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.

Tranexamic acid toxicity in human periarticular tissues.

OBJECTIVES: Tranexamic acid (TXA) is an anti-fibrinolytic medication commonly used to reduce perioperative bleeding. Increasingly, topical administration as an intra-articular injection or perioperative wash is being administered during surgery. Adult soft tissues have a poor regenerative capacity and therefore damage to these tissues can be harmful to the patient. This study investigated the effects of TXA on human periarticular tissues and primary cell cultures using clinically relevant concentrations. METHODS: Tendon, synovium, and cartilage obtained from routine orthopaedic surgeries were used for ex vivo and in vitro studies using various concentrations of TXA. The in vitro effect of TXA on primary cultured tenocytes, fibroblast-like synoviocytes, and chondrocytes was investigated using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) cell viability assays, fluorescent microscopy, and multi-protein apoptotic arrays for cell death. RESULTS: There was a significant (p < 0.01) increase in cell death within all tissue explants treated with 100 mg/ml TXA. MTT assays revealed a significant (p < 0.05) decrease in cell viability in all tissues following treatment with 50 mg/ml or 100 mg/ml of TXA within four hours. There was a significant (p < 0.05) increase in cell apoptosis after one hour of exposure to TXA (100 mg/ml) in all tissues. CONCLUSION: The current study demonstrates that TXA caused significant periarticular tissue toxicity ex vivo and in vitro at commonly used clinical concentrations.Cite this article: M. McLean, K. McCall, I. D. M. Smith, M. Blyth, S. M. Kitson, L. A. N. Crowe, W. J. Leach, B. P. Rooney, S. J. Spencer, M. Mullen, J. L. Campton, I. B. McInnes, M. Akbar, N. L. Millar. Tranexamic acid toxicity in human periarticular tissues. Bone Joint Res 2019;8:11-18. DOI: 10.1302/2046-3758.81.BJR-2018-0181.R1.

Effects of a Six-Month Multi-Ingredient Nutrition Supplement Intervention of Omega-3 Polyunsaturated Fatty Acids, vitamin D, Resveratrol, and Whey Protein on Cognitive Function in Older Adults: A Randomised, Double-Blind, Controlled Trial.

OBJECTIVES: To investigate the impact of a six-month multi-ingredient nutrition supplement intervention (Smartfish®), containing omega-3 polyunsaturated fatty acids (PUFAs), vitamin D, resveratrol, and whey protein, on cognitive function in Irish older adults. DESIGN: Double-blind, randomised controlled trial (ClinicalTrials.gov: NCT02001831). A quantitative, mixed-model design was employed in which the dependent variable (cognitive function) was analysed with a between-subjects factor of group (placebo, intervention) and within-subjects factor of testing occasion (baseline, three-months, six-months). SETTING: Community-based intervention including assessments conducted at University College Dublin, Ireland. PARTICIPANTS: Thirty-seven community-dwelling older adults (68-83 years; mean (x̄)= 75.14 years; standard deviation (SD)= 3.64; 18 males) with normal cognitive function (>24 on the Mini Mental State Examination) were assigned to the placebo (n= 17) or intervention (n= 20) via a block randomisation procedure. INTERVENTION: Daily consumption for six-months of a 200mL liquid juice intervention comprising 3000mg omega-3 PUFAs [1500mg docosahexaenoic acid (DHA) and 1500mg eicosapentaenoic acid (EPA)], 10µg vitamin D3, 150mg resveratrol and 8g whey protein isolate. The placebo contained 200mL juice only. MEASUREMENTS: A standardised cognitive assessment battery was conducted at baseline and follow-ups. Individual test scores were z-transformed to generate composite scores grouped into cognitive domains: executive function, memory, attention and sensorimotor speed. Motor imagery accuracy and subjective awareness of cognitive failures variables were computed from raw scores. RESULTS: A hierarchical statistical approach was used to analyse the data; first, by examining overall cognitive function, then by domain, and then by individual test scores. Using mixed between-within subjects, analyses of variance (ANOVAs), no significant differences in overall cognitive function or composite cognitive domains were observed between groups over time. The only significant interaction was for Stroop Color-Word Time (p< 0.05). The intervention group demonstrated reduced task completion time at three- and six-month follow-ups, indicating enhanced performance. CONCLUSION: The present nutrition intervention encompassed a multi-ingredient approach targeted towards improving cognitive function, but overall had only a limited beneficial impact in the older adult sample investigated. Future investigations should seek to establish any potential clinical applications of such targeted interventions with longer durations of supplementation, or in populations with defined cognitive deficits.

