Complex biophysical changes and reduced neuronal firing in an SCN8A variant associated with developmental delay and epilepsy

Mutations in the SCN8A gene, encoding the voltage-gated sodium channel NaV1.6, are associated with a range of neurodevelopmental syndromes. The p.(Gly1625Arg) (G1625R) mutation was identified in a patient diagnosed with Developmental epileptic encephalopathy (DEE). While most of the characterized DEE-associated SCN8A mutations were shown to cause a gain-of-channel function, we show that the G1625R variant, positioned within the S4 segment of domain IV, results in complex effects. Voltage-clamp analyses of NaV1.6G1625R demonstrated a mixture of gain- and loss-of-function properties, including reduced current amplitudes, increased time constant of fast voltage-dependent inactivation, a depolarizing shift in the voltage dependence of activation and inactivation, and increased channel availability with high-frequency repeated depolarization. Current clamp analyses in transfected cultured neurons revealed that these biophysical properties caused a marked reduction in the number of action potentials when firing was driven by the transfected mutant NaV1.6. Accordingly, computational modeling of mature cortical neurons demonstrated a mild decrease in neuronal firing when mimicking the patients' heterozygous SCN8A expression. Structural modeling of NaV1.6G1625R suggested the formation of a cation-π interaction between R1625 and F1588 within domain IV. Double-mutant cycle analysis revealed that this interaction affects the voltage dependence of inactivation in NaV1.6G1625R. Together, our studies demonstrate that the G1625R variant leads to a complex combination of gain and loss of function biophysical changes that result in an overall mild reduction in neuronal firing, related to the perturbed interaction network within the voltage sensor domain, necessitating personalized multi-tiered analysis for SCN8A mutations for optimal treatment selection.

Acute effect of antiseizure drugs on background oscillations in Scn1aA1783V Dravet syndrome mouse model

Dravet syndrome (Dravet) is a rare and severe form of developmental epileptic encephalopathy. Antiseizure medications (ASMs) for Dravet patients include valproic acid (VA) or clobazam (CLB), with or without stiripentol (STP), while sodium channel blockers like carbamazepine (CBZ) or lamotrigine (LTG) are contraindicated. In addition to their effect on epileptic phenotypes, ASMs were shown to modify the properties of background neuronal activity. Nevertheless, little is known about these background properties alterations in Dravet. Here, utilizing Dravet mice (DS, Scn1aA1783V/WT), we tested the acute effect of several ASMs on background electrocorticography (ECoG) activity and frequency of interictal spikes. Compared to wild-type mice, background ECoG activity in DS mice had lower power and reduced phase coherence, which was not corrected by any of the tested ASMs. However, acute administration of Dravet-recommended drugs, VA, CLB, or a combination of CLB + STP, caused, in most mice, a reduction in the frequency of interictal spikes, alongside an increase in the relative contribution of the beta frequency band. Conversely, CBZ and LTG increased the frequency of interictal spikes, with no effect on background spectral properties. Moreover, we uncovered a correlation between the reduction in interictal spike frequency, the drug-induced effect on the power of background activity, and a spectral shift toward higher frequency bands. Together, these data provide a comprehensive analysis of the effect of selected ASMs on the properties of background neuronal oscillations, and highlight a possible correlation between their effect on epilepsy and background activity.

271 DEVELOPMENT OF AN INNOVATIVE INTER-DISCIPLINARY PARKINSON’S CLINIC IN AN AMBULATORY CARE SETTING

Background

Ambulatory services provide specialist outpatient care, reducing costs associated with inpatient admissions and enabling the person to remain at home for longer (Report of the National Acute Medicine Programme, 2010). An Older Person’s Ambulatory Care Hub was established in a large teaching hospital. Prior service evaluation demonstrated that approximately one third of patients attending had a diagnosis of Parkinson’s Disease (PD). People with PD should have a collaborative approach between patient, family and healthcare providers to optimally manage their condition (NICE, 2017), therefore, the need was identified to evolve the traditional medical model to an interdisciplinary approach. The aim of this project was to complete a service evaluation and breakdown of Interdisciplinary Team (IDT) referrals.

Methods

An IDT working group including Clinical Nutrition (CN), Medical, Nursing, Occupational Therapy (OT), Physiotherapy (PT), and Speech and Language Therapy (SLT) was established. A comprehensive assessment form was developed and outcome measures were chosen. A short pilot was conducted and necessary amendments were made. A weekly clinic was established which included an IDT assessment, followed by a huddle with the medical team where referrals were generated. Data pertaining to the number of attendees and referrals generated were collected over a 3-month period.

Results

Over the data collection period, 31 patients attended the clinic. Referrals were as follows; Medical: 19, PT: 13, SLT: 10, OT: 7, CN: 6, Medical Social Work: 2. Patients requiring urgent medical review were seen immediately after the IDT huddle.

