Randomised trial of genetic testing and targeted intervention to prevent the development and progression of Paget's disease of bone

INTRODUCTION

Paget's disease of bone (PDB) frequently presents at an advanced stage with irreversible skeletal damage. Clinical outcomes might be improved by earlier diagnosis and prophylactic treatment.

METHODS

We randomised 222 individuals at increased risk of PDB because of pathogenic SQSTM1 variants to receive 5 mg zoledronic acid (ZA) or placebo. The primary outcome was new bone lesions assessed by radionuclide bone scan. Secondary outcomes included change in existing lesions, biochemical markers of bone turnover and skeletal events related to PDB.

RESULTS

The median duration of follow-up was 84 months (range 0-127) and 180 participants (81%) completed the study. At baseline, 9 (8.1%) of the ZA group had PDB lesions vs 12 (10.8%) of the placebo group. Two of the placebo group developed new lesions versus none in the ZA group (OR 0.41, 95% CI 0.00 to 3.43, p=0.25). Eight of the placebo group had a poor outcome (lesions which were new, unchanged or progressing) compared with none of the ZA group (OR 0.08, 95% CI 0.00 to 0.42, p=0.003). At the study end, 1 participant in the ZA group had lesions compared with 11 in the placebo group. Biochemical markers of bone turnover were significantly reduced in the ZA group. One participant allocated to placebo required rescue therapy with ZA because of symptomatic disease. The number and severity of adverse events did not differ between groups.

CONCLUSIONS

Genetic testing for pathogenic SQSTM1 variants coupled with intervention with ZA is well tolerated and has favourable effects on the progression of early PDB.

TRIAL REGISTRATION NUMBER

ISRCTN11616770.

Inflammatory Arthritis in Systemic Sclerosis: Its Epidemiology, Associations, and Morbidity

OBJECTIVE

To describe the epidemiology, associations, and impact of inflammatory arthritis (IA) in systemic sclerosis (SSc).

METHODS

Patients with SSc prospectively enrolled in the Australian Scleroderma Cohort Study were included. IA was defined clinically as the presence of synovitis on examination. Logistic regression was used to determine the associations of IA with SSc manifestations and serological parameters. Patient-reported outcome measures were used to capture physical function and health-related quality of life (HRQoL).

RESULTS

IA was a common SSc manifestation affecting one-third (33.3%) of patients over a median follow-up of 4.3 (1.7-8.4) years. Associations of IA included diffuse SSc (odds ratio [OR] 1.33, 95% confidence interval [95% CI] 1.01-1.74, P = 0.042), concurrent musculoskeletal manifestations (joint contractures and tendon friction rubs, OR 1.70, 95% CI 1.34-2.15, P < 0.001); myositis (OR 2.11, 95% CI 1.39-3.20, P < 0.001), and sicca symptoms (OR 1.57, 95% CI 1.14-2.16, P = 0.006), whereas IA was negatively associated with pulmonary arterial hypertension (OR 0.52, 95% CI 0.35-0.78, P = 0.002). Neither the presence of rheumatoid factor nor U1 small nuclear RNP were associated with IA (OR 1.13, 95% CI 0.88-1.44, P = 0.331, OR 1.46, 95% CI 0.89-2.39, P = 0.129 respectively). Positive anticyclic citrullinated protein antibodies, although at low frequency, were more common in those with IA compared with those without IA (7.5% vs 1.5%, P < 0.001). IA was associated with significantly lower HRQoL score (P < 0.001) and more physical disability than in those without IA (P < 0.001).

CONCLUSION

IA is a common disease manifestation that is more frquently seen in diffuse disease. IA is associated with poor HRQoL and physical disability. Further research is needed into the effective management of IA in SSc.

Safer medicines To reduce falls and refractures for OsteoPorosis (#STOP): a study protocol for a randomised controlled trial of medical specialist-initiated pharmacist-led medication management reviews in primary care

INTRODUCTION

Minimal trauma fractures (MTFs) often occur in older patients with osteoporosis and may be precipitated by falls risk-increasing drugs. One category of falls risk-increasing drugs of concern are those with sedative/anticholinergic properties. Collaborative medication management services such as Australia's Home Medicine Review (HMR) can reduce patients' intake of sedative/anticholinergics and improve continuity of care. This paper describes a protocol for an randomised controlled trial to determine the efficacy of an HMR service for patients who have sustained MTF.

METHOD AND ANALYSIS

Eligible participants are as follows: ≥65 years of age, using ≥5 medicines including at least one falls risk-increasing drug, who have sustained an MTF and under treatment in one of eight Osteoporosis Refracture Prevention clinics in Australia. Consenting participants will be randomised to control (standard care) or intervention groups. For the intervention group, medical specialists will refer to a pharmacist for HMR focused on reducing falls risk predominately through making recommendations to reduce falls risk medicines, and adherence to antiosteoporosis medicines. Twelve months from treatment allocation, comparisons between groups will be made. The main outcome measure is participants' cumulative exposure to sedative and anticholinergics, using the Drug Burden Index. Secondary outcomes include medication adherence, emergency department visits, hospitalisations, falls and mortality. Economic evaluation will compare the intervention strategy with standard care.

ETHICS AND DISSEMINATION

Approval was obtained via the New South Wales Research Ethics and Governance Information System (approval number: 2021/ETH12003) with site-specific approvals granted through Human Research Ethics Committees for each research site. Study outcomes will be published in peer-reviewed journals. It will provide robust insight into effectiveness of a pharmacist-based intervention on medicine-related falls risk for patients with osteoporosis. We anticipate that this study will take 2 years to fully accrue including follow-up.

TRIAL REGISTRATION NUMBER

ACTRN12622000261718.

Outcome Predictors of Immune-Mediated Necrotising Myopathy-A Retrospective, Multicentre Study

OBJECTIVES

Evidence-based treatment protocols are currently lacking for immune-mediated necrotising myopathy. In this multicentre retrospective study, we examined baseline clinical characteristics and treatment variables that may predict short-term outcome of patients with immune-mediated necrotising myopathy.

METHODS

Muscle biopsies from the John Hunter Hospital and the Royal Adelaide Hospital obtained between 2012 and 2019 were reviewed at a single laboratory at South Australia Pathology. All biopsies with histological features of IMNM were identified. Demographics of study subjects, clinical information, and myositis-specific antibody status were recorded along with muscle strength, serum CK and treatment regimens at baseline, three and six months. Primary outcome measures were muscle strength and serum creatinine kinase at 3- and 6-months. Mixed-effects regression models in a Bayesian framework were performed using Statistical Package R.

RESULTS

Female sex, older age, initial prednisone dose and intravenous methylprednisolone were associated with greater improvement in serum creatine kinase. In patients with moderate-to-severe disease at baseline, early intravenous immunoglobulin was associated with greater improvement in hip flexor strength at six months.

CONCLUSION

Early IVIg was associated with clinical improvement in short-term follow-up in IMNM. Female sex, older age, initial oral prednisone dose and initial use of IV methylprednisolone were associated with better biochemical improvement.