Open reduction and plate fixation of dorsally displaced fractures of the distal radius: surgical technique, clinical and radiological outcome.

Thirty-five unstable dorsally displaced fractures of the distal radius in 34 patients (mean age 39) were studied; 28 fractures were intra-articular. All fractures had open reduction and fixation, through a dorsal approach, with mini-fragment plates placed between the first and second dorsal tendon compartments and deep to the fourth compartment. A congruous reduction of the articular surface was obtained in all cases. Twenty-four patients were available for follow-up (median 38 months). The Modified Mayo wrist score was excellent in 12 cases, good in four, and fair in eight. The median Patient Evaluation Measure score was 23.5. There were no cases of extensor tendon rupture. Radiographic assessment at follow-up showed a mean palmar angle of 6 degrees. There was evidence of osteoarthritis in six patients who had had intra-articular fractures. Open reduction and plating gives satisfactory medium term results for treatment of displaced intra-articular fractures of the distal radius in young patients.

Preemptive analgesia with lidocaine prevents Failed Back Surgery Syndrome.

Failed Back Surgery Syndrome (FBSS) is commonly encountered in pain-treatment settings in the United States. We tested whether potential key factors in this syndrome, such as extracellular concentrations of excitatory amino acids (EAAs), are increased in the dorsal horn by synaptic release due to unintentional stretch and/or deformation/compression/transection of dorsal spinal structures during surgery. We hypothesized that pharmacological nerve block as a form of preemptive analgesia prior to any insult to dorsal root neurons will prevent an abnormally high increase in extracellular concentrations of EAAs in the dorsal horn and ultimately the establishment of central sensitization during back surgery. The L4 and L5 dorsal roots were cut bilaterally near the spinal cord to provide an adequate model to test for preemptive analgesia. Amino acid concentrations were measured by dorsal horn microdialysis sampling; EAAs aspartate and glutamate were significantly increased by 80% and 65% respectively, as were other amino acids compared to sham control values. Topical application of 1% Lidocaine, a voltage-gated Na(+) channel blocker, for 10 min prior to L4 and L5 bilateral dorsal rhizotomy (BDR) significantly attenuated the increase in EAA concentrations such that their values were not different from sham controls. Behavioral tests demonstrated significant hindlimb mechanical allodynia after BDRs that was significantly attenuated by Lidocaine pretreatment. Thus, Lidocaine pretreatment could offer a safe measure for prevention of chronic pain for back surgical procedures if given by intramuscular injection, topical administration onto spinal nerves and/or the dorsal spinal surface during surgical procedures that include nerve entrapment release, intervertebral disc modification and laminectomies.

Compliance and outcome in treatment-resistant anorexia and bulimia: a retrospective study.

OBJECTIVES: To investigate the extent to which compliance with treatment is related to outcome, and factors associated with compliance in a group of treatment-resistant eating-disordered in-patients. DESIGN: A retrospective case study design was employed where clinic staff made expert ratings of eating behaviours, attitudes and outcome of former in-patients. METHOD: Ten health-care staff at a specialist eating disorders clinic rated overall success of treatment outcome at discharge, as well as compliance, severity of disordered eating behaviours and body-image disturbance at both admission and discharge for 46 anorexic and 14 bulimic patients. RESULTS: For all participants, high compliance at admission was associated with lower levels of body image disturbance, less disordered eating behaviours and higher ratings of overall treatment success at discharge. Compliance at admission predicted the body mass index (BMI) at discharge for anorexic participants and predicted higher ratings of overall treatment success at discharge for all participants. In all participants, compliance at admission was related to the extent of eating-disordered behaviours at admission. CONCLUSIONS: Results suggest the importance of compliance in facilitating recovery and treatment success among treatment-resistant eating-disordered in-patients. The promotion of strategies to improve compliance in this population should be considered. A role for motivational interviewing is discussed.

Health behavior counseling at annual exams.

OBJECTIVE: To determine if patients expected and desired health behavior discussions at annual exams, and if these discussions motivated high-risk patients to modify a health behavior. METHODS: 1213 patients seen for an annual exam at Gundersen Clinic were sent a survey. Patients were asked if discussions about weight, exercise, tobacco use and stress occurred at their exam. Patients were also asked if the discussions were expected and desired and if the discussions motivated them to modify a health behavior. RESULTS: 571 surveys were returned. Over 50% of high-risk patients for each health behavior had a discussion. Patients who were overweight, obese, smoked or had excess stress were more likely to want and expect discussions than lower risk counterparts. Obese and overweight patients were also more likely to report being motivated to maintain or lose weight. CONCLUSION: Patients in need of weight, smoking and stress management counseling expected and desired behavior discussions and were motivated to modify their behavior.

