IQ driving QI: the Asia Pacific Consortium on Osteoporosis (APCO): an innovative and collaborative initiative to improve osteoporosis care in the Asia Pacific.

Asia Pacific Consortium on Osteoporosis (APCO) comprises of clinical experts from across the Asia Pacific region, uniting to develop solutions to problems facing osteoporosis management and care. The vision of APCO is to reduce the burden of osteoporosis and fragility fractures in the Asia Pacific region. INTRODUCTION: The Asia Pacific (AP) region comprises 71 countries with vastly different healthcare systems. It is predicted that by 2050, more than half the world's hip fractures will occur in this region. The Asia Pacific Consortium on Osteoporosis (APCO) was set up in May 2019 with the vision of reducing the burden of osteoporosis and fragility fractures in the AP region. METHODS: APCO has so far brought together 39 clinical experts from countries and regions across the AP to develop solutions to challenges facing osteoporosis management and fracture prevention in this highly populous region of the world. APCO aims to achieve its vision by engaging with relevant stakeholders including healthcare providers, policy makers and the public. The initial APCO project is to develop and implement a Framework of pan-AP minimum clinical standards for the screening, diagnosis and management of osteoporosis. RESULTS AND CONCLUSIONS: The Framework will serve as a platform upon which new national clinical guidelines can be developed or existing guidelines be revised, in a standardised fashion. The Framework will also facilitate benchmarking for provision of quality of care. It is hoped that the principles underlying the formation and functioning of APCO can be adopted by other regions and that every health care facility and progressively every country in the world can follow our aspirational path and progress towards best practice.

Alendronate prevents bone loss in patients with acute spinal cord injury: a randomized, double-blind, placebo-controlled study.

CONTEXT: Patients who sustain an acute spinal cord injury (SCI) experience rapid dramatic reductions in bone mineral density (BMD), especially marked in sublesional areas and sometimes leading to hypercalcemia and hypercalciuria, as well as increased fracture risk. OBJECTIVE: In this prospective, double-blind, randomized, placebo-controlled study, we evaluated the hypothesis that oral alendronate administration would preserve BMD when administered soon after acute SCI. PATIENTS AND INTERVENTION: Thirty-one patients with acute SCI were randomly allocated to receive oral alendronate 70 mg/wk or placebo, within 10 d of acute SCI, for 12 months. MAIN OUTCOME MEASUREMENTS: At entry and at 3, 6, 12, and 18 months, total body bone density, lumbar and hip BMD, ultrasound of the calcaneus, 24-h urinary calcium, and serum C-telopeptide (betaCTX) were measured. RESULTS: At study entry, patients in the two groups were well matched for age, gender, severity of neurological deficit, BMD, urinary calcium, and betaCTX. BMD indices declined steadily in the placebo group, and this effect was attenuated significantly by alendronate. After 12 months, there was a 5.3% difference (P<0.001) in total body BMD and a 17.6% difference (P<0.001) in the total hip BMD between the two groups. Alendronate compared with placebo induced significant (P<0.001) reductions in urinary calcium excretion and serum betaCTX. No treatment-related side effects were noted. CONCLUSIONS: We conclude that alendronate therapy, 70 mg/wk, initiated soon after acute SCI, prevents bone loss and is not associated with side effects.

Hip fracture mortality and morbidity--can we do better?

AIMS: To determine the mortality and morbidity from fractures of the neck of femur in Christchurch Hospital and to determine the extent that hip fracture patients are investigated and treated for osteoporosis. METHODS: All patients treated for a fractured hip at Christchurch Hospitals between May 1998 and April 1999 were identified. Their radiographs were reviewed and each fracture was classified. Dates of death were recorded where applicable. Surviving patients were contacted at least twelve months after their fracture and asked questions relating to functional outcome following surgery. The numbers of patients who had ever had a bone density scan, treatment for osteoporosis and/or a measurement of vitamin D were recorded. RESULTS: There were 331 fractures among 329 patients (242 women, 87 men), mean age of 79.7 (standard deviation 10.5) years. Twelve-month mortality was 26%. Men had a higher mortality rate than women for all fracture types that was independent of age. Follow up of the 231 surviving patients 12-24 months later revealed 27% still had pain and 60% had worsened mobility that they attributed to the fracture. Worsened mobility affected people living at home more than people living in institutional care. 32 people (15%) had had a vitamin D concentration measured and in 22 of these (69%) levels were below the reference range. CONCLUSIONS: The mortality and morbidity after hip fracture is high, especially in men. There were few significant correlates with greater morbidity except for fixation by hemi arthroplasty. More attention to hip fracture prevention is needed. Few subjects were on any therapy for osteoporosis other than calcium supplements. Vitamin D deficiency is an important but under-recognised condition.

Effects of diary food supplements on bone mineral density in teenage girls.