Patients' attitudes and experiences of transition from paediatric to adult healthcare in rheumatology: a qualitative systematic review

OBJECTIVES

We aimed to describe patients' attitudes and experiences of transition from paediatric to adult healthcare in rheumatology to inform patient-centred transitional care programmes.

METHODS

We searched MEDLINE, EMBASE, PsycINFO and CINAHL to August 2019 and used thematic synthesis to analyse the findings.

RESULTS

From 26 studies involving 451 people with juvenile-onset rheumatic conditions we identified six themes: a sense of belonging (comfort in familiarity, connectedness in shared experiences, reassurance in being with others of a similar age, desire for normality and acceptance); preparedness for sudden changes (confidence through guided introductions to the adult environment, rapport from continuity of care, security in a reliable point of contact, minimizing lifestyle disruptions); abandonment and fear of the unknown (abrupt and forced independence, ill-equipped to hand over medical information, shocked by meeting adults with visible damage and disability, vulnerability in the loss of privacy); anonymous and dismissed in adult care (deprived of human focus, sterile and uninviting environment, disregard of debilitating pain and fatigue); quest for autonomy (controlled and patronized in the paediatric environment, liberated from the authority of others, freedom to communicate openly); and tensions in parental involvement (overshadowed by parental presence, guilt of excluding parents, reluctant withdrawal of parental support).

CONCLUSION

Young people feel dismissed, abandoned, ill-prepared and out of control during transition. However, successful transition can be supported by preparing for changes, creating a sense of belonging and negotiating parental involvement and autonomy. Incorporating patient-identified priorities into transitional services may improve satisfaction and outcomes in young people with juvenile-onset rheumatic conditions.

Patient and parent perspectives on transition from paediatric to adult healthcare in rheumatic diseases: an interview study

OBJECTIVES

To describe the experiences, priorities, and needs of patients with rheumatic disease and their parents during transition from paediatric to adult healthcare.

SETTING

Face-to-face and telephone semistructured interviews were conducted from December 2018 to September 2019 recruited from five hospital centres in Australia.

PARTICIPANTS

Fourteen young people and 16 parents were interviewed. Young people were included if they were English speaking, aged 14-25 years, diagnosed with an inflammatory rheumatic disease (eg, juvenile idiopathic arthritis, juvenile dermatomyositis, systemic lupus erythematosus, panniculitis, familial Mediterranean fever) before 18 years of age. Young people were not included if they were diagnosed in the adult setting.

RESULTS

We identified four themes with respective subthemes: avoid repeat of past disruption (maintain disease stability, preserve adjusted personal goals, protect social inclusion); encounter a daunting adult environment (serious and sombre mood, discredited and isolated identity, fear of a rigid system); establish therapeutic alliances with adult rheumatology providers (relinquish a trusting relationship, seek person-focused care, redefine personal-professional boundaries, reassurance of alternative medical supports, transferred trust to adult doctor) and negotiate patient autonomy (confidence in formerly gained independence, alleviate burden on patients, mediate parental anxiety).

CONCLUSIONS

During transition, patients want to maintain disease stability, develop a relationship with their adult provider centralised on personal goals and access support networks. Strategies to comprehensively communicate information between providers, support self-management, and negotiate individualised goals for independence during transition planning may improve satisfaction, and health and treatment outcomes.

Can Patient-Reported Symptoms Be Used to Measure Disease Activity in Systemic Sclerosis?

OBJECTIVE

To evaluate the association between patient-reported symptoms and changes in disease activity over time in systemic sclerosis (SSc).

METHODS

Using data from 1,636 patients enrolled in the Australian Scleroderma Cohort Study, we used generalized estimating equations to determine the relationship between patient-reported worsening of Raynaud's phenomenon (RP), skin involvement, and breathlessness in the month preceding each study visit and features of disease activity in the corresponding organ systems. The associations between the following parameters were analyzed: patient-reported worsening RP and the presence of new-onset digital pitting and digital ulcers; patient-reported worsening skin involvement and increasing modified Rodnan skin thickness score (MRSS); new areas of skin involvement and new-onset joint contractures; patient-reported worsening breathlessness and deteriorating respiratory functions test (RFT) results, indicated by a 10% decrease in forced vital capacity (FVC) and a 15% decrease in diffusing capacity for carbon monoxide (DLco), new-onset interstitial lung disease (ILD), and new-onset pulmonary arterial hypertension (PAH).

RESULTS

We found a significant association between patient-reported worsening RP and the presence of digital ulcers (odds ratio [OR] 1.53 [95% confidence interval (95% CI) 0.60-0.93]), patient-reported worsening skin involvement and increasing MRSS (OR 2.10 [95% CI 1.54-2.86]), and worsening patient breathlessness and deteriorating RFTs (FVC OR 2.12 [95% CI 1.70-2.65]; DLco OR 1.97 [95% CI 1.34-2.02]), new-onset ILD (OR 1.91 [95% CI 1.40-2.61]), and new-onset PAH (OR 5.08 [95% CI 3.59-7.19]).

CONCLUSION

These results demonstrate that patient-reported symptoms are associated with clinically meaningful changes in disease activity in patients with SSc. This suggests that when objective measures of change in disease status are unavailable, patient-reported symptoms could be used to indicate a change in SSc disease activity.

Occupational silica exposure in an Australian systemic sclerosis cohort

Objective

To determine the frequency of self-reported occupational exposure to silica in SSc patients enrolled in the Australian Scleroderma Cohort Study, and to compare the disease characteristics of the silica-exposed patients with those of the non-exposed patients.

Method

Data collected over a 12-year period from 1670 SSc patients were analysed. We compared the demographic and clinical characteristics of those who reported occupational silica exposure with those who did not. A subgroup analysis of male patients was performed, as well as a multivariable analysis of correlates of silica exposure.

Results

Overall, 126 (7.5%) of the cohort reported occupational silica exposure. These individuals were more likely to be male (73 of 231, i.e. 31.6% males exposed) and to have worked in mining and construction industries. Those who reported silica exposure were younger at the onset of SSc skin involvement [odds ratio (OR) 0.9, P = 0.02], of male gender (OR 14.9, P &lt; 0.001), have joint contractures (OR 1.8, P = 0.05) and have higher physical disability as defined by scleroderma HAQ (OR 1.4, P = 0.01).

Conclusion

The highest percentage of silica exposure was found in males. These patients were more likely to have the presence of certain clinical manifestations and Scl-70 antibody, which is known to confer a poor prognosis. These findings support the association between occupational silica exposure and the subsequent development of SSc. Further investigation is required to describe the range of clinical manifestations and disease course, including prognosis and treatment response, in those diagnosed with occupationally induced SSc compared with idiopathic SSc.

