The Epidemiology of Osteoporosis in the Frail Institutionalized Elderly

As our population ages, the proportion of frail elderly people requiring assisted accommodation in aged care facilities is increasing. This population is at high risk of falls and fractures, which bring significant morbidity and mortality. The prevalence of osteoporosis also increases with age, but there have been few studies of bone density in residents of hostels and nursing homes. This thesis looked at the prevalence of osteoporosis and falls in elderly people in residential care, to define the size of the problem and identify risk factors for low bone density and falling, with particular reference to vitamin D levels. Two thousand and five men and women aged between 65 and 104 years were enrolled in the Falls and Fracture Risk in the Elderly Epidemiology (FREE) study between 1999 and 2003. The key findings from analysis of this population were firstly, that quantitative ultrasound (QUS) measures were higher in men than women independent of age, and that in men there was no significant decline in either BUA or VOS, but in women BUA declined by over 3% per decade and VOS by 1% per decade. Both ultrasound machines used in the study were shown to be reliable, with precision unaffected by advanced age. QUS was found to be sensitive to longitudinal change even in this frail elderly cohort. Vitamin D deficiency was found in the majority of elderly aged care facility residents but supplementation conferred higher serum 25-OH-vitamin D levels. Vitamin D levels were not shown to be related to BUA, VOS or the risk of falling in this population. Serum parathyroid hormone might be important in determining future falls risk. In summary, the results of this thesis give an important insight into the prevalence of osteoporosis and falls in the frail elderly, and how these might be predicted. Future study of prospective fracture rates in this group will then be able to assess relative risk factors for osteoporotic fracture, and identify those individuals who might benefit from directed fracture prevention strategies

The Epidemiology of Osteoporosis in the Frail Institutionalized Elderly

As our population ages, the proportion of frail elderly people requiring assisted accommodation in aged care facilities is increasing. This population is at high risk of falls and fractures, which bring significant morbidity and mortality. The prevalence of osteoporosis also increases with age, but there have been few studies of bone density in residents of hostels and nursing homes. This thesis looked at the prevalence of osteoporosis and falls in elderly people in residential care, to define the size of the problem and identify risk factors for low bone density and falling, with particular reference to vitamin D levels. Two thousand and five men and women aged between 65 and 104 years were enrolled in the Falls and Fracture Risk in the Elderly Epidemiology (FREE) study between 1999 and 2003. The key findings from analysis of this population were firstly, that quantitative ultrasound (QUS) measures were higher in men than women independent of age, and that in men there was no significant decline in either BUA or VOS, but in women BUA declined by over 3% per decade and VOS by 1% per decade. Both ultrasound machines used in the study were shown to be reliable, with precision unaffected by advanced age. QUS was found to be sensitive to longitudinal change even in this frail elderly cohort. Vitamin D deficiency was found in the majority of elderly aged care facility residents but supplementation conferred higher serum 25-OH-vitamin D levels. Vitamin D levels were not shown to be related to BUA, VOS or the risk of falling in this population. Serum parathyroid hormone might be important in determining future falls risk. In summary, the results of this thesis give an important insight into the prevalence of osteoporosis and falls in the frail elderly, and how these might be predicted. Future study of prospective fracture rates in this group will then be able to assess relative risk factors for osteoporotic fracture, and identify those individuals who might benefit from directed fracture prevention strategies

A comparison of the predictive accuracy of three screening models for pulmonary arterial hypertension in systemic sclerosis

Introduction: There is evidence that early screening for pulmonary arterial hypertension (PAH) in systemic sclerosis (SSc) improves outcomes. We compared the predictive accuracy of two recently published screening algorithms (DETECT 2013 and Australian Scleroderma Interest Group (ASIG) 2012) for SSc-associated PAH (SSc-PAH) with the commonly used European Society of Cardiology/European Respiratory Society (ESC/ERS 2009) guidelines. Methods: We included 73 consecutive SSc patients with suspected PAH undergoing right heart catheterization (RHC). The three screening models were applied to each patient. For each model, contingency table analysis was used to determine sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values for PAH. These properties were also evaluated in an ‘alternate scenario analysis’ in which the prevalence of PAH was set at 10%. Results: RHC revealed PAH in 27 (36.9%) patients. DETECT and ASIG algorithms performed equally in predicting PAH with sensitivity and NPV of 100%. The ESC/ERS guidelines had sensitivity of 96.3% and NPV of only 91%, missing one case of PAH; these guidelines could not be applied to three patients who had absent tricuspid regurgitant (TR) jet. The ASIG algorithm had the highest specificity (54.5%). With PAH prevalence set at 10%, the NPV of the models was unchanged, but the PPV dropped to less than 20%. Conclusions: In this cohort, the DETECT and ASIG algorithms out-perform the ESC/ERS guidelines, detecting all patients with PAH. The ESC/ERS guidelines have limitations in the absence of a TR jet. Ultimately, the choice of SSc-PAH screening algorithm will also depend on cost and ease of application