Conclusion

This project demonstrates a service evaluation of a novel IDT PD Clinic. This clinic highlights the need for an IDT approach to management of people with PD. Future service developments include obtaining patient feedback, pre-clinic calls to patients by a Healthcare Assistant to explain the purpose of the clinic, and adapting the clinic as appropriate.

Rapid systematic review of smoking cessation interventions for people who smoke and have cancer

Background

Higher rates of cancer are reported in smokers compared to non-smokers, and continued smoking following a cancer diagnosis is associated with reduced health outcomes and survival. Despite international evidence of increased risks, a substantial percentage of people with a cancer diagnosis continue to smoke. Patients may be unaware of the additional risks associated with continued smoking, and health care professionals may not engage with quit supports. As part of a larger feasibility study to develop a smoking cessation pathway in cancer services in Ireland, a rapid review of the evidence was completed.

Methods

Systematic searches of PubMed, Embase, and CINAHL 2015 to December 2020 were conducted; with studies restricted to adults with a cancer diagnosis [lung, breast, cervical, head and neck] and published in English. No restriction was placed on study designs. 6404 studies were identified and uploaded into COVIDENCE platform, Cochrane's systematic review methods were adopted throughout, PRISMA reporting guidelines were used, and narrative data synthesis was completed (CRD 42020214204).

Results

The twenty-three-studies report evidence from USA, Canada, England, Lebanon, and Australia. The setting for all interventions was hospitals and cancer clinics. Evidence identifies high dropout rates, inconsistencies in approaches and duration of smoking cessation interventions with varied outcomes. A wide-ranging number of critical components emerged associated with optimal quit support- including the timing of and frequency of quit conversations, use of electronic records, in-person support meetings, provision of nicotine replacement therapy and extended use of Varenicline, smoking cessation services embedded in oncology depts, and engaging with families wanting to quit at the same time.

Conclusions

Developing tailored smoking cessation interventions are needed for smokers diagnosed with cancer to enable engagement.

Key messages

• Continued smoking following a cancer diagnosis is associated with reduced health outcomes.

• Smoking cessation programmes for cancer patient should be tailored to meet needs.

AB0894 Efficacy and Safety of Guselkumab in Biologic-Naïve Patients With Active Axial Psoriatic Arthritis: Study Design of a Phase 4, Randomized, Double-Blind, Placebo-Controlled Trial

Background

Established criteria for classifying axial psoriatic arthritis (PsA) are lacking, and assessments of disease activity often rely on measures developed for ankylosing spondylitis (AS). There is an unmet need to systematically identify and measure efficacy of treatments for axial PsA patients (pts). Guselkumab (GUS), a selective interleukin (IL)-23p19 inhibitor, was efficacious in improving signs and symptoms of active PsA in 2 phase 3, randomized, placebo (PBO)-controlled studies: DISCOVER-1 and DISCOVER-2. In a post-hoc pooled analysis of DISCOVER-1&2 pts with investigator-confirmed sacroiliitis, GUS-treated pts had greater improvements in axial symptoms compared with PBO.1 Imaging in DISCOVER-1&2 was restricted to the sacroiliac (SI) joints, occurring prior to/at screening as confirmed by the investigator, and locally read.

Objectives

To design a new, dedicated study to evaluate the effects of GUS on axial PsA prospectively.

Methods

Cumulative evidence from DISCOVER-1&2, including exposure–response relationship, covariate adjustment for modest baseline imbalances across treatment groups, subgroup analyses, and comparisons within and across these studies, was considered in designing a new trial. Data from the pivotal registrational studies suggest similar efficacy with GUS every-4-weeks (Q4W) and Q8W regimens in treating PsA signs and symptoms, including symptoms of axial involvement. Power calculations were based on mean changes in Bath AS Disease Activity Index (BASDAI) scores in DISCOVER-1&2.

Results

The phase 4, randomized, PBO-controlled STAR study is specifically designed to prospectively assess efficacy outcomes in PsA pts with magnetic resonance imaging (MRI)-confirmed axial inflammation. Based on observed mean (SD) changes from baseline in BASDAI score from DISCOVER-1&2 (Table 1), 405 pts, randomized (1:1:1) to GUS Q4W, GUS at W0, W4, then Q8W, or PBO →GUS Q8W at W24, are planned for enrollment (Figure 1). STAR eligibility criteria include PsA ≥6 months and active disease (≥3 swollen & ≥3 tender joints, C-reactive protein [CRP] ≥0.3 mg/dL) despite prior non-biologic disease-modifying antirheumatic drugs, apremilast, and/or non-steroidal anti-inflammatory drugs. Pts will be naïve to biologics and Janus kinase inhibitors and have BASDAI ≥4, spinal pain score (visual analog scale [VAS]) ≥4, and screening MRI-confirmed axial disease (positive spine and/or SI joints defined as centrally read Spondyloarthritis Research Consortium of Canada [SPARCC] score ≥3). Follow-up MRIs of spine and SI joints will be obtained at W0, W24, and W52 and also centrally read, with readers blinded to treatment group and timepoint. Spinal/SI joint inflammation will be scored using the SPARCC method, with the former also assessed using the CAN-DEN method. The primary endpoint is mean change in BASDAI at W24; controlled (hierarchical) secondary endpoints, all at W24, include AS Disease Activity Score (ASDAS-CRP), Disease Activity Index for PsA (DAPSA), ≥40% improvement in Assessment in AS criteria (ASAS40), and mean changes in spine/SI joint SPARCC scores.