Characteristics of Early Paget's Disease in SQSTM1 Mutation Carriers: Baseline Analysis of the ZiPP Study Cohort

Mutations in SQSTM1 are strongly associated with Paget's disease of bone (PDB), but little is known about the clinical characteristics of those with early disease. Radionuclide bone scans, biochemical markers of bone turnover, and clinical characteristics were analyzed in SQSTM1 mutation carriers who took part in the Zoledronic acid in the Prevention of Paget's disease (ZiPP) study. We studied 222 individuals, of whom 54.9% were female, with mean ± SE age of 50.1 ± 0.6 years. Twelve SQSTM1 mutations were observed, including p.Pro392Leu, which was present in 141 of 222 (63.5%) subjects. Bone scan examination revealed evidence of PDB in 20 subjects (9.0%), ten of whom (50%) had a single affected site. Participants with lesions were older than those without lesions but the difference was not significant (53.6 ± 9.1 versus 49.8 ± 8.9; p = .07). The mean age of participants with lesions was not significantly different from the age at which their parents were diagnosed with PDB (55 years versus 59 years, p = .17). All individuals with lesions were asymptomatic. Serum concentrations of total alkaline phosphatase (ALP) normalized to the upper limit of normal in each center were higher in those with lesions (0.75 ± 0.69 versus 0.42 ± 0.29 arbitary units; p < .0001). Similar findings were observed for other biochemical markers of bone turnover, but the sensitivity of ALP and other markers in detecting lesions was poor. Asymptomatic PDB is present in about 9% of SQSTM1 mutation carriers by the fifth decade. Further follow-up of this cohort will provide important information on the natural history of early PDB and its response to treatment. © 2020 The Authors. Journal of Bone and Mineral Research published by American Society for Bone and Mineral Research.

SAT0638-HPR CHARACTERIZING THE IMPACT OF AXIAL SPONDYLOARTHRITIS ON DAILY LIFE: GENDER AND PATIENT-REPORTED OUTCOMES ASSOCIATED WITH FUNCTIONAL LIMITATION IN CANADA. RESULTS FROM THE IMAS SURVEY

Background:

Understanding the most limiting daily activities reported by patients is important for a holistic healthcare approach.

Objectives:

To evaluate the degree of functional limitation on daily activities and its association with PROs in Canada.

Methods:

The International Map of Axial Spondyloarthritis (IMAS) is a cross-sectional online survey of non-selected patients with self-reported axSpA conducted in 22 countries and endorsed by the Axial Spondyloarthritis International Federation. IMAS captures the patients’ perspective of the burden of axSpA. The Canadian adaptation included a review of the survey by an advisory board of axSpA patients and a national steering committee composed of the Canadian Spondylitis Association, rheumatologists and axSpA patients. Canadian participants were recruited from 2018 to 2019. Socio-demographics variables, BASDAI and mental health (GHQ-12) data were collected. Degree of functional limitation in 18 daily activities was evaluated using a 3-point Likert scale. Bivariate analysis was performed to assess activities associated with poorer BASDAI and mental health status.

Table 1.

BASDAI and mental health (GHQ-12)- impact on daily activities (N = 542)

BASDAIMean ± SDGHQ-12Mean ± SDLow limitationMedium + High Limitationp-valueLow limitationMedium + High Limitationp-valueDressing / undressing5.5 ± 2.06.4 ± 4.4<.001*4.4 ± 3.85.7 ±4.0.007*Washing / personal grooming5.6 ±2.06.3 ± 2.0.002*4.7 ± 4.15.6 ± 4.1.099Taking a bath / shower5.6 ±2.06.6 ±1.8<.001*4.2 ± 4.05.9 ± 4.0.002*Tying shoe laces5.4 ± 2.06.1 ± 2.0.005*4.3 ± 3.85.2 ± 4.1.044*Walking / getting around the house5.5 ± 2.06.4 ± 1.9<.001*4.2 ± 3.95.6 ± 4.1.005*Stair climbing5.1 ±1.96.3 ±1.8<.001*3.4 ± 3.45.4 ± 4.0<.001*Lying down / getting up from bed5.2 ± 2.06.3 ± 1.9<.001*3.6 ± 3.65.5 ± 4.1<.001*Going to the toilet5.4 ± 2.06.7 ± 1.9<.001*4.3 ± 4.25.6 ± 3.9.024*Shopping5.6 ± 1.86.2 ± 1.9.003*4.1 ± 3.75.3 ± 4.1.025*Cooking5.6 ± 1.96.3 ± 1.8.008*3.7 ± 3.65.8 ±4.2<.001*Eating5.9 ± 2.16.9 ± 1.9.024*5.0 ± 4.45.8 ± 3.9.282Housework / cleaning4.9 ± 2.06.0 ± 1.8<.001*3.7 ± 3.64.8 ± 4.0.021*Walking down the street5.4 ± 1.96.1 ± 2.0.005*4.4 ± 3.85.1 ± 4.1.228Using public transportation5.6 ± 1.96.1 ± 1.9.1804.4 ± 4.05.3 ± 4.0.155Driving5.5 ± 2.06.1 ± 2.1.021*4.2 ± 3.95.3 ± 4.2.050Doing physical exercise4.7 ± 2.15.8 ± 1.9<.001*3.4 ± 3.74.7 ± 4.0.002*Engaging in intimate relations5.2 ± 1.96.0 ±1.9<.0014.0 ± 3.85.1 ± 4.0.015*Caring for children / grandchildren5.2 ± 1.96.0 ± 2.0.0033.7 ± 3.85.2 ± 4.1.005

* p≤.05

Results:

542 axSpA patients participated. Mean age was 44.3±13.9 years and 63% were female. Mean BASDAI was 5.3±2.1, mean GHQ-12 score was 4.0±3.8 and 50% were on biologics. 94% reported ≥1 limitation in daily activities, of which physical exercise (30%), house cleaning (22%), intimacy (21%) and stair climbing (21%) were most commonly severely impacted (high limitation). Women reported significantly higher limitations in house cleaning, stair climbing, driving, moving around the house and caring for young children (p<.05 for all activities vs men). Compared with low limitation, medium–high limitation in most activities was significantly associated with higher disease activity and worsened mental health for the overall population (Table 1).

Conclusion:

Canadian axSpA patients, particularly women, are limited in daily life activities beyond those captured by other validated scales. Strong association between functional limitation, disease activity and mental health emphasizes the need for holistic evaluation of axSpA patients.

Disclosure of Interests:

Proton Rahman Grant/research support from: Janssen and Novartis, Consultant of: Abbott, AbbVie, Amgen, BMS, Celgene, Lilly, Janssen, Novartis, and Pfizer., Speakers bureau: Abbott, AbbVie, Amgen, BMS, Celgene, Lilly, Janssen, Novartis, Pfizer, Marco Garrido-Cumbrera: None declared, Sherry Rohekar: None declared, Michael Mallinson: None declared, Gerald Major: None declared, Algis Jovaisas: None declared, Nigil Haroon: None declared, Wendy Gerhart: None declared, Artur J. deBrum Fernandes: None declared, Martin Cohen: None declared, Jon Chan: None declared, Patrick Leclerc Employee of: Novartis, Julie Schneiderman Employee of: Novartis, Robert Inman: None declared

SAT0629-HPR FACTORS ASSOCIATED WITH USE OF BIOLOGICAL THERAPIES FOR AXIAL SPONDYLOARTHRITIS IN CANADA. RESULTS FROM THE IMAS SURVEY

Background:

Biologics have revolutionized the treatment of axial spondyloarthritis (axSpA). However, there is limited knowledge about factors associated with their use in Canada.

