Osteoporotic fracture admissions compared to other major medical admissions in Irish public hospitals.

Multinational reports suggest Ireland has one of the greatest illness burdens related to osteoporosis. Hospital care represents the costliest portion of health services. We found public hospital bed days for fragility fractures in Ireland increased by 43% between 2008 and 2017 which exceeded those for other common diseases. INTRODUCTION: Recent multinational reports suggest Ireland has one of the greatest illness burdens related to osteoporosis, manifesting clinically as fragility fractures (FF). International reports show that FF incidence, rate of hospital admission and cost are similar or greater than those for breast cancer, myocardial infarction and stroke. Studies addressing the illness burden of osteoporosis in Ireland are few, and none compares fragility fractures to other common chronic diseases. METHODS: A retrospective analysis of national administrative data for all public hospital admissions was performed on adults aged 50 years and older from January 2008 to December 2017. RESULTS: In 2017, public hospital bed days for FF totalled 249,887 outnumbering Chronic Obstructive Pulmonary Disease (COPD): 131,897; 6 solid cancers (CA): 118,098; myocardial infarction (MI): 83,477; and diabetes mellitus (DM): 31,044. Bed days for FF increased by 43% between 2008 and 2017, in contrast to a 32%, 28% and 31% reduction for CA, MI and DM, respectively, and a 12% increase for COPD. Public hospital bed days for FF in 2016 were greater than MI, stroke, atrial fibrillation and chest pain combined but less than a combination of COPD, pneumonia and lower respiratory tract infection. CONCLUSION: Osteoporotic fractures represent a large and rapidly increasing illness burden amongst older Irish adults, with substantial care requirements and the resulting onus on our healthcare system. Urgent action is needed to address this public health issue and the services for those at risk of fracture.

Is it time to consider population screening for fracture risk in postmenopausal women? A position paper from the International Osteoporosis Foundation Epidemiology/Quality of Life Working Group.

The IOF Epidemiology and Quality of Life Working Group has reviewed the potential role of population screening for high hip fracture risk against well-established criteria. The report concludes that such an approach should strongly be considered in many health care systems to reduce the burden of hip fractures. INTRODUCTION: The burden of long-term osteoporosis management falls on primary care in most healthcare systems. However, a wide and stable treatment gap exists in many such settings; most of which appears to be secondary to a lack of awareness of fracture risk. Screening is a public health measure for the purpose of identifying individuals who are likely to benefit from further investigations and/or treatment to reduce the risk of a disease or its complications. The purpose of this report was to review the evidence for a potential screening programme to identify postmenopausal women at increased risk of hip fracture. METHODS: The approach took well-established criteria for the development of a screening program, adapted by the UK National Screening Committee, and sought the opinion of 20 members of the International Osteoporosis Foundation's Working Group on Epidemiology and Quality of Life as to whether each criterion was met (yes, partial or no). For each criterion, the evidence base was then reviewed and summarized. RESULTS AND CONCLUSION: The report concludes that evidence supports the proposal that screening for high fracture risk in primary care should strongly be considered for incorporation into many health care systems to reduce the burden of fractures, particularly hip fractures. The key remaining hurdles to overcome are engagement with primary care healthcare professionals, and the implementation of systems that facilitate and maintain the screening program.

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.

Antigenic response to CT-P13 and infliximab originator in inflammatory bowel disease patients shows similar epitope recognition.