BACKGROUND: Bone mineral density (BMD) is largely genetically determined and this influence is most powerful in the period of rapid skeletal development in childhood and late adolescence but environmental factors such as exercise and dietary calcium intake may influence up to 20%. AIMS OF THE STUDY: The aims of the study were to examine healthy late adolescent females for the effects and benefits of a high calcium intake from dairy product foods on bone mineral density, body composition, lipids and biochemistry. The secondary aim is determine whether a high intake of dairy product foods in the diet is acceptable for this age group long term. METHODS: Ninety-one teenage girls who participated in a two-year randomised controlled study on the effect of dairy food supplementation on dietary patterns, body composition and bone density in post-pubertal teenage girls were approached one year after the cessation of the study to determine the effects of the cessation of dairy supplements on bone mineral density, dietary habits, biochemical markers, body composition and blood lipids. Bone mineral density and bone mineral content were assessed at the hip, spine and total body. Anthropometric data were collected, and exercise, Tanner, dietary assessment, preference and compliance questionnaires were administered. Lipid profiles, hydroxyproline excretion and urinary calcium and sodium excretion measurements were performed. RESULTS: There were no significant differences between the 2 groups for height, weight, lean and fat mass. The supplemented group had significantly higher calcium, phosphorus and protein intake during the supplementation period (p < 0.001). No differences were seen between the groups 12 months after supplementation finished. There were no significant differences in exercise level, preference or acceptability of dairy products or in the lipids and bone markers between baseline the end of supplementation and 1 year follow-up. There was a significant increase in trochanter (4.6%), lumbar spine (1.5%) and femoral neck (4.8%) BMD (p < 0.05) in the high calcium group at the end of supplementation. There was an increase in bone mineral content at the trochanter (p < 0.05) and lumbar spine; however the latter was not statistically significant, in the high calcium group at the end of supplementation. There was no difference in vertebral height or width at any stage of the study, indicating no influence on bone size. CONCLUSIONS: In this 3 year study (2 years of supplementation, 1 year follow-up), teenage girls, aged 15-18 years, were able to significantly increase their BMD at the trochanter, femoral neck and lumbar spine when supplemented with dairy product foods to a mean calcium intake of 1160 mg/d. There was also an effect seen on the BMC particularly at the trochanter and to a lesser extent at the lumbar spine. The dietary calcium intake achieved did not adversely affect body weight, fat and lean mass or blood lipid profiles. Twelve months after the supplementation finished the girls had returned to their baseline diet, indicating self-selection of a high dairy product diet may be hard to achieve.

Asymptomatic low bone mineral density in otherwise healthy people: four year follow up.

AIM: To determine the effect of screening a normal population for low bone density on lifestyle, subsequent bone density and fracture risk. METHOD: A cross sectional study of 726 subjects screened for low bone density identified 60 with bone density greater than one standard deviation below an age and sex matched mean. Those who accepted further assessment were followed clinically and with repeat bone densitometry for up to four years. Those declining assessment were contacted four years later and questioned about lifestyle changes and fractures. They were offered repeat bone densitometry. RESULTS: Twenty five subjects accepted intervention and were advised on lifestyle modification and treated with calcium supplements (18) calcitriol (5) or oestrogen (1). 22 of the 35 subjects who initially declined intervention volunteered to have their bone density repeated. Bone density increased in the group accepting intervention compared to the 22 subjects in the group who initially declined assessment (p < 0.05). Several laboratory investigations had a low yield. Lifestyle modification in the group declining assessment did not significantly affect subsequent bone density. Fractures occurred infrequently in both groups. CONCLUSION: After screening the normal population for low bone density, significant improvements in bone density can be achieved in patients accepting further intervention.

Comparative study of norfloxacin and trimethoprim for the treatment of elderly patients with urinary tract infection.

One hundred elderly hospitalised patients, aged 70 to 97 years (mean 81.7 years; SD 7.1 years) with a urinary tract infection were entered into a randomised study to compare the efficacy, safety and tolerance of norfloxacin 400 mg twice daily for three days with trimethoprim 300 mg once daily for three days. Forty-two of 49 patients (86%) were cured with norfloxacin, compared with 35 of 51 (69%) with trimethoprim (p less than 0.05). No patient reported any side effects during treatment. Two patients treated with norfloxacin and three treated with trimethoprim developed a disturbance of liver function. Three deaths occurred within 28 days of treatment with trimethoprim but were unrelated to the treatment. In this study norfloxacin proved superior to trimethoprim for the treatment of uncomplicated urinary tract infections in elderly hospitalised patients.

A comparison of long acting nifedipine and enalapril in elderly hypertensives: a randomised, single-blind, cross-over study.

The effects of nifedipine and enalapril on blood pressure (BP), heart rate, plasma and urine electrolyte, plasma renin activity (PRA), aldosterone and catecholamines, were studied in ten elderly hypertensive subjects in a randomised, single-blind, cross-over trial. Both nifedipine and enalapril were effective in lowering supine and erect systolic and diastolic BP, with nifedipine causing a significant (P less than 0.05) rise in heart rate. Arterial pressure rose to pre-treatment levels on withdrawal of both drugs. Plasma glucose fell significantly (P less than 0.02) on enalapril therapy, whilst no other biochemical changes were observed. PRA, aldosterone and adrenaline rose on nifedipine therapy whereas PRA showed a greater rise on enalapril with a fall in plasma aldosterone and no change in plasma adrenaline. Plasma noradrenaline was not altered by either agent. Unacceptable side effects occurred in patients taking nifedipine resulting in discontinuation of therapy in 2 patients and death in another. Nifedipine or enalapril monotherapy is effective in lowering BP in the elderly hypertensives. Although more experience is needed, the side effect profile of both agents especially enalapril, appears satisfactory.