Objectives:

To evaluate sociodemographic, healthcare and patient-reported outcomes (PROs) associated with the use of biologics in Canadian axSpA patients.

Methods:

The International Map of Axial Spondyloarthritis (IMAS) is a cross-sectional online survey of non-selected patients with self-reported axSpA, conducted in 21 countries and endorsed by the Axial Spondyloarthritis International Federation (ASIF). IMAS captures the patients’ perspective of the burden of axSpA. The Canadian adaptation included a review of the survey by an advisory board of axSpA patients and a national steering committee composed of the Canadian Spondylitis Association, rheumatologists and patients. Participants were recruited between August 2018 and February 2019. Sociodemographic and healthcare-related variables, as well as PROs (disease activity [BASDAI, 0–10], spinal stiffness [3–12], functional limitation [0–54] and psychological distress [GHQ-12]) were collected. Respondents were divided in 2 groups 1) biologic and 2) NSAIDs or no treatment, based on reported pharmacologic treatments. Statistical analyses were performed to assess associations between variables and biologic use (bivariate) and the relative weight of these associations (multivariate).

Results:

542 axSpA patients were recruited. Mean age was 44.3±13.9 years, 63.1% were female, 66.4% married and 81.0% educated to university/college level. 22.8% of patients lived >50 km from their rheumatologist. Mean BASDAI was 5.3±2.1 and mean GHQ-12 score (mental health) was 4.0±3.8. Nearly half (49.6%) were currently on a biologic. Reported incidence of side effects was lower for patients having biologics (42.5%) vs. a NSAIDs (53.7%) as part of their treatment armamentarium. Only 15.7% of patients had discontinued biologic therapy, the main reasons for withdrawal being physician recommendation (50%), side effects (50%) and personal choice (34%). Variables associated with biologic use included: membership of a patient support group (p<0.001), non-manual work (p=0.008), higher income level (p=0.039), having a combination of public and private insurance schemes (p<0.001) and diagnosis by a rheumatologist (p<0.001). Associated PROs were spinal stiffness (p=0.011) and diagnostic delay (p=0.030). In the multivariate analysis, all variables except income and diagnostic delay were associated with biologic use (Table 1).

Table 1.

Analysis of sociodemographic and clinical variables in relation to pharmacologic treatment

VariableUnivariate linear regressionMultivariate stepwise linear regressionB95% CIB95% CIIncome level0.0011.000–1.000NANAEmployment—manual worker–0.7610.266–0.822–0.8380.228–0.820Member of a patient support group0.9371.797–3.6281.1161.754–5.309Health insurance scheme—combination0.2091.162–1.3070.2151.132–1.357Diagnostic delay0.0090.993–1.026NANASpinal Stiffness (3–12)0.0991.022–1.1930.2201.090–1.424Diagnosed by rheumatologist0.5351.412–2.0670.3351.041–1.877

B, B coefficient; NA, [not applicable]

Conclusion:

Canadian axSpA patients with greater social status, disease awareness, and insurance options are more likely to receive biologic therapy. Furthermore, Canadian physicians are more inclined to prescribe biologics to patients with increased spinal stiffness.

Disclosure of Interests:

Robert Inman: None declared, Marco Garrido-Cumbrera: None declared, Jon Chan: None declared, Martin Cohen: None declared, Artur J. deBrum Fernandes: None declared, Wendy Gerhart: None declared, Nigil Haroon: None declared, Algis Jovaisas: None declared, Gerald Major: None declared, Michael Mallinson: None declared, Sherry Rohekar: None declared, Patrick Leclerc Employee of: Novartis, Julie Schneiderman Employee of: Novartis, Proton Rahman Grant/research support from: Janssen and Novartis, Consultant of: Abbott, AbbVie, Amgen, BMS, Celgene, Lilly, Janssen, Novartis, and Pfizer., Speakers bureau: Abbott, AbbVie, Amgen, BMS, Celgene, Lilly, Janssen, Novartis, Pfizer

Clinical Features of Systemic Sclerosis-Mixed Connective Tissue Disease and Systemic Sclerosis Overlap Syndromes

OBJECTIVE

To describe the clinical characteristics and outcomes of systemic sclerosis-mixed connective tissue disease (SSc-MCTD) and SSc overlap syndrome.

METHODS

We included patients from the Australian Scleroderma Cohort Study who met American College of Rheumatology/European Alliance of Associations for Rheumatology criteria for SSc. Three mutually exclusive groups were created: SSc-MCTD, SSc overlap, and SSc only. Univariate comparison of clinical features was performed by analysis of variance or chi-square test. Survival analysis was performed using Kaplan-Meier (KM) curves and Cox proportional hazards regression models.

RESULTS

Of 1,728 patients, 97 (5.6%) had SSc-MCTD, and 126 (7.3%) had SSc overlap. Those with MCTD-SSc were more commonly Asian (18.3% versus 10.1% in SSc overlap, and 3.6% in SSc only; P < 0.0001) and younger at disease onset (38.4 years versus 46.5 or 46.8 years, P < 0.0001). Those with SSc-MCTD or SSc overlap were more likely to have limited cutaneous SSc. All 3 groups had similar frequency of interstitial lung disease (ILD), although pulmonary arterial hypertension (PAH) was less common in SSc overlap. Synovitis and myositis were more common in SSc overlap and SSc-MCTD than in SSc only. KM curves showed better survival in SSc-MCTD than SSc overlap or SSc only (P = 0.011), but this was not significant after adjustment for sex and age at disease onset. SSc-specific antibodies were survival prognostic markers, with antinuclear antibody centromere or anti-RNP conferring better survival than anti-Scl-70 or anti-RNA polymerase III (P = 0.005). Patients with SSc-MCTD and SSc overlap had lower mortality following diagnosis of ILD and PAH than patients with SSc only.

CONCLUSION

This study provides insights into the clinical characteristics of patients with SSc-MCTD, SSc overlap, and SSc only and shows that anti-RNP antibodies are associated with better survival than anti-Scl-70 and anti-RNA polymerase III antibodies.

Zoledronate in the prevention of Paget's (ZiPP): protocol for a randomised trial of genetic testing and targeted zoledronic acid therapy to prevent SQSTM1-mediated Paget's disease of bone

INTRODUCTION

Paget's disease of bone (PDB) is characterised by increased and disorganised bone remodelling affecting one or more skeletal sites. Complications include bone pain, deformity, deafness and pathological fractures. Mutations in sequestosome-1 (SQSTM1) are strongly associated with the development of PDB. Bisphosphonate therapy can improve bone pain in PDB, but there is no evidence that treatment alters the natural history of PDB or prevents complications. The Zoledronate in the Prevention of Paget's disease trial (ZiPP) will determine if prophylactic therapy with the bisphosphonate zoledronic acid (ZA) can delay or prevent the development of PDB in people who carry SQSTM1 mutations.