AIM: To test the cross-immunogenicity of anti-CT-P13 IBD patients' sera to CT-P13/infliximab originator and the comparative antigenicity evoked by CT-P13/infliximab originator sera. METHODS: Sera of patients with IBD with measurable anti-CT-P13 antibodies were tested for their cross-reactivity to 5 batches of infliximab originator and CT-P13. Anti-drug antibody positive sera from treated patients were used to compare antigenic epitopes. RESULTS: All 42 anti-CT-P13 and 37 anti-infliximab originator IBD sera were cross-reactive with infliximab originator and CT-P13 respectively. Concentration of anti-drug antibodies against infliximab originator or CT-P13 were strongly correlated both for IgG1 and IgG4 (P < 0.001). Anti-CT-P13 sera of patients with IBD (n = 32) exerted similar functional inhibition on CT-P13 or infliximab originator TNF binding capacity and showed reduced binding to CT-P13 in the presence of five different batches of CT-P13 and infliximab originator. Anti-CT-P13 and anti-infliximab originator IBD sera selectively enriched phage-peptides from the VH (CDR1 and CDR3) and VL domains (CDR2 and CDR3) of infliximab. Sera reactivity detected major infliximab epitopes in these regions of infliximab in 60%-79% of patients, and no significant differences were identified between CT-P13 and infliximab originator immunogenic sera. Minor epitopes were localised in framework regions of infliximab with reduced antibody reactivity shown, in 30%-50% of patients. Monoclonal antibodies derived from naïve individuals and ADA-positive IBD patients treated with CT-P13 provided comparable epitope specificity to five different batches of CT-P13 and infliximab originator. CONCLUSIONS: These results strongly support a similar antigenic profile for infliximab originator and CT-P13, and point toward a safe switching between the two drugs in anti-drug antibody negative patients.

Emerging trends in hospitalisation for fragility fractures in Ireland.

BACKGROUND: We analysed hospital admissions and bed occupancy for fragility fractures in Ireland over a 15-year period to assess fracture admission trends and to project admissions over the next three decades. METHODS: We used the Hospital In-Patient Enquiry (HIPE) scheme to extract data on fracture admissions to Irish hospitals between 2000 and 2014 inclusive. We calculated absolute numbers and age-standardised rates of hospitalisations for men and women ≥ 50 years for each osteoporotic-type fracture. We projected fracture numbers and bed days using these trends, and associated costs to 2046 based on 2014 rates. RESULTS: The absolute number of all fragility fracture admissions increased by 30% between 2000 and 2014, for both men (40%) and women (27%). In-patient bed days for osteoporotic fractures have increased by 51% in the same period. Hip fractures dominated admissions, accounting for 36.5% of all admissions and almost half (46.7%) of all bed days. Age-standardised rates of hip fracture admission decreased significantly (p < 0.001) in women, but not in men, while rates of non-hip osteoporotic fracture admissions have not changed significantly for men or women. Hospitalisations for all osteoporotic fractures are projected to increase by 150% to 31,605 in 2046, 58% of whom will be 80 years or older. CONCLUSIONS: There has been a significant increase in the number of fracture admissions in Irish men and women over the past 15 years. This is projected to increase further over the next three decades which will place a significant burden on the Irish healthcare system.

ANCA-associated vasculitis: a comparison of cases presenting to nephrology and rheumatology services.

BACKGROUND: Anti-neutrophil cytoplasmic antibody (ANCA) -associated vasculitis (AAV) is a disease characterized by inflammation of small vessels and detectable ANCA in the circulation. Patients may develop a broad spectrum of clinical features ranging from indolent sino-nasal disease and rashes to fulminant renal failure or acute life-threatening pulmonary haemorrhage. Consequently, patients with AAV present to a variety of specialties including nephrology and rheumatology, whose training and approaches to management of such patients may differ. There is little literature comparing patients presenting to different specialties and their outcomes. METHODS: We compared two cohorts of patients with ANCA-positive AAV presenting to either the rheumatology or nephrology department at Galway University Hospitals from June 2002 to July 2011. A standardized data collection form was used to collect information regarding baseline demographics, manifestations of AAV, initial management, relapses and complications. RESULTS: Forty-five patients were included in this study (15 rheumatology/30 nephrology). The nephrology cohort was older, had a higher C-reactive protein, Birmingham Vascular Activity Score and ANCA titer at presentation compared to the rheumatology group. Induction treatment varied between the cohorts with rheumatology patients most commonly receiving a combination of oral corticosteroids (73%) and methotrexate (60%) and nephrology patients receiving a combination of intravenous corticosteroids (93%) and cyclophosphamide (90%). Fifty-three percent of the rheumatology patients who completed induction therapy relapsed compared to 30% of the nephrology patients. CONCLUSION: This study presents two different cohorts of patients with the same disease that were managed by two different disciplines. It highlights the heterogeneity of AAV and the importance of interdisciplinary communication and cooperation when managing these patients.