Table 1.

Power calculations for the primary endpoint in the Phase 4 STAR study.

Historical trial data*Observed mean (SD) change in BASDAI from W0-24Effect sizePower(N=135; α=0.05)**PBO-1.28 (2.24)GUS 100 mg Q4W-2.51 (2.00)1.23>99%GUS 100 mg Q8W-2.61 (2.47)1.33>99%

* From the pooled DISCOVER-1&2 trials

**Power calculations based on N=135 per study group (1:1:1 randomization) and 2-sided significance of 0.05 using a 2-sample T-test assuming equal variances

BASDAI, Bath Ankylosing Spondylitis Disease Activity Index; GUS, guselkumab; PBO, placebo; Q4W, every 4 weeks; Q8W, every 8 weeks; SD, standard deviation; W, week

Conclusion

The phase 4 STAR study will allow for an in-depth, prospective evaluation of the effects of selectively inhibiting the IL-23p19 subunit with GUS in pts with MRI-confirmed axial PsA.

References

[1]Mease, et al. Lancet Rheum. 2021;3(10):e715-e723.

Disclosure of Interests

Dafna D Gladman Consultant of: AbbVie, Amgen, BMS, Celgene, Eli Lilly, Galapagos, Gilead, Janssen, Novartis, Pfizer, and UCB, Grant/research support from: Abbvie, Amgen, BMS, Celgene, Eli Lilly, Janssen, Novartis, Pfizer and UCB, Philip J Mease Speakers bureau: AbbVie, Aclaris, Amgen, BMS, Celgene, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Inmagene, Janssen, Novartis, Pfizer, SUN Pharma, and UCB, Consultant of: AbbVie, Aclaris, Amgen, BMS, Celgene, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Inmagene, Janssen, Novartis, Pfizer, SUN Pharma, and UCB, Grant/research support from: AbbVie, Aclaris, Amgen, BMS, Celgene, Eli Lilly, Galapagos, Gilead, GlaxoSmithKline, Inmagene, Janssen, Novartis, Pfizer, SUN Pharma, and UCB, Paul Bird Speakers bureau: AbbVie, Eli Lilly, Gilead, Janssen, MSD, Pfizer, and UCB, Consultant of: Eli Lilly, Gilead, Janssen, Novartis, and Pfizer, Enrique Soriano Speakers bureau: AbbVie, Amgen, Bristol Myers Squibb, Eli Lilly, Janssen, Novartis, Pfizer, Roche, and UCB, Consultant of: AbbVie, Janssen, Novartis, and Roche, Grant/research support from: AbbVie, Janssen, Novartis, Pfizer, Roche, and UCB, Soumya D Chakravarty Shareholder of: Johnson & Johnson, Employee of: Janssen Scientific Affairs, LLC, May Shawi Shareholder of: Johnson & Johnson, Employee of: Janssen Global Services, LLC, Stephen Xu Shareholder of: Johnson & Johnson, Employee of: Janssen Research & Development, LLC, Sean Quinn Shareholder of: Johnson & Johnson, Employee of: Janssen Scientific Affairs, LLC, Cinty Gong Shareholder of: Johnson & Johnson, Employee of: Janssen Scientific Affairs, LLC, Evan Leibowitz Shareholder of: Johnson & Johnson, Employee of: Janssen Scientific Affairs, LLC, Lai-Shan Tam Consultant of: Janssen, Pfizer, Sanofi, AbbVie, Boehringer Ingelheim, and Lilly, Grant/research support from: Amgen, Boehringer Ingelheim, Janssen, GSK, Novartis, and Pfizer, Philip Helliwell Speakers bureau: AbbVie, Janssen, and Novartis, Consultant of: Galapagos and Janssen, Grant/research support from: AbbVie, Janssen, and Pfizer, Arthur Kavanaugh Consultant of: Abbvie, Amgen, Bristol Myers Squibb, Eli Lilly, Gilead, Janssen, Novartis, Pfizer, and UCB, Atul Deodhar Speakers bureau: AbbVie, Eli Lilly, Janssen, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Amgen, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Eli Lilly, Galapagos, Glaxo Smith & Kline, Janssen, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Eli Lilly, Glaxo Smith & Kline, Novartis, Pfizer, and UCB, Mikkel Østergaard Speakers bureau: AbbVie, Boehringer-Ingelheim, Bristol Myers Squibb, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Consultant of: AbbVie, Boehringer-Ingelheim, Bristol Myers Squibb, Celgene, Eli-Lilly, Hospira, Janssen, Merck, Novartis, Novo, Orion, Pfizer, Regeneron, Roche, Sandoz, Sanofi, and UCB, Grant/research support from: AbbVie, Bristol Myers Squibb, Celgene, and Novartis, Xenofon Baraliakos Speakers bureau: AbbVie, Biocad, Chugai, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche, and UCB, Consultant of: AbbVie, Biocad, Chugai, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche, and UCB, Grant/research support from: AbbVie, Biocad, Chugai, Eli Lilly, Janssen, MSD, Novartis, Pfizer, Roche, and UCB