METHODS AND ANALYSIS

People with a family history of PDB aged >30 years who test positive for SQSTM1 mutations are eligible to take part. At the baseline visit, participants will be screened for the presence of bone lesions by radionuclide bone scan. Biochemical markers of bone turnover will be measured and questionnaires completed to assess pain, health-related quality of life (HRQoL), anxiety and depression. Participants will be randomised to receive a single intravenous infusion of 5 mg ZA or placebo and followed up annually for between 4 and 8 years at which point baseline assessments will be repeated. The primary endpoint will be new bone lesions assessed by radionuclide bone scan. Secondary endpoints will include changes in biochemical markers of bone turnover, pain, HRQoL, anxiety, depression and PDB-related skeletal events.

ETHICS AND DISSEMINATION

The study was approved by the Fife and Forth Valley Research Ethics Committee on 22 December 2008 (08/S0501/84). Following completion of the trial, a manuscript will be submitted to a peer-reviewed journal. The results of this trial will inform clinical practice by determining if early intervention with ZA in presymptomatic individuals with SQSTM1 mutations can prevent or slow the development of bone lesions with an adverse event profile that is acceptable.

TRIAL REGISTRATION NUMBER

ISRCTN11616770.

External Validation and Evaluation of Adding MRI or Extended Myositis Antibody Panel to the 2017 EULAR/ACR Myositis Classification Criteria

Objective

To externally validate the European League Against Rheumatism/American College of Rheumatism (EULAR/ACR) classification criteria for idiopathic inflammatory myositis (IIM) and determine the optimal cut points for Australian patients. To determine the level of agreement with traditional criteria and assess the effect of including magnetic resonance imaging (MRI) and an extended myositis antibody panel as well as extending histological criteria to include myofiber invasion.

Methods

Data were collected on adult patients referred for muscle biopsy to two Australian teaching hospitals. Patients were scored for “risk of IIM” according to EULAR/ACR criteria, using clinician diagnosis as the gold standard.

Results

Overall, 87 of 204 patients had IIM. For patients with muscle biopsy, the optimal cut point of 5.25 (sensitivity 90%, specificity 89%) was lower than the EULAR/ACR cut point of 6.7, which in our cohort showed reduced sensitivity (71% vs 93%) but comparable specificity (89% vs 88%). We found moderate agreement between the EULAR/ACR criteria and Bohan and Peter (κ = 0.45, 95% confidence interval [CI] = 0.28, 0.62, P < 0.001) and Targoff (κ = 0.40, 95% CI = 0.23, 0.57, P < 0.001). Inclusion of MRI (area under curve [AUC] = 0.86, 95% CI = 0.79, 0.93) or non‐Jo1 antibodies (AUC = 0.84, 95% CI = 0.77, 0.91) as covariates improved the probability of IIM diagnosis (AUC = 0.80, 95% CI = 0.75, 0.86). Extending histologic criteria to include myofiber invasion slightly improved sensitivity (75% vs 71%) with the same level of specificity (89% vs 89%).

Conclusion

Application of the EULAR/ACR criteria to an Australian cohort showed comparable specificity but lower sensitivity, and a lower optimal cut point. Inclusion of MRI or non‐Jo1 antibodies as covariates may improve the accuracy of determining the probability of IIM diagnoses. Extending the histologic criteria to include myofiber invasion did not reduce specificity.

Significance of anti-neutrophil cytoplasmic antibodies in systemic sclerosis

Background

Up to 12% of patients with systemic sclerosis (SSc) have anti-neutrophil cytoplasmic antibodies (ANCA). However, the majority of these patients do not manifest ANCA-associated vasculitis (AAV) and the significance of ANCA in these patients is unclear. The aim of this study is to determine the prevalence of ANCA in a well-characterised SSc cohort and to examine the association between ANCA and SSc clinical characteristics, other autoantibodies, treatments and mortality.

Methods

Clinical data were obtained from 5 centres in the Australian Scleroderma Cohort Study (ASCS). ANCA positive was defined as the presence of any one or combination of cytoplasmic ANCA (c-ANCA), perinuclear ANCA (p-ANCA), atypical ANCA, anti-myeloperoxidase (anti-MPO) or anti-proteinase-3 (anti-PR3). Associations of demographic and clinical features with ANCA were investigated by logistic or linear regression. Survival analysis was performed using Kaplan-Meyer curves and Cox regression models.

Results

Of 1303 patients, 116 (8.9%) were ANCA positive. Anti-PR3 was more common than anti-MPO (13.8% and 11.2% of ANCA-positive patients, respectively). Only 3 ANCA-positive patients had AAV. Anti-Scl-70 was more common in ANCA positive vs ANCA negative (25% vs 12.8%, p < 0.001), anti-MPO positive vs anti-MPO negative (38.5% vs 13.6%, p = 0.006) and anti-PR3 positive vs anti-PR3 negative patients (44.4% vs 13.4%, p < 0.001). A higher prevalence of interstitial lung disease (ILD) was found in the ANCA positive (44.8% vs 21.8%, p < 0.001) and the anti-PR3 positive groups (50.0% vs 23.4%, p = 0.009). In multivariable analysis, ANCA-positive status remained associated with ILD after adjusting for anti-Scl-70 antibodies. Pulmonary embolism (PE) was more common in ANCA-positive patients (8.6% vs 3.0%, p = 0.002) and anti-PR3-positive patients (16.7% vs 3.3%, p = 0.022). ANCA-positive status remained associated with PE in a multivariable analysis adjusting for anti-phospholipid antibodies. Kaplan-Meier analysis revealed increased mortality in ANCA-positive patients (p = 0.006). In Cox regression analysis, ANCA was associated with increased mortality, after adjusting for age and sex.

Conclusions

ANCA is associated with increased prevalence of ILD and PE in SSc. ANCA should be tested in SSc, as it identifies individuals with worse prognosis who require close monitoring for adverse outcomes.

Demonstration of differences in colonic volumes, transit, chyme consistency, and response to psyllium between healthy and constipated subjects using magnetic resonance imaging

BACKGROUND

In functional gastrointestinal disorders a lack of objective biomarkers limits evaluation of underlying mechanisms. We aimed to demonstrate the utility of magnetic resonance imaging for this task using psyllium, an effective constipation treatment, in patients and controls.

METHODS

Two crossover studies: (i) adults without constipation (controls, n = 9) took three treatments in randomized order for 6 days - maltodextrin (placebo), psyllium 3.5 g t.d.s and 7 g t.d.s., (ii) adults with chronic constipation (patients, n = 20) took placebo and psyllium 7 g t.d.s. for 6 days. MRI was performed fasting and postprandially on day 6. Measurements included small bowel and ascending colon water content, colonic volume, transit time, and MR relaxometry (T1, T2) to assess colonic chyme. Stool water percentage was measured.

RESULTS

7 g psyllium t.d.s. increased fasting colonic volumes in controls from median 372 mL (IQR 284-601) to 578 mL (IQR 510-882), and in patients from median 831 mL (IQR 745-934) to 1104 mL (847-1316), P < .05. Mean postprandial small bowel water was higher in controls and patients after 7 g psyllium t.d.s. vs placebo. Whole gut transit was slower in patients than controls (P < .05). T1 of the descending colon chyme (fasting) was lower in patients (213 ms, 176-420) than controls (440 ms, 352-884, P < .05) on placebo, but increased by 7 g psyllium t.d.s. (590 ms, 446-1338), P < .001. Descending colon T1 correlated with baseline stool water content and stool frequency on treatment.