Expanding access to rheumatology care: the rheumatology general practice toolbox.

Management guidelines for many rheumatic diseases are published in specialty rheumatology literature but rarely in general medical journals. Musculoskeletal disorders comprise 14% of all consultations in primary care. Formal post-graduate training in rheumatology is limited or absent for many primary care practitioners. Primary care practitioners can be trained to effectively treat complex diseases and have expressed a preference for interactive educational courses. The Rheumatology General Practice (GP) Toolbox is an intensive one day course designed to offer up to date information to primary care practitioners on the latest diagnostic and treatment guidelines for seven common rheumatic diseases. The course structure involves a short lecture on each topic and workshops on arthrocentesis, joint injection and DXA interpretation. Participants evaluated their knowledge and educational experience before, during and after the course. Thirty-two primary care practitioners attended, who had a median of 13 (IQR 6.5, 20) years experience in their specialty. The median number of educational symposia attended in the previous 5 years was 10 (IQR-5, 22.5), with a median of 0 (IQR 0, 1) in rheumatology. All respondents agreed that the course format was appropriate. Numerical improvements were demonstrated in participant's confidence in diagnosing and managing all seven common rheumatologic conditions, with statistically significant improvements (p < 0.05) in 11 of the 14 aspects assessed. The Rheumatology Toolbox is an effective educational method for disseminating current knowledge in rheumatology to primary care physicians and improved participant's self-assessed competence in diagnosis and management of common rheumatic diseases.

Appropriateness of referrals to a tertiary referral centre for bone mineral density testing.

INTRODUCTION: Evidence-based guidelines for who should have a dual-energy X-ray absorptiometry (DXA) scan are well established. Much attention has been appropriately focussed on increasing the proportion of persons at high risk for fracture who are being referred for such investigation. Little literature exists on the extent of inappropriate referrals for DXA. In this cross-sectional study we assessed the prevalence of inappropriate referrals for DXA studies at our centre using modified International Society for Clinical Densitometry (ISCD) guidelines. METHODS: All DXA referrals were vetted for appropriateness and priority using established ISCD criteria. We evaluated the reasons for DXA referral on all subjects and studied the prevalence of missing information, and the number of referrals for DXA deemed to be inappropriate at our institution. RESULTS: Two thousand and twenty-five DXA referrals were reviewed. Information was missing on many requests (e.g., menopausal status, body mass index), and 33 % of the referrals were deemed as inappropriate. Compared to those deemed appropriate, inappropriate referrals were more likely to be younger females, had no risk factors for osteoporosis, had an inappropriate referral reason, and had less/missing information. CONCLUSIONS: In this study we have noted a concerning number of DXA referrals with limited information or no appropriate indication for such an examination. Education of referring physicians should focus on not only improving referrals for subjects at high risk, but also inappropriate referrals for subjects at low risk.

A case of occupational gout.

Gout can occur in any joint but most commonly afflicts the first metatarsophalangeal joint. Many theories have been suggested as explanations for this preferential joint involvement. We describe a case of gout occurring in the fingers of a man with occupational cold exposure, a case of "occupational" gout, and support for the involvement of temperature in acute attacks of gout.

Curing of dental composites by use of InGaN light-emitting diodes.

A potential application of blue-light-emitting InGaN LED's as a polymerizing source for dental composite materials is described. We compared a basic LED device with a conventional curing light in vitro to determine the polymerization parameters and to examine the effect of the curing process on the physical properties of these materials. It was determined that an array of six LED's was able to set a range of composite materials more quickly than a conventional light source, with the cured compounds showing similar hardness and material shrinkage parameters but with a lower material temperature rise during the curing process using the array. These findings indicate that a device consisting of several InGaN LED's would be an effective instrument for curing certain light-sensitive materials, particularly dental composites.