Colchicine and quality of life in patients with acute coronary syndromes: results from the COPS randomized trial

Background

Recent data suggest that colchicine may reduce cardiovascular events among patients presenting with acute coronary syndromes. This sub-study of the Australian COPS trial aimed to assess whether colchicine affects health status outcomes.

Methods

Health status was assessed at baseline and 12-months using the EuroQol-5 Dimension 5-level (EQ-5D-5L) score and the full 19-question Seattle Angina Questionnaire (SAQ). Data were available for 786 patients (388 randomized to colchicine, 398 to placebo).

Results

Baseline characteristics were well matched between groups; mean age was 60.1 (SD 14.8) years, and 20% were female. Baseline health status scores were impaired, and most parameters demonstrated significant improvement from baseline to 12-months (EQ-5D-5L Visual Analogue Score [VAS] 69.3 to 77.7; SAQ angina frequency score 83.0 to 95.3, both p<0.001). No significant differences in adjusted mean score change among any of the EQ-5D-5L or SAQ dimensions were observed between treatment groups in either intention-to-treat or per-protocol analysis. There were borderline interactions in EQ-5D-5L scores for those with previous MI vs not, and in SAQ scores for those with obesity vs not. In categorical analysis using observed data, patients treated with colchicine were more likely to have clinically significant improvement in physical limitation score over the period (36% improved vs. 28%, P<0.05). Baseline health status scores were not associated with the primary endpoint at 12 months.

Conclusions

Treatment with colchicine did not appear to affect change in measures of health status following acute coronary syndromes, but it did lead to a greater likelihood of improvement in physical limitation scores.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Peninsula Health, Monash University

A practical approach to cardiac imaging in adults with Duchenne muscular dystrophy - echocardiography or cardiac MRI?

Funding Acknowledgements

Type of funding sources: None.

Background

The incidence of cardiomyopathy in Duchenne muscular dystrophy (DMD) increases with age, accounting for up to 20% of mortality in the third decade of life. As patients are frequently asymptomatic until advanced stages of disease, imaging plays an essential role in screening for cardiac involvement and monitoring progression. Guidelines recommend annual transthoracic echocardiography assessment, with periodic use of cardiac magnetic resonance imaging (CMR). However, some studies suggest that CMR should be the gold standard imaging in DMD. This study aimed to review the use echo and CMR in adult patients with DMD, with particular focus on practical utility and real-world limitations.

Methods

 

A retrospective chart review of 24 patients attending our DMD cardiomyopathy clinic was undertaken. Demographic data including age, genotyping and medical therapy were noted. Results of cardiac imaging, as well as discussions regarding referral for CMR were recorded.

Results

All patients had echocardiography performed in our facility (table 1) and all had a documented discussion regarding referral for CMR in their medical notes. 15 patients (60%) were unsuitable for CMR and were not referred. Reasons were inability to lie flat due to breathing/claustrophobia (n = 12) and difficulty with positioning due to contractures (n = 9). 2 patients (8%) attended for CMR but were unable to proceed due to difficulty with positioning in the scanner. 4 patients (16.5%) had CMR performed, 3 additional patients were referred and awaited CMR. Results outlined in table 1 and image 1 show correlation between measurement of left ventricular ejection fraction (LVEF) on echo and CMR. Wall motion abnormalities and fibrosis were better detected with CMR. 

Conclusion

 

Significant limitations were seen with both imaging techniques. Accessibility of CMR for adults with DMD is poor, related primarily to the severity of underlying musculoskeletal and respiratory disease. Echocardiography is easily accessible, but images are frequently suboptimal. Despite this, strong correlation was seen in assessment of LV function in those who underwent both echocardiography and CMR, with indication that echocardiography can accurately guide intensification of medications and cardiac device therapy. CMR remains the optimal modality for the assessment of myocardial fibrosis. Improving accessibility of CMR for patients with DMD should be prioritised for the future of this modality.

POS1216 SYMPTOM RATES, ATTITUDES AND MEDICATION ADHERENCE OF RHEUMATIC AND MUSCULOSKELETAL DISEASE PATIENTS DURING THE SARS-CoV2 PANDEMIC

Background:

SARS-CoV2 has caused over two million deaths globally. The relationship between rheumatic and musculoskeletal disease (RMDs), immunosuppressive medications and COVID-19 is unclear.

Objectives:

This study explores the rates of COVID-19 symptoms and positive tests, DMARD adherence and attitudes to virtual clinics. amongst RMD patients.