CONCLUSIONS AND INFERENCES

MRI measurements can objectively demonstrate the mode of action of therapy targeting intestinal fluid content in constipation.

The role of inflammatory markers in assessment of disease activity in systemic sclerosis

OBJECTIVES

The role of the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in the assessment of disease activity in systemic sclerosis (SSc) remains controversial. We sought to evaluate the relationship between clinical features of SSc and raised inflammatory markers and to determine if changes in ESR and CRP reflect changes in other disease features over time.

METHODS

One thousand, five hundred and forty-five patients enrolled in the Australian Scleroderma Cohort Study were observed over a mean 3.52±2.91 years and assessed at 6,119 study visits. Generalised estimating equations were used to determine the relationship between ESR≥20mm/hr and CRP≥5mg/L and features of disease. The associations between change in inflammatory markers and change in skin scores and respiratory function tests were analysed.

RESULTS

Overall, there was a significant association between raised ESR and forced vital capacity (FVC)<80% predicted, diffusing capacity of the lung (DLCO)<80% predicted, pulmonary arterial hypertension (PAH), body mass index (BMI), proximal muscle strength, anaemia, and hypocomplementaemia (p<0.05). Raised CRP was significantly associated with modified Rodnan Skin Score>20, FVC<80%, DLCO<80%, PAH, digital ulcers, BMI, synovitis, tendon friction rub, anaemia, and hypocomplementaemia (p<0.05). A significant deterioration in respiratory function tests (RFTs) was associated with a 2-fold increase in both ESR and CRP (p<0.05).

CONCLUSIONS

Raised inflammatory markers are associated with pulmonary, cutaneous and musculoskeletal manifestations of SSc. Rising inflammatory markers are correlated with declining respiratory function tests. This suggests inflammatory markers have a role in the assessment of SSc disease activity.

The Costs of Confronting Osteoporosis: Cost Study of an Australian Fracture Liaison Service

Fracture liaison services (FLS) are an accepted approach to lowering rates of osteoporotic refractures. However, resource allocations to FLS are open to challenge, as most relevant cost analyses are based on anticipated, rather than observed, benefits. To support informed decision making, we have estimated the cost of operating an FLS, from the perspective of the Australian health system, with real life costs. On the basis of hospital records, we compared total costs of two cohorts of patients presenting with minimal trauma fractures (MTFs) at two hospital emergency departments (EDs) across a 6‐month period (July to December 2010). The treatment cohort (FLS Cohort, n = 515) attended an ED at a hospital offering FLS post‐fracture care; the Usual Care Cohort (n = 416) attended an ED at a hospital without an FLS. Hospital records were reviewed for further attendance of both groups at their respective hospitals’ EDs with refractures for the subsequent 3 years. Costs were constructed from “bottom up” with a “microcosting” approach. Total costs for both cohorts included any FLS and the costs of refractures. Cohort costs were estimated for every 1000 patients over the 3 observed years. Compared with the Usual Care Cohort, the FLS Cohort had 62 fewer fractures per 1000 patients and $617,275 lower costs over 3 years. In a sensitivity analysis, where 20% of the Usual Care Cohort received FLS preventative treatment, FLS Cohort costs were lower by $880,154. As both hospitals consistently process around 2000 patients per year, the estimated annual saving is $1.2 million to $1.8 million (Australian dollars). From the perspective of the Australian public health system, investment in FLS can be a financially effective way of reducing the cost of osteoporotic fracture management. © 2018 The Authors JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Unleashing the tiger - iatrogenic autoimmunity from cancer immunotherapy drugs

Immune checkpoint inhibitors can lead to the development of organ and non-organ specific immune related adverse events.

Assessment of motion of colonic contents in the human colon using MRI tagging

BACKGROUND

We have previously reported a non-invasive, semi-automated technique to assess motility of the wall of the ascending colon (AC) using Magnetic Resonance Imaging. This study investigated the feasibility of using a tagged MRI technique to visualize and assess the degree of flow within the human ascending colon in healthy subjects and those suffering from constipation.

METHODS

An open-labeled study of 11 subjects with constipation and 11 subjects without bowel disorders was performed. MRI scans were acquired fasted, then 60 and 120 minutes after ingestion of a 500 mL macrogol preparation. The amount of free fluid in the small and large bowel was assessed using a heavily T2-weighted MRI sequence. The internal movement of the contents of the AC was visualized using a cine tagged MRI sequence and assessed by a novel analysis technique. Comparisons were made between fasting and postprandial scans within individuals, and between the constipation and control groups.

KEY RESULTS

Macrogol significantly increased the mobile, MR visible water content of the ascending colon at 60 minutes postingestion compared to fasted data (controls P=.001, constipated group P=.0039). The contents of the AC showed increased motion in healthy subjects but not in the constipated group with significant differences between groups at 60 minutes (P<.002) and 120 minutes (P<.003).

CONCLUSIONS AND INFERENCES

This study successfully demonstrated the use of a novel MRI tagging technique to visualize and assess the motion of ascending colon contents following a 500 mL macrogol challenge. Significant differences were demonstrated between healthy and constipated subjects.

Evidence of effectiveness of a fracture liaison service to reduce the re-fracture rate

SUMMARY

We assessed the ability of a fracture liaison service (FLS) to directly reduce re-fracture risk. Having a FLS is associated with a ∼40% reduction in the 3-year risk of major bone and ∼30% of any bone re-fracture. The number needed to treat to prevent a re-fracture is 20.

INTRODUCTION

FLS have been promoted as the most effective interventions for secondary fracture prevention, and while there is evidence of increased rate of investigation and treatment at institutions with a FLS, only a few studies have considered fracture outcomes directly. We therefore sought to evaluate the ability of our FLS to reduce re-fracture risk.

METHODS

Historical cohort study of all patients ≥50 years presenting over a 6-month period with a minimal trauma fracture (MTF) to the emergency departments of a tertiary hospital with a FLS, and one without a FLS. Baseline characteristics, mortality and MTFs over a 3-year follow-up were recorded.

RESULTS

Five hundred fifteen patients at the FLS hospital and 416 patients at the non-FLS hospital were studied. Over 3 years, 63/515 (12%) patients at the FLS hospital and 70/416 (17%) at the non-FLS hospital had a MTF. All patients were analysed in an intention-to-treat analysis regardless of whether they were seen in the FLS follow-up clinic. Statistical analysis using Cox proportional hazard models in the presence of a competing risk of death from any cause was used. After adjustment for baseline characteristics, there was a ∼30% reduction in rate of any re-fracture at the FLS hospital (hazard ratio (HR) 0.67, confidence interval (CI) 0.47-0.95, p value 0.025) and a ∼40% reduction in major re-fractures (hip, spine, femur, pelvis or humerus) (HR 0.59, CI 0.39-0.90, p value 0.013).

CONCLUSIONS

We found a ∼30% reduction in any re-fractures and a ∼40% reduction in major re-fractures at the FLS hospital compared with a similar non-FLS hospital. The number of patients needed to treat to prevent one new fracture over 3 years is 20.