The CEDAR Study: A longitudinal study of the clinical effects of conventional DMARDs and biologic DMARDs in Australian rheumatology practice

Objectives. To observe the choices of conventional disease modifying antirheumatic drugs (cDMARDs) and biologic DMARDs (bDMARDs) in the management of rheumatoid arthritis (RA) in Australian routine clinical practice, to assess treatment survival and determine the effect of cDMARDs/bDMARDs on disease activity. Methods. Routinely collected, deidentified clinical data was sourced from 20 Australian rheumatology practices. RA patients aged ≥18 years, who had received cDMARDs/bDMARDs and a recorded subsequent visit, were included. A linear mixed model was used to determine the change over time and the percentage reduction in disease activity was summarized. Results. 12,526 RA patients were included: 72% females, mean age 62 years. cDMARDs and bDMARDs were used in 92% and 30% of patients, respectively. The most commonly prescribed cDMARD was methotrexate (76% patients); median time to stopping treatment was 337 months [95% CI: 279–ND]. Etanercept was the most commonly prescribed bDMARD (12% patients); median time to stopping treatment was 79 months [95% CI: 57–93]. Of 5,341 patients with a first change in medication (cDMARD or bDMARD), 87% had therapy escalation and 13% deescalation. Reduction in DAS28-ESR, 6-month post-DMARDs initiation ranged from 3%, adalimumab, to 14%, leflunomide and tocilizumab. Conclusions. In this large Australian cohort of unselected community RA patients, the choices of cDMARDs/bDMARDs are aligned with current international guidelinesThis work was supported by Roche Products Pty Limited (Australia)

The inclusion of N-terminal pro-brain natriuretic peptide in a sensitive screening strategy for systemic sclerosis-related pulmonary arterial hypertension: a cohort study

INTRODUCTION: Pulmonary arterial hypertension (PAH) is a major cause of mortality in systemic sclerosis (SSc). Screening guidelines for PAH recommend multiple investigations, including annual echocardiography, which together have low specificity and may not be cost-effective. We sought to evaluate the predictive accuracy of serum N-terminal pro-brain natriuretic peptide (NT-proBNP) in combination with pulmonary function tests (PFT) (‘proposed’ algorithm) in a screening algorithm for SSc-PAH. METHODS: We evaluated our proposed algorithm (PFT with NT-proBNP) on 49 consecutive SSc patients with suspected pulmonary hypertension undergoing right heart catherisation (RHC). The predictive accuracy of the proposed algorithm was compared with existing screening recommendations, and is presented as sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). RESULTS: Overall, 27 patients were found to have pulmonary hypertension (PH) at RHC, while 22 had no PH. The sensitivity, specificity, PPV and NPV of the proposed algorithm for PAH was 94.1%, 54.5%, 61.5% and 92.3%, respectively; current European Society of Cardiology (ESC)/European Respiratory Society (ERS) guidelines achieved a sensitivity, specificity, PPV and NPV of 94.1%, 31.8%, 51.6% and 87.5%, respectively. In an alternate case scenario analysis, estimating a PAH prevalence of 10%, the proposed algorithm achieved a sensitivity, specificity, PPV and NPV for PAH of 94.1%, 54.5%, 18.7% and 98.8%, respectively. CONCLUSIONS: The combination of NT-proBNP with PFT is a sensitive, yet simple and non-invasive, screening strategy for SSc-PAH. Patients with a positive screening result can be referred for echocardiography, and further confirmatory testing for PAH. In this way, it may be possible to shift the burden of routine screening away from echocardiography. The findings of this study should be confirmed in larger studies

Identification of the most common problems by patients with ankylosing spondylitis using the international classification of functioning, disability and health