Methods:

An online population survey was disseminated via the Arthritis Ireland website and social media channels.

Results:

There were 1381 respondents with RMD, 74.8% were on immunosuppressive medication. COVID-19 symptoms were reported by 3.7% of respondents of which 0.46% tested positive, no different from the general population at that timepoint. The frequency of COVID-19 symptoms was higher for respondents with spondyloarthropathy [odds ratio (OR) 2.06, 95% CI: 1.14, 3.70] and lower in those on immunosuppressive medication (OR 0.48, 95% CI: 0.27, 0.88), and those compliant with health authority (HSE) guidance (OR 0.47, 95% CI: 0.25, 0.89). Adherence to RMD medications was reported in 84.1%, with 57.1% using health authority guidelines for information on medication use. Importantly, adherence rates were higher amongst those who cited guidelines (89.3% vs 79.9%, P <0.001), and conversely lower in those with COVID-19 symptoms (64.0% vs 85.1%, P =0.009). Finally, the use of virtual clinics was supported by 70.4% of respondents.

Conclusion:

The rate of COVID-19 positivity in RMD patients was similar to the general population. COVID-19 symptoms were lower amongst respondents on immunosuppressive medication and those adherent to medication guidelines. Respondents were supportive of HSE advice and virtual rheumatology clinics.

Disclosure of Interests:

Kieran Murray Grant/research support from: Bresnihan Molloy and Newman fellowships, Sean Quinn: None declared, Matthew Turk: None declared, Anna O’Rourke: None declared, Eamonn Molloy: None declared, Lorraine O’Neill: None declared, Anne Barbara Mongey: None declared, Ursula Fearon: None declared, Douglas Veale: None declared.

POS0964 CHARACTERISTICS AND BURDEN OF DISEASE IN PATIENTS WITH RADIOGRAPHIC VERSUS NON-RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS IN THE ANKYLOSING SPONDYLITIS REGISTRY OF IRELAND COHORT

Background:

Axial spondyloarthritis (axSpA) is an umbrella term for types of inflammatory arthritis that primarily affect the spine and the sacroiliac joints. It is comprised of patients with both radiographic (r-axSpA) and non-radiographic features (nr-axSpA). R-axSpA was historically known as Ankylosing Spondylitis. Previous studies have shown the burden of disease to be largely similar in patients with radiographic versus non-radiographic axial spondyloarthritis in cohorts both in the US and Europe [1]. The Ankylosing Spondylitis Registry of Ireland (ASRI) was formed with the objective to measure the burden of axial spondyloarthritis in the population and identify early predictors of a poor outcome. All patients in the registry are 18 years or older and meet Assessment of Spondyloarthritis International Society (ASAS) criteria for a diagnosis of SpA.

Objectives:

To compare the characteristics and burden of disease in patients with radiographic versus non-radiographic axial spondyloarthritis in the ASRI cohort.

Methods:

Patients with radiographic axial spondyloarthritis (r-axSpA) were defined as those with x-ray evidence of sacroiliitis. Patients with non-radiographic axial spondyloarthritis (nr-axSpA) were defined as having MRI evidence of sacroiliitis but no x-ray evidence of sacroiliitis. A standardised clinical assessment was performed on each patient and structured interviews provided patient-reported data. For each patient the following scores were captured: Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Metrology Index (BASMI), Health Assessment Questionnaire (HAQ) assesses the self-reported functional status for performing activities of daily living, and the Ankylosing Spondylitis Quality of Life (ASQoL) questionnaire. Categorical variables were summarized as percentages with frequency counts, and continuous variables with a mean and standard deviation. Statistical comparisons between subgroups were evaluated using 2 sample t-tests for continuous variables and chi-square tests for categorical variables.

Results:

764 patients were available for analysis. Analysis of radiographic status showed 88.1% (n=673) of patients with r-axSpA and 11.9% (n=91) with nr-axSpA. Patients with nr-axSpA were younger (41.3 vs. 46.6 years, p<0.01), had shorter disease duration (14.8 vs. 20.2 years, p<0.01), lower proportion of males (66.6% vs. 78.4%, p=0.02) with lower rates of HLA-B27 positivity (73.6% vs. 90.5%, p<0.01). The nr-axSpA group had lower BASDAI (3.37 vs. 4.05, p=0.01), BASFI (2.46 vs. 3.88, p<0.01), BASMI (2.33 vs. 4.34, p<0.01), ASQoL (5.2 vs. 6.67, p=0.02), and HAQ scores (0.38 vs. 0.57, p<0.01). There were no significant differences in the prevalence of extra-articular manifestations.

Conclusion:

This study provides evidence that the burden of disease is less in patients with non-radiographic axial spondyloarthritis than radiographic axial spondyloarthritis, as demonstrated by better BASDAI, BASFI, BASMI, HAQ and ASQoL scores.