Colon wall motility: comparison of novel quantitative semi-automatic measurements using cine MRI

BACKGROUND

Recently, cine magnetic resonance imaging (MRI) has shown promise for visualizing movement of the colonic wall, although assessment of data has been subjective and observer dependent. This study aimed to develop an objective and semi-automatic imaging metric of ascending colonic wall movement, using image registration techniques.

METHODS

Cine balanced turbo field echo MRI images of ascending colonic motility were acquired over 2 min from 23 healthy volunteers (HVs) at baseline and following two different macrogol stimulus drinks (11 HVs drank 1 L and 12 HVs drank 2 L). Motility metrics derived from large scale geometric and small scale pixel movement parameters following image registration were developed using the post ingestion data and compared to observer grading of wall motion. Inter and intra-observer variability in the highest correlating metric was assessed using Bland-Altman analysis calculated from two separate observations on a subset of data.

KEY RESULTS

All the metrics tested showed significant correlation with the observer rating scores. Line analysis (LA) produced the highest correlation coefficient of 0.74 (95% CI: 0.55-0.86), p < 0.001 (Spearman Rho). Bland-Altman analysis of the inter- and intra-observer variability for the LA metric, showed almost zero bias and small limits of agreement between observations (-0.039 to 0.052 intra-observer and -0.051 to 0.054 inter-observer, range of measurement 0-0.353).

CONCLUSIONS & INFERENCES

The LA index of colonic motility derived from cine MRI registered data provides a quick, accurate and non-invasive method to detect wall motion within the ascending colon following a colonic stimulus in the form of a macrogol drink.

Australian and New Zealand recommendations for the diagnosis and management of gout: integrating systematic literature review and expert opinion in the 3e Initiative

AIM

To develop evidence-based recommendations for the diagnosis and management of gout in Australia and New Zealand as part of the multi-national 3e Initiative.

METHOD

Using a formal voting process, a panel of 78 international rheumatologists selected 10 key clinical questions pertinent to the diagnosis and management of gout. An additional question was also developed by participating Australian and New Zealand rheumatologists. Each question was investigated with a systematic literature review. MEDLINE, EMBASE, Cochrane CENTRAL and abstracts from 2010 to 2011 European League Against Rheumatism and American College of Rheumatology meetings were searched in each review. Relevant studies were independently reviewed by two individuals for data extraction and synthesis and risk of bias assessment. Using this evidence, 47 Australian and New Zealand rheumatologists developed national recommendations. For each recommendation the level of agreement was assessed and the level of evidence graded.

RESULT

Eleven recommendations were produced relating to the diagnosis of gout, different aspects of the management of gout, cardiovascular and renal comorbidities and the management of asymptomatic hyperuricemia. The mean level of agreement with the recommendations was 9.1 on a 1-10 scale, with 10 representing full agreement.

CONCLUSION

Eleven Australian and New Zealand recommendations on the diagnosis and management of gout were developed combining systematically reviewed evidence with local expertise, enhancing their utility in clinical practice.

The association of antiphospholipid antibodies with cardiopulmonary manifestations of systemic sclerosis

OBJECTIVES

To determine the prevalence and correlates of antiphospholipid antibodies (APLA) in systemic sclerosis (SSc).

METHODS

Nine hundred and forty SSc patients were tested for APLA using an ELISA assay at recruitment. Clinical manifestations were defined as present, if ever present from SSc diagnosis. Logistic regression analysis was used to determine the associations of APLA.

RESULTS

One or more types of APLA were present in 226 (24.0%) patients. Anticardiolipin (ACA) IgG (ACA-IgG) antibodies were associated with right heart catheter-diagnosed pulmonary arterial hypertension (PAH), with higher titres corresponding with a higher likelihood of PAH (moderate titre (20-39 U/ml) ACA-IgG odds ratio [OR] 1.70, 95% CI: 1.01-2.93, p=0.047; high titre (>40 U/ml) ACA-IgG OR 4.60, 95% CI:1.02-20.8, p=0.047). Both ACA-IgM (OR 2.04, 95% CI: 1.4-3.0, p<0.0001) and ACA-IgG (OR 1.84, 95% CI: 1.2-2.8, p=0.005) were associated with interstitial lung disease (ILD). Increasing ACA-IgM and IgG titres were associated with increased likelihood of ILD. ACA-IgG was a marker of coexistent pulmonary hypertension and ILD (ILD-PH) (OR 2.10, 95% CI: 1.1-4.2, p=0.036). We also found an association between ACA-IgG and digital ulcers (OR 1.76, 95% CI: 1.16-2.67, p=0.008) and ACA-IgM and Raynaud's phenomenon (OR 2.39, 95% CI: 1.08-5.27, p=0.031). There was no association between APLA and SSc disease subtype, peak skin score, presence of other autoantibodies, mortality or other disease manifestations.

CONCLUSIONS

The association of APLA with PAH, ILD, ILD-PH, Raynaud's phenomenon and digital ulcers suggests that endothelial abnormalities and small vessel thrombosis may be important in the pathogenesis of these disease features.

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.

Australian and New Zealand national evidence-based recommendations for the investigation and follow-up of undifferentiated peripheral inflammatory arthritis: an integration of systematic literature research and rheumatological expert opinion

AIM

To develop Australian and New Zealand (ANZ) recommendations for the investigation and follow-up of undifferentiated peripheral inflammatory arthritis (UPIA) using an evidence-based approach.

METHODS

Ten questions pertaining to the investigation and follow-up of patients with UPIA in daily rheumatological practice were defined by clinicians using a modified Delphi approach. A systematic literature search was conducted for each of the final questions. The results were presented to a workshop of 54 ANZ rheumatologists in May 2009. Discussions were held to develop consensus statements for each question, based on published evidence and clinical experience/expertise.

RESULTS

Ten recommendations were made on diagnostic value of clinical features in the patient's history and examination, predictors of poor prognosis and persistence, synovial fluid analysis, serology, imaging and human leukocyte antigen B27 testing. The lack of specific research to inform recommendations presented a challenge. Dynamic discussion groups outlined individual experience in areas without good quality clinical trial evidence. The median strength of support for the final set of recommendations was 7/10 (interquartile range 6-8), ranging from 6 to 9 for individual statements.

CONCLUSION

Ten ANZ recommendations for the investigation and follow-up of UPIA were formulated, based on available evidence and extensive clinical experience. The systematic literature review was of limited value while animated discussion of individual experience, with subsequent information exchange, highlighted the importance of merging clinical expertise with published literature to establish practical recommendations that can improve quality of care in rheumatology.

A fracture prevention service reduces further fractures two years after incident minimal trauma fracture

AIM

To evaluate the impact of a fracture prevention clinic service on initiation of treatment, continuing treatment and subsequent minimal trauma fractures (MTF).