End-user exposures to synthetic vitreous fibers: II. Fabrication and installation fabrication of commercial products.

This article summarizes the results of exposure monitoring conducted during the installation and fabrication of commercial synthetic vitreous fiber (SVF) products. Included in this investigation were fiberglass duct insulation and construction applications (duct board, duct liner, and duct wrap), pipe and vessel insulation, batt insulation for prefabricated homes, and general fiberglass products. Commercial mineral wool products sampled as a part of this investigation included ceiling tiles, building safing, and loose insulation for prefabricated homes. A total of 520 valid air samples were collected as a part of this investigation and were analyzed using gravimetric, phase contrast microscopy (PCM), or scanning electron microscopy (SEM). Airborne fiber-size distributions were also determined for a subset of samples collected for SEM analysis. As a result of the task-based sampling strategy used in this study, sample times reflect exposures over the time the person was actually engaged in SVF-related work activities, and exposure results are therefore presented as task-length averages (TLAs). Thirty-five total dust samples were collected as a part of this investigation, resulting in 14 TLAs ranging from 0.3 to 7.6 mg/m3. A total of 125 PCM-based TLAs were collected, with the mean TLA time for all product and occupation categories ranging from 277 to 443 minutes. The mean PCM-based TLAs for all product/occupations were below 1.0 f/cm3, ranging from 0.04 to 0.68 f/cm3. A total of 116 SEM TLAs were determined. Average SEM-based TLA concentrations were slightly lower than the PCM-based estimates and ranged from <0.01 to 0.16 f/cm3. The geometric mean fiber diameters for commercial products and occupations sampled as a part of the investigation ranged from 0.8 microm to 1.9 microm. Geometric mean fiber length varied by a factor of approximately three, ranging from 9.5 microm to 29.5 microm.

Lack of relationship between functional ability and skin score in patients with systemic sclerosis.

OBJECTIVE: To examine the hypothesis that functional ability is related to skin score in patients with systemic sclerosis (SSc). METHODS: In 140 patients with SSc attending clinics in the northwestern region of England, functional ability (measured using a recently developed 11 item functional questionnaire) was correlated with skin score (measured using a modified Rodnan technique--17 sites, maximum score 3 for each site). RESULTS: The median functional score was 6 (range 0-31) and the median skin score 7 (range 0-37). There was no correlation between functional score and total skin score (rS = 0.11, p = 0.19, Spearman). Because most of the questions of the functional score related to upper limb function, separate analyses were undertaken restricting consideration of skin involvement to (1) upper limbs only and (2) digital skin only, versus the overall functional score. Again, no evidence of an association was observed. CONCLUSION: Functional ability in this broad group of patients with SSc cannot be predicted from the skin score. Although skin score is useful prognostically, it is not a major determinant of a patient's ability to perform activities of everyday living.

Provider attitudes and use of alternative medicine in a midwestern medical practice in 2001.

OBJECTIVE: To determine the current level of use, referral and desire for service of different complementary and alternative (CAM) therapies among Gundersen Lutheran Medical Center providers. METHODS: A survey was conducted in January of 2001 of all medical and associate staff. RESULTS: The response rate was 79%; 55% reported using 1 or more of 18 therapies for themselves. Over 25% of providers used nutritional supplements, herbal medicines, or hydrotherapy with a patient. Over half of providers had referred a patient for biofeedback or chiropractic care. Over half of providers would like to offer acupuncture, biofeedback, chiropractic care, hydrotherapy, nutritional supplements, or massage to patients in the future. Associate staff, female staff, primary care providers, and those who had personally used CAM therapies were more likely to have used, referred, or wish to offer more therapies in the future. There was little support for aromatherapy, magnetic field therapy, naturopathic medicine, or ethnic healing methods. CONCLUSIONS: Use of and desire for complementary therapies at Gundersen Lutheran was higher than expected by the Integrative Medicine Oversight Committee. Health care organizations should consider having a process in place to manage the increasing demands for complementary and alternative therapies.

Community Mothers Programme--seven year follow-up of a randomized controlled trial of non-professional intervention in parenting.

