk can be detected and monitored in TA, and highlights the importance of effective management of cardiovascular risk factors in these patients.

Testosterone suppression in men with prostate cancer is associated with increased arterial stiffness.

Low androgen levels in men are associated with increased cardiovascular risk, through unclear mechanisms. We measured arterial stiffness ('compliance') in 21 men receiving complete testosterone suppression therapy for prostate cancer, and in 25 controls. Systemic arterial compliance (SAC), which assesses proximal aortic stiffness, was calculated by simultaneous recording of aortic flow and carotid artery pressure (the 'area method'). Aorto-femoral (A-F), aorto-radial (A-R) and femoral-dorsalis pedis (F-DP) pulse-wave velocities (PWVs) were recorded using the 'Complior' system. SAC was significantly lower in the androgen-depleted men compared to controls (0.81 +/- 0.53 vs. 1.18 +/- 0.43 arbitrary compliance units, p = 0.01, mean +/- SD). Correspondingly, their A-F PWV was higher (14.1 (10.1-21.8) vs. 12.4 (9.6-17.4) m/s, p = 0.03, median (range)). Cases tended to be older (75 +/- 7 vs. 71 +/- 6 years, p = 0.07), and to have higher systolic blood pressure (148 +/- 22 vs. 143 +/- 17 mmHg, p = 0.40); however, SAC was still significantly lower (p = 0.03) after adjustment for age and stratification for central systolic pressure (< or = or > the median). Adjustment of A-F PWV for age and central systolic pressure reduced significance to p = 0.07. There was no significant difference in peripheral PWVs between groups. In conclusion, testosterone suppression is associated with increased aortic stiffness, only partly explained by age and blood pressure. Loss of androgens in men might therefore adversely affect cardiovascular risk.

The effect of reminder calls in reducing non-attendance rates at care of the elderly clinics.

BACKGROUND: DNA ("did not attend") at outpatient clinics is an important problem costing the NHS an estimated pound266 million annually. The national DNA rate for 1996-1997 for all clinics was 12%. The DNA rate at Hammersmith Hospital for the same year in the care of the elderly specialty was 21%. The aim of this study was to establish why this was so, and to test the efficacy of a reminder call in increasing attendance rates at care of the elderly clinics. METHODS: 23 DNAs from seven clinics were contacted to ascertain the reasons for non-attendance (group I). For seven further clinics, 84 patients were contacted in advance to reconfirm their appointment (group II). RESULTS: From group II 12 patients were identified who were unaware of their appointment (14%), six of whom agreed to attend; thus six potential DNAs were prevented. Eleven vacant appointments were identified in advance. The unexpected DNA rate was reduced to 5% from a potential 21% as a result of this exercise. The DNA rate for all patients with dementia (both groups) was 44%, whereas the DNA rate for all patients without this diagnosis (both groups) was 16% (p < 0.001). CONCLUSIONS: A preclinic phone call reminder to elderly patients is feasible, increases attendance rates, and identifies vacant appointments. Patients with dementia are more likely to miss clinic appointments; therefore they and their carers need specific reminders about appointment dates.