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.

Mononeuritis multiplex as a presenting feature of Wegener granulomatosis: a case report.

We report the case of a man presenting with clinical features of a mononeuritis multiplex, a perinuclear-ANCA (p-ANCA), and a renal biopsy suggestive of Wegener granulomatosis (WG). We wish to highlight this case as a learning point for clinicians as WG rarely presents in this form, and can be easily overlooked as a cause of mononeuritis multiplex.

Joint erosion in rheumatoid arthritis: interactions between tumour necrosis factor alpha, interleukin 1, and receptor activator of nuclear factor kappaB ligand (RANKL) regulate osteoclasts.

BACKGROUND: Osteoclasts, specialised bone resorbing cells regulated by RANKL and M-CSF, are implicated in rheumatoid joint erosion. Lymphocyte-monocyte interactions activate bone resorption, this being attributed to tumour necrosis factor alpha (TNFalpha) and interleukin 1 beta (IL1beta) enhanced osteoblast expression of RANKL. In animal studies, TNF potently increases osteoclast formation in the presence of RANKL. RANKL-independent osteoclastogenesis also occurs, though IL1 is required for resorptive function in most studies. These inflammatory cytokines have a pivotal role in rheumatoid arthritis, OBJECTIVE: To study the interactions of TNFalpha and IL1beta with RANKL, particularly the time course of the interactions and the role of lymphocytes. METHOD: Cultures of lymphocytes and monocytes (osteoclast precursors) or of purified CD14(+) cells alone (osteoclast precursors) were exposed to various combinations of TNFalpha, RANKL, and IL1beta or the inhibitors osteoprotegerin, IL1 receptor antagonist, or neutralising antibodies to RANKL or to IL1. Osteoclastogenesis and resorptive activity were assessed on microscopy of dentine slices. RESULTS: TNFalpha potently increased osteoclast proliferation/differentiation in the presence of RANKL. This effect was greatest when RANKL was present before but not after exposure of osteoclast precursor cells to TNFalpha. The resorptive activity of osteoclasts generated by TNFalpha in the absence of RANKL was critically dependent upon IL1, which was expressed by lymphocyte-monocyte interaction. CONCLUSION: TNFalpha potently enhances RANKL mediated osteoclast activity. Interactions between TNFalpha and IL1 also result in osteoclastic activity independently of RANKL. These findings will inform therapeutic approaches to the prevention of joint erosion in rheumatoid arthritis.

A prospective study of discordance in diagnosis of osteoporosis using spine and proximal femur bone densitometry.

The T-score definition of osteoporosis, originally intended for epidemiologic research in this condition, is frequently used in making treatment decisions for individual patients. Discordance in classification depending on the site and type of measurement has been reported in retrospective and cross-sectional studies, but the impact of such discordance on clinical practice is unknown. This is potentially important in view of a recent proposal to confine osteoporosis diagnosis to densitometry at the hip. Having excluded those with degenerative changes in the lumbar spine, we compared the T-score classification of a prospective cohort of patients referred for their first dual-energy X-ray absorptiometry (DXA) scan, analyzing data for men and women in 10-year age groups. Total hip and neck of femur DXA identified significantly fewer osteoporotic patients than spine DXA, and this reduced sensitivity could not be improved by adjusting the T-score threshold without an unacceptable increase in non-osteoporotic cases. The majority of patients undetected by proximal femur DXA were at significantly increased risk of vertebral fracture. DXA at the lumbar spine had only moderate sensitivity and specificity for osteoporosis redefined by total hip densitometry, indicating differential rates of bone loss at the proximal femur and spine. We conclude that, as the most usual indication for bone densitometry is to aid the determination of an individual's fracture risk, both proximal femur and lumbar spine should continue to be assessed.

Corticosteroid injection for the treatment of carpal tunnel syndrome.

OBJECTIVE: To compare low and high dose, and short and long acting corticosteroids in the treatment of carpal tunnel syndrome. METHODS: A randomised, controlled, single blind trial with electromyographic and subjective outcome measures. RESULTS: 25 mg hydrocortisone is as effective as higher doses or long acting triamcinolone at a six week and six month follow up. CONCLUSION: As low dose steroid is as effective, and potentially less toxic, this should be the recommended dose for injection of carpal tunnel syndrome.

A diagnostic algorithm for carpal tunnel syndrome based on Bayes's theorem.

OBJECTIVE: To construct a diagnostic algorithm based on Bayes's theorem and using simple clinical tests to allow accurate diagnosis without resort to nerve conduction studies. METHOD: A cohort of patients being referred with possible carpal tunnel syndrome had clinical and electrophysiological testing, from which the simple calculations for sensitivity, specificity and prevalence were made and subsequently used in the formula of Bayes's theorem. The algorithm was then tested prospectively in a further cohort of similarly referred patients. RESULTS: The algorithm proved to be reliable when tested prospectively, and was similar to nerve conduction studies in diagnostic accuracy. CONCLUSION: A simple algorithm of clinical tests can identify patients without resort to nerve conduction studies, facilitating early treatment.

Pyramids to myriads: the combination conundrum in rheumatoid arthritis.

Rheumatoid arthritis continues to be a cause of significant morbidity and disability. Increased understanding of the immunopathogenesis of the disease, of its progression over time, and of patient characteristics which correlate with outcome, have allowed more appropriate therapy. However, currently available disease-modifying therapy fails to adequately control disease in many patients, and many combinations of these drugs have therefore been described. In this review, we critically evaluate the existing literature, identifying combinations for which reasonable evidence of efficacy exists, and highlighting important issues in interpreting such evidence as well as issues of drug monitoring in such patients.