BACKGROUND: The Community Mothers Programme aims at using experienced volunteer mothers in disadvantaged areas to give support to first-time parents in rearing their children up to 1 year of age. The programme was evaluated by randomized controlled trial in 1990. METHODS: Seven years later, trial participants were interviewed about child health, nutrition, cognitive stimulation, parenting skills, and maternal self-esteem. The aim of this study was to see whether the demonstrated benefits at 1 year of age of this programme could be sustained at age 8. RESULTS: One-third of the original group (38 intervention, 38 control), were contacted and interviewed. The risk for having an accident requiring a hospital visit was lower in the intervention group: relative risk (RR) 0.59, 95 per cent confidence interval (CI) 0.31-1.11. Intervention children were more likely to visit the library weekly: RR 1.58, 95 per cent CI 1.10-2.26. Intervention mothers were more likely to check homework every night: RR 1.23, 95 per cent CI 1.05-1.43 (p=0.006); and to disagree with the statement 'children should be smacked for persistently bad behaviour': RR 2.11, 95 per cent CI 1.10-4.06. They were more likely to disagree with the statement 'I do not have much to be proud of': RR 1.24, 95 per cent CI 1.04-1.40; and to make a positive statement about motherhood than controls: RR 1.53, 95 per cent CI 1.06-2.20. Subsequent children of intervention mothers were more likely to have completed Haemophilus influenzae b: RR 1.26, 95 per cent CI 1.06-1.51; and polio immunization: RR 1.19, 95 per cent CI 1.02-1.40. CONCLUSIONS: The Community Mothers programme had sustained beneficial effects on parenting skills and maternal self-esteem 7 years later with benefit extending to subsequent children.

Enhancing RNA repair efficiency by combining trans-splicing ribozymes that recognize different accessible sites on a target RNA.

Recent reports have demonstrated that trans-splicing ribozymes can be employed to repair mutant RNAs. One key factor that influences RNA repair efficiency is the accessibility of the substrate RNA for ribozyme binding, which is complicated by the fact that RNAs may assume multiple conformations and have proteins bound to them in vivo. Here we describe a strategy to map accessible sites on sickle beta-globin (beta(s)-globin) transcripts in vitro and in vivo and to use this information to enhance RNA repair efficiency. Two sites upstream of the sickle mutation were identified as accessible in some fraction of the beta-globin RNA by mapping with a ribozyme library and the accessibility of those sites was assessed by in vitro cleavage analyses. Ribozymes targeting either site could only convert a certain fraction of the beta(s)-globin RNA to product but not drive the reaction to completion. However, cleavage and splicing reactions were driven further toward completion when the two ribozymes were both added to the reactions, suggesting that the substrate RNA is present in multiple conformations in vitro. These two ribozymes were each able to repair beta(s)-globin transcripts in erythrocyte precursors derived from peripheral blood from individuals with sickle cell disease. Moreover, the relative accessibility of the targeted sites in vivo is as predicted by mapping and in vitro analyses. These results demonstrate that this novel RNA mapping strategy represents an effective means to determine the accessible regions of target RNAs and that combinations of trans-splicing ribozymes can be employed to enhance RNA repair efficiency of clinically relevant transcripts such as beta(s)-globin RNA.

Lung cancer among workers in chromium chemical production.

BACKGROUND: An elevated risk of lung cancer among workers in chromate production facilities has previously been reported. This excess risk is believed to be the result of exposure to hexavalent chromium. There have been mixed reports about whether trivalent chromium exposure is also associated with an excess lung cancer risk. Previous studies of measured hexavalent chromium exposure and lung cancer risk have not examined cigarette smoking as a risk factor. METHODS: A cohort of 2,357 workers first employed between 1950 and 1974 at a chromate production plant was identified. Vital status of the workers was followed until December 31, 1992. Work histories of cohort members were compiled from the beginning of employment through 1985, the year the plant closed. Annual average exposure estimates, based on historical exposure measurements, were made for each job title in the plant for the years 1950-1985. These exposure estimates were used to calculate the cumulative hexavalent chromium exposure of each member of the study population. Following closure of the plant, settled dust samples were collected and analyzed for hexavalent and trivalent chromium. The trivalent/hexavalent concentration ratios in each plant area were combined with historic air-sampling data to estimate cumulative trivalent chromium exposure for each individual in the study cohort. Smoking status (yes/no) as of the beginning of employment and clinical signs of potential chromium irritation were identified from company records. RESULTS: Cumulative hexavalent chromium exposure showed a strong dose-response relationship for lung cancer. Clinical signs of irritation, cumulative trivalent chromium exposure, and duration of work were not found to be associated with a risk of lung cancer when included in a proportional hazards model with cumulative hexavalent chromium exposure and smoking. Age-specific data on cumulative hexavalent chromium exposure, observed and expected numbers of lung cancer cases, and person-years of observation are provided. CONCLUSIONS: Cumulative hexavalent chromium exposure was associated with an increased lung cancer risk; cumulative trivalent chromium exposure was not. The excess risk of lung cancer associated with cumulative hexavalent chromium exposure was not confounded by smoking status. The current study offers the best quantitative evidence to date of the relationship between hexavalent chromium exposure and lung cancer. Am. J. Ind. Med. 38:115-126, 2000. Published 2000 Wiley-Liss, Inc.