References:

[1]López-Medina C, et al. Characteristics and burden of disease in patients with radiographic and non-radiographic axial Spondyloarthritis: a comparison by systematic literature review and meta-analysis. RMD Open, 2019. 5(2) p1108.

Table 1.r-axSpAnr-axSpAp valuen67391Age (years)46.6 (+/-12.4)41.3 (+/-12.4)<0.01Disease duration (years)20.2 (+/-12.4)14.8 (+/-11.7)<0.01Delay to diagnosis (years)8.41 (+/-8.6)6.34 (+/-7.2)0.03Males78.8% (528)65.9% (60)0.02Females21.5% (145)34.1% (31)0.02HLA-B27+90.50%(440 of 486 available results)73.60%(53 of 72 available results)<0.01BASDAI4.05 (+/-2.39)3.37 (+/-2.31)0.01BASFI3.88 (+/-3.00)2.46 (+/-2.39)<0.01BASMI4.34 (+/-2.08)2.33 (+/-1.42)<0.01ASQoL6.67 (+/-5.55)5.2 (+/-5.53)0.02HAQ0.57 (+/-0.54)0.38 (+/-0.44)<0.01Psoriasis17.8% (120)15.4% (14)0.31IBD11% (74)8.8% (8)0.58Uveitis33.9% (228)34.1% (31)0.54

Disclosure of Interests:

Sean Quinn: None declared, Sinead Maguire: None declared, Finbar Barry O’Shea: None declared, Lorraine O’Neill: None declared, Eamonn Molloy: None declared, Ursula Fearon Speakers bureau: Abbvie, Grant/research support from: Janssen, Abbvie, Pfizer, UCB, Phil Gallagher: None declared, Douglas Veale Speakers bureau: AbbVie, BMS, Celgene, Pfizer, MSD, Roche, Consultant of: AbbVie, Actelion, BMS, Novartis, Pfizer, MSD, Roche, Regeneron/Sanofi, Grant/research support from: AbbVie, Pfizer, MSD, Novartis, Roche, Janssen.

Cosmic-ray antinuclei as messengers of new physics: status and outlook for the new decade

The precise measurement of cosmic-ray antinuclei serves as an important means for identifying the nature of dark matter and other new astrophysical phenomena, and could be used with other cosmic-ray species to understand cosmic-ray production and propagation in the Galaxy. For instance, low-energy antideuterons would provide a "smoking gun" signature of dark matter annihilation or decay, essentially free of astrophysical background. Studies in recent years have emphasized that models for cosmic-ray antideuterons must be considered together with the abundant cosmic antiprotons and any potential observation of antihelium. Therefore, a second dedicated Antideuteron Workshop was organized at UCLA in March 2019, bringing together a community of theorists and experimentalists to review the status of current observations of cosmic-ray antinuclei, the theoretical work towards understanding these signatures, and the potential of upcoming measurements to illuminate ongoing controversies. This review aims to synthesize this recent work and present implications for the upcoming decade of antinuclei observations and searches. This includes discussion of a possible dark matter signature in the AMS-02 antiproton spectrum, the most recent limits from BESS Polar-II on the cosmic antideuteron flux, and reports of candidate antihelium events by AMS-02; recent collider and cosmic-ray measurements relevant for antinuclei production models; the state of cosmic-ray transport models in light of AMS-02 and Voyager data; and the prospects for upcoming experiments, such as GAPS. This provides a roadmap for progress on cosmic antinuclei signatures of dark matter in the coming years.

Misoprostol for open myomectomy: a systematic review and meta-analysis of randomised control trials

BACKGROUND

Excessive blood loss is a significant risk of myomectomy with the potential need for hysterectomy.

OBJECTIVE

To study the effectiveness of preoperative misoprostol compared with placebo at open myomectomy on intra- and postoperative outcomes.

SEARCH STRATEGY

PubMed, Cochrane, Scopus, MEDLINE and EMBASE.

SELECTION CRITERIA

Randomised control studies of women undergoing open myomectomy for symptomatic fibroids who were given either misoprostol or placebo preoperatively.

DATA COLLECTION AND ANALYSIS

The revised Cochrane risk-of-bias tool for randomised trials was used to assess the risk of bias. Primary outcomes were blood loss, drop in haemoglobin and need for blood transfusion. Secondary outcomes were operative time, postoperative pyrexia and length of postoperative stay. Pooled effect sizes with corresponding 95% CI were calculated using random effects models. Data were analysed using two statistical models for statistical reliability.

RESULTS

Eight studies were included with a total of 385 patients, of which 192 received misoprostol. Preoperative misoprostol was significantly associated with lower blood loss by -170.32 ml (95% CI -201.53 to -139.10), lower drop in haemoglobin by -0.48 g/dl (95% CI -0.65 to -0.31), reduced need for blood transfusion (odds ratio [OR] -0.48, 95% CI -0.65 to -0.31), and a reduction in operative time by -11.64 minutes (95% CI -15.73 to -7.54). There was no difference in postoperative pyrexia or length of postoperative stay.