Objective: The International Classification of Functioning, Disability and Health (ICF) aims to classify functioning and health by a number of categories divided over 3 components: body functions and body structures, participation and activities, and environmental factors. We identified the common health problems of patients with ankylosing spondylitis (AS) based on the ICF from the perspective of the patient.Methods: During structured interviews with the extended ICF checklist, trained assessors collected data from 111 patients with AS. ICF categories identified by more than 5% of the patients as at least mildly impaired or restricted were selected. Categories identified by less than 5% were removed. Additional impairments/restrictions reported by more than 5% of the patients, after the structured interviews and not yet included in the checklist, were added.Results: One hundred nineteen (72%) out of 165 categories of the extended ICF checklist were identified to be at least mildly impaired or restricted. Within each of the 4 components of the ICF, at least one-third of the categories were impaired or restricted for more than 50% of the patients. Thirty-nine (33%) categories were related to movement and mobility. Within the component "environmental factors" the categories "support of immediate family" and "health professionals" were the most important facilitators, "climate" was the most important barrier. Eight impairments were additionally mentioned as relevant. These were hierarchically lower levels of ICF categories previously included and they were added.Conclusion: One hundred twenty-seven ICF categories represent the comprehensive classification of functioning in AS from the patients' perspective. The results underscore the need to address the 4 ICF components when classifying functioning and to emphasize that functioning implies more than physical functioning

Evidence-based recommendations for the diagnosis of ankylosing spondylitis: results from the Australian 3E initiative in rheumatology

• As part of the 3E program, we conducted a systematic literature review and gathered consensus from 23 practising Australian rheumatologists to develop guidelines for early identification of ankylosing spondylitis and specialist referral. • In three rounds of break-out sessions followed by discussion and voting, the specialist panel addressed three questions related to diagnosis of ankylosing spondylitis: In individuals with back pain, what are the early clinical features that suggest ankylosing spondylitis? How useful is imaging in identifying early ankylosing spondylitis? Based on which clinical features should a general practitioner refer a patient to a rheumatologist for further evaluation? • The panel agreed on six recommendations related to the three questions: 1a. Early clinical features to suggest ankylosing spondylitis include inflammatory back pain and age at symptom onset < 45 years. 1b. The absence of symptomatic response to an appropriate course of non-steroidal anti-inflammatory drugs makes the diagnosis of ankylosing spondylitis less likely. 1c. Raised inflammatory markers are supportive, but their absence does not rule out the diagnosis of ankylosing spondylitis. 2a. Despite low sensitivity to detect changes of early ankylosing spondylitis, plain radiographs of the pelvis and spine are appropriate initial imaging techniques. 2b. Magnetic resonance imaging is a useful imaging modality for detecting early changes of ankylosing spondylitis. 3. Individuals with inflammatory back pain should be referred to a rheumatologist for further evaluation. • Effective dissemination and implementation of these recommendations are important to standardise the approach to early diagnosis of ankylosing spondylitis

Australian and New Zealand evidence-based recommendations for pain management by pharmacotherapy in adult patients with inflammatory arthritis

Aim: To develop Australian and New Zealand evidence-based recommendations for pain management by pharmacotherapy in adult patients with optimally treated inflammatory arthritis (IA). Methods: Four hundred and fifty-three rheumatologists from 17 countries including 46 rheumatologists from Australia and New Zealand participated in the 2010 3e (Evidence, Expertise, Exchange) Initiative. Using a formal voting process, rheumatologists from 15 national scientific committees selected 10 clinical questions regarding the use of pain medications in IA. Bibliographic fellows undertook a systematic literature review for each question, using MEDLINE, EMBASE, Cochrane CENTRAL and 2008–09 EULAR/ACR abstracts. Relevant studies were retrieved for data extraction and risk of bias assessment. Rheumatologists from Australia and New Zealand used the evidence to develop a set of national recommendations. These recommendations were then formulated and assessed for agreement and the potential impact on clinical practice. The Oxford Levels of Evidence and Grade of Recommendation were applied to each recommendation. Results: The systematic reviews identified 49 242 references, from which 167 studies which met the pre-specified inclusion criteria. Combining this evidence with expert opinion led to the development of 10 final Australian and New Zealand recommendations. The recommendations relate to pain measurement, and the use of analgesic medications in patients with and without co-morbidities and during pregnancy and lactation. The recommendations reflect the clinical practice of the majority of the participating rheumatologists (mean level of agreement 7.24–9.65). Conclusions: Ten Australian and New Zealand evidence-based recommendations regarding the management of pain by pharmacotherapy in adults with optimally treated IA were developed. They are supported by a large panel of rheumatologists, thus enhancing their utility in everyday clinical practice