METHOD

Participants were people aged 50 and over, with a minimal trauma fracture presenting to the Emergency Department (ED) in a large tertiary referral hospital in New South Wales, Australia, between February 2007 and March 2009. A cohort of patients who attended a Fracture Prevention Clinic (clinic group) were compared with a cohort who did not attend the clinic (non-clinic group). A telephone questionnaire was conducted with participants or their carers between December 2010 and April 2011 at least 12 months post-fracture presentation. Questionnaire items included demographics, fracture types, osteoporosis treatment, recurrent fractures and smoking and dietary habits. Data were compared using chi-squared test for categorical variables and Student's t-test or Mann-Whitney U-test for continuous variables.

RESULTS

Two hundred and fourteen clinic attendees and 220 non-clinic attendees were surveyed between 12 and 40 months (mean 24 months) post-initial fracture. New fracture rates were lower in the clinic group (5.1%) than the non-clinic group (16.4%, P < 0.001). Treatment rates for bone fragility were higher in the clinic group (81.3%) than in the non-clinic group (54.1%, P < 0.001) with 66.8% of the clinic group and 34.1% of the non-clinic group on a bisphosphonate or strontium ranelate at the time of the survey (P < 0.001).

CONCLUSION

Patients managed by a fracture prevention clinic service following a MTF have fewer new fractures and are more likely to be on treatment for bone fragility.

Bisphosphonate resistance in Paget's disease of bone

OBJECTIVE

To determine whether resistance to one bisphosphonate predicts resistance to another bisphosphonate.

METHODS

One hundred patients with Paget's disease were treated with intravenous (IV) pamidronate. The initial dose was 120 mg, followed by further doses of 240 mg, until either biochemical remission was achieved or a total dose of 1 gm was given. Biochemical remission was defined as an alkaline phosphatase level within the reference range. Patients whose disease failed to respond to pamidronate were then treated with alendronate for 6 months. Patients whose disease failed to respond to alendronate were given either tiludronate for 3 months, or clodronate for 6 months.

RESULTS

Sixteen of the 100 patients treated with pamidronate failed to achieve a biochemical response despite a cumulative dose of 1 gm. Of the 16 nonresponders, 1 died of an unrelated cause, and the remaining 15 patients were treated with alendronate. In 2 of these patients, the treatment was changed to another bisphosphonate because of gastrointestinal intolerance to alendronate. Of the remaining 13 patients, 9 (69%) achieved full biochemical remission. In 4 other patients, both pamidronate and alendronate therapy were unsuccessful (1 patient responded to tiludronate, tiludronate therapy was unsuccessful in 1, clodronate was unsuccessful in 1, and 1 patient elected to receive no further treatment). Of the 2 patients who could not receive alendronate because of gastrointestinal intolerance, 1 achieved normalization with tiludronate, and a repeat course of pamidronate was unsuccessful in the other. In total, 73% of patients in whom initial treatment with IV pamidronate was unsuccessful responded to a change in bisphosphonate treatment.

CONCLUSION

Failure to achieve biochemical normalization is likely to be specific to the individual drug rather than indicative of bisphosphonate class resistance.

Molecular analysis of the stylar-expressed Solanum chacoense small asparagine-rich protein family related to the HT modifier of gametophytic self-incompatibility in Nicotiana

Gametophytic self-incompatibility (GSI) systems involving the expression of stylar ribonucleases have been described and extensively studied in many plant families including the Solanaceae, Rosaceae and Scrophulariaceae. Pollen recognition and rejection is governed in the style by specific ribonucleases called S-RNases, but in many self-incompatibility (SI) systems, modifier loci that can modulate the SI response have been described at the genetic level. Here, we present at the molecular level, the isolation and characterization of two Solanum chacoense homologues of the Nicotiana HT modifier that had been previously shown to be necessary for the SI reaction to occur in N. alata (McClure et al., 1999). HT homologues from other solanaceous species have also been isolated and a phylogenetic analysis reveals that the HT genes fall into two groups. In S. chacoense, these small proteins named ScHT-A and ScHT-B are expressed in the style and are developmentally regulated during anthesis identically to the S-RNases as well as following compatible and incompatible pollination. To elucidate the precise role of each HT isoform, antisense ScHT-A and RNAi ScHT-B lines were generated. Conversion from SI to self-compatibility (SC) was only observed in RNAi ScHT-B lines with reduced levels of ScHT-B mRNA. These results confirm the role of the HT modifier in solanaceous SI and indicate that only the HT-B isoform is directly involved in SI.

Differential shunting of EPSPs by action potentials

Neurons encode information and communicate via action potentials, which are generated following the summation of synaptic events. It is commonly assumed that action potentials reset the membrane potential completely, allowing another round of synaptic integration to begin. We show here that the conductances underlying the action potential act instead as a variable reset of synaptic integration. The strength of this reset is cell type-specific and depends on the kinetics, location, and timing of the synaptic input. As a consequence, distal synapses, as well as inputs mediated by N-methyl-d-aspartate receptor activation, can contribute disproportionately to synaptic integration during action potential firing.

Efficacy of fish oil concentrate in the treatment of rheumatoid arthritis

OBJECTIVE

To determine the efficacy of fish oil derived (n-3) fatty acid supplementation (3-6 capsules/day) in subjects with rheumatoid arthritis (RA) whose (n-6) fatty acid intake in the background diet was < 10 g/day, compared to olive/corn oil capsule supplement over a 15 week period.

METHODS

A placebo controlled, double blind, randomized 15 week study to determine the effect of supplementation on clinical variables in 50 subjects with RA whose background diet was naturally low in (n-6) fatty acids. Fish oil containing 60% (n-3) fatty acids was supplemented at a rate of 40 mg/kg body weight.

RESULTS

Analysis of 9 clinical variables indicated there was a significant difference (p < 0.02) between control and treatment groups. Five subjects in the treatment group and 3 in the control group met the American College of Rheumatology 20% improvement criteria. Dietary supplementation resulted in a significant increase in eicosapentaenoic acid in plasma and monocyte lipids in the supplemented group.

CONCLUSION

The findings suggest that fish oil supplementation that delivers (n-3) fatty acids at a dose of 40 mg/kg body weight/day, with dietary (n-6) fatty acid intake < 10 g/day in the background diet, results in substantial cellular incorporation of (n-3) fatty acids and improvements in clinical status in patients with RA.

Dialogues in the exam room: medical interviewing by resident family physicians

BACKGROUND

Limited information exists about the application of the biopsychosocial model in medical practice. This study expanded our knowledge about the extent to which psychosocial content is included in medical interviews conducted by resident family physicians.

METHODS

Interviews of 180 patients conducted by six second-year family practice residents were audiotaped and transcribed. Physician statements were analyzed and coded as social talk, physician-centered statements, patient-centered statements, and discussion of patient affect, family, health promotion, and patient education.

RESULTS

The proportion of interviews in which specific physician interactions occurred were physician-centered statements: 100%, patient-centered statements: 66%, dealing with patient affect: 18%, information about family: 61%, initiation of health promotion: 33%, and initiation of patient education: 46%. Discussions of patient opinion/perception, patient affect, family information, and health promotion occurred most commonly during well-care visits and with female patients.

CONCLUSIONS

In this sample of residents, providers extended the interview beyond a purely biomedical focus. However, the psychosocial focus often was brief and applied inconsistently across patients.