CONCLUSION

Moderate- to high-quality studies have established that misoprostol minimises blood loss and need for blood transfusion at open myomectomy. This low-cost and readily available drug should be routinely administered prior to open myomectomy to improve clinical outcomes.

TWEETABLE ABSTRACT

Use of misoprostol at open myomectomy reduces blood loss and need for blood transfusion with no impact on postoperative pyrexia.

Efficacy of influenza vaccine (Fluvax) in cancer patients on treatment: a prospective single arm, open-label study

PURPOSE

Influenza virus infection has significant morbidity and mortality in patients with medical co-morbidities who are also immunosuppressed. The efficacy of the seasonal influenza vaccine has not been well studied in patients receiving chemotherapy. We assessed the efficacy of seasonal influenza vaccine in patients with non-haematological malignancy on active treatment (chemotherapy and targeted therapy).

METHODS

A prospective single arm, open label study with 53 patients with non-haematological cancers recruited during the 2011 and 2012 influenza seasons. Participants had one dose of 2011/2012 trivalent vaccine containing strains A/California/7/2009(H1N1), A/Perth/16/2009 (H3N2) and B/Brisbane/60/2008 (Fluvax) prior to or in-between treatment cycles. Haemagglutination inhibition antibody (HIA) titres in serum were measured at baseline 3, 6 and 24 weeks. Primary endpoint: seroconversion rate (SCR) at 3 weeks. Secondary endpoints: late SCR at 6 weeks. rate of sustained sero-protection titres (SPR) at 24 weeks. Seroconversion was defined as postvaccination ≥ 4-fold increase in HIA titre and sero-protection defined as a HIA ≥ 1:40.

RESULTS

The SCR at 3 weeks were 35%, 30% and 22.5% to the H1N1, H3N2 and B/Bris strains, respectively. There were no new cases of late SC at 6 weeks or 24 weeks. The SPR at 3 weeks were 72.5%, 65% and 40%, respectively, to H1N1, H3N2 and B/Bris. The SPR at 24 weeks to H1N1, H3N2 and B/Bris were 40%, 52.5% and 17.5%, respectively.

CONCLUSIONS

Patients on various solid tumour treatments achieve sero-protection rate congruent with the general population. The sero-protection HIA titres were not sustained at 24 weeks postvaccination.

Social Media Research Strategy to Understand Clinician and Public Perception of Health Care Messages

Introduction:

Despite the potential of social media to influence public health and generate insights, the process of monitoring and analyzing the dissemination of health care messages on social media has been described as difficult and in need of improvement.

Objectives:

The objective of this study was to describe and demonstrate a reproducible methodology for cataloging and analyzing health care–related social media comments and provide insight into how clinicians and members of the general public respond to health care messaging on social media.

Methods:

We collected social media comments related to the American Dental Association’s 2016 “Evidence-Based Clinical Practice Guideline for the Use of Pit-and-Fissure Sealants” between April 10, 2017, and October 31, 2017, from Facebook, Twitter, LinkedIn, Reddit, and online message boards for the New York Times, FiveThirtyEight, and Dentaltown. Using data provided in the comments, we conducted engagement analysis as well as content, network, and sentiment analysis across 8 categories.

Results:

We collected 671 comments. Among our findings, Facebook (472 of 671) was the most popular platform among commentators; almost half of all comments (335 of 671) aligned with the recommendations of the 2016 American Dental Association sealants guideline; clinicians were more likely than the general public to like a comment that suggested an improvement to the guideline; and >75% of comments (521 of 671) were supported by anecdotal evidence.

Conclusion:

As the prevalence of anecdotes on social media suggests, the likelihood of falsehoods spreading on social media is high. Insights gleaned from the methodology described in this research could help combat the spread of such misinformation by providing disseminators of health care messaging with insight into their target audiences. Armed with this knowledge, disseminators can craft health care messages that more effectively engage clinicians and the general public.

Knowledge Transfer Statement:

The methodology used in this research provides a reproducible strategy for tracking social media engagement with health care messages. Engagement results can assist future delivery of health care messages to key stakeholders and ensure better implementation and adoption of these communications.

COPD care in Saudi Arabia: physicians' awareness and knowledge of guidelines and barriers to implementation

OBJECTIVE

To assess Saudi physicians' awareness and knowledge about chronic obstructive pulmonary disease (COPD) guideline recommendations.

METHODS

Cross-sectional study including physicians involved in COPD care in five hospitals in the Eastern Province of Saudi Arabia. The level of physicians' knowledge was considered as satisfactory (score > 80%), fair (score 50-80%) or poor (<50% of total score).

RESULTS

Among the 44 physicians included in the study, the mean ± standard deviation knowledge score was 29.5 ± 4.2 out of 45 points (65.5%). Most physicians appeared to be unaware of any COPD guidelines (n = 27, 61.4%), and reported not adhering to guidelines (n = 28, 63.6%).