Clinical findings of irritation among chromium chemical production workers.

BACKGROUND: Several reports of workers in chromate production and chromeplating have indicated that exposure to hexavalent chromium is associated with skin and nasal irritation. METHODS: A cohort of 2, 357 workers first employed between 1950 and 1974 at a chromate production plant was identified. Clinical findings of irritation were identified by a physician as a result of routine examinations or visits to the medical clinic by members of the cohort. Percentages of the cohort with various clinical findings, the time from hire to occurrence of the first finding, and the mean and median annual hexavalent chromium (measured as CrO(3)) concentration for the job title where the clinical finding first occurred were determined. A proportional hazards model was used to evaluate the relationship between hexavalent chromium exposure and first occurrence of each of the clinical findings. RESULTS: Nasal irritation and nasal ulceration were the most common clinical findings reported, occurring in more than 60% of the cohort. The average time to first occurrence of these findings was less than 3 months, whereas the time to first occurrence of the other findings ranged from 10 to 22 months. Median exposure to hexavalent chromium at the time of occurrence for most of the findings was about 20 microg/m(3). The proportional hazards model indicated that ulcerated nasal septum, irritated skin, and perforated eardrum were significantly associated with ambient hexavalent chromium exposure; all clinical findings with the exception of conjunctivitis and irritated skin were associated with the calendar year of hire, with the risk being lower as the calendar year of hire became more recent. Annual average ambient hexavalent chromium concentrations generally dropped in the plant over the period of the study. CONCLUSIONS: Workers in the chromate production plant in this study experienced a variety of nasal and skin irritations. Irritated and ulcerated nasal septa, in particular, were quite common clinical findings, occurring in over 60% of the cohort, and they occurred in relatively short periods of time-less than 3 months from date of hire. Annual average concentrations of chromium may not be a good predictor of clinical findings of irritation. Am. J. Ind. Med. 38:127-131, 2000. Published 2000 Wiley-Liss, Inc.

An evaluation of employee exposure to volatile organic compounds in three photocopy centers.

Personal and area samples from three copy centres were collected in thermal desorption tubes and analyzed using gas chromatography-mass spectrometry. Real-time personal total volatile organic compounds (TVOC) were measured using a data-logging photoionization detector. Fifty-four different VOCs were detected in the area samples. The maximum concentration measured was 1132.0 ppb (toluene, copy center 3, day 1). Thirty-eight VOCs were detected in the personal samples and concentrations ranged from 0.1 ppb (1,1-biphenyl, p-dichlorobenzene, propylbenzene, styrene, and tetrachloroethylene) to 689.6 ppb (toluene). Real-time TVOC measurements indicated daily fluctuations in exposure, ranging from <71 to 21,300 ppb. The time-weighted average exposures for the photocopier operators on days 1 and 2 were 235 and 266 ppb and 6155 and 3683 ppb, in copy centers 2 and 3, respectively. Personal exposure measurements of individual VOCs were below accepted occupational standards and guidelines. For example, the maximum concentration was 0.3% of the permissible exposure limits (toluene, copy center 3). Exposures were highest in copy center 3; this is likely due to the presence of offset printing presses. It is concluded that photocopiers contribute a wide variety of VOCs to the indoor air of photocopy centers; however, exposures are at least 100 times below established standards.

Bone density of women who have recovered from anorexia nervosa.

OBJECTIVE: To examine bone density in 19 women who had previously experienced classical anorexia nervosa from which they had been fully recovered for a mean of 21 years (current characteristics: median age 40.2 years; Eating Attitudes Test [EAT] score 2; body mass index [BMI] 21.1; average 1.8 offspring). METHOD: Probands were compared, blindly, in respect of bone density, with 13 control subjects matched for age and sex and with no history of eating disorders. Dual energy X-ray absorptiometry (DXA) was used to evaluate the bone mineral density (BMD) of the lumbar spine and the head of the femur. RESULTS: Femur BMD was still significantly less among ex-anorectic sufferers. Two subjects had experienced pathological fractures while anorectic, both having been strenuous exercisers. None appeared to have suffered post illness fractures. BMD at follow-up did not relate to the severity or chronicity of previous anorexia nervosa. DISCUSSION: Full clinical recovery from anorexia nervosa does not quite confer full establishment of normal bone density. However, pathological fractures are not a feature thereafter, within middle life.