CONCLUSION

Saudi physicians' knowledge about Global Initiative for Chronic Obstructive Lung Disease guidelines was assessed as fair. It is therefore highly recommended to increase physicians' awareness and knowledge about COPD-related guidelines.

Odontogenic orbital abscess with intracranial and pulmonary involvement

A 58-year-old woman presented to the emergency department with left ptosis and complete ophthalmoplegia. Imaging demonstrated a left orbital abscess. Her past medical history included cavitatory lung disease and "aseptic" meningitis 2 months previously. An anaerobic organism and commensal of the oral flora, Peptostreptococcus sp., was cultured from the orbital abscess. The patient was found to have a carious upper molar with chronic buccal abscess, which was extracted. This case presents an uncommon pathogen arising from an odontogenic infection as the etiology for orbital abscess, cavitatory lung disease, and meningitis in one patient.

A rising incidence and poorer male outcomes characterise early onset paediatric inflammatory bowel disease

BACKGROUND

The incidence of paediatric inflammatory bowel disease diagnosed before age 10 years is reportedly increasing, but national data are limited.

AIM

To characterise the epidemiology, phenotype and clinical outcomes of children diagnosed with inflammatory bowel disease before age 10 years, and compare with data from children diagnosed aged 10-16 years.

METHODS

A review of all Irish cases of early onset inflammatory bowel disease (diagnosis <10 years, EO-IBD) presenting between January 2000 and December 2014 was undertaken and compared to a cohort of later onset paediatric inflammatory bowel disease patients (diagnosis between 10 and 16 years, LO-IBD). Diagnostic investigations, phenotype, treatments, and long-term clinical and surgical outcomes were analysed.

RESULTS

One hundred and ninety children (99 male) with EO-IBD were identified; 92 (48%) CD, 77 (41%) UC and 21 (11%) IBDU. The incidence of EO-IBD increased by 0.6 per 100 000 per year (0.8-3.2 per 100 000 per year), with a significant increase in UC by 0.06 per 100 000 per year (P=.02). Males with CD had more upper GI disease (L4a; 48% vs 21%; P=.007), more extensive disease distribution (L3±L4; 31% vs 11%; P=.05) and more severe disease activity at presentation (52% vs 31%; P=.05) than females. Fewer patients with early onset than later onset Crohn's disease had ileocolonic disease (L3; 10% vs 20%; P<.001). More relapses were observed in the first year post-diagnosis in early onset than later onset IBD (1.02 vs 0.5 mean relapses; P<.001).

CONCLUSIONS

EO-IBD is increasing in incidence. Males have more extensive and severe disease phenotypes, and younger patients have higher relapse rates than older children. Further research to explain these findings is warranted.

Testing Hadronic Interactions at Ultrahigh Energies with Air Showers Measured by the Pierre Auger Observatory

Ultrahigh energy cosmic ray air showers probe particle physics at energies beyond the reach of accelerators. Here we introduce a new method to test hadronic interaction models without relying on the absolute energy calibration, and apply it to events with primary energy 6-16 EeV (E_{CM}=110-170  TeV), whose longitudinal development and lateral distribution were simultaneously measured by the Pierre Auger Observatory. The average hadronic shower is 1.33±0.16 (1.61±0.21) times larger than predicted using the leading LHC-tuned models EPOS-LHC (QGSJetII-04), with a corresponding excess of muons.

Measurement of the Radiation Energy in the Radio Signal of Extensive Air Showers as a Universal Estimator of Cosmic-Ray Energy

We measure the energy emitted by extensive air showers in the form of radio emission in the frequency range from 30 to 80 MHz. Exploiting the accurate energy scale of the Pierre Auger Observatory, we obtain a radiation energy of 15.8±0.7(stat)±6.7(syst)  MeV for cosmic rays with an energy of 1 EeV arriving perpendicularly to a geomagnetic field of 0.24 G, scaling quadratically with the cosmic-ray energy. A comparison with predictions from state-of-the-art first-principles calculations shows agreement with our measurement. The radiation energy provides direct access to the calorimetric energy in the electromagnetic cascade of extensive air showers. Comparison with our result thus allows the direct calibration of any cosmic-ray radio detector against the well-established energy scale of the Pierre Auger Observatory.

The Video Interaction Guidance approach applied to teaching communication skills in dentistry

PURPOSE

To examine dentists' views of a novel video review technique to improve communication skills in complex clinical situations.

MATERIALS AND METHODS

Dentists (n = 3) participated in a video review known as Video Interaction Guidance to encourage more attuned interactions with their patients (n = 4). Part of this process is to identify where dentists and patients reacted positively and effectively. Each dentist was presented with short segments of video footage taken during an appointment with a patient with intellectual disabilities and communication difficulties. Having observed their interactions with patients, dentists were asked to reflect on their communication strategies with the assistance of a trained VIG specialist.

RESULTS

Dentists reflected that their VIG session had been insightful and considered the review process as beneficial to communication skills training in dentistry. They believed that this technique could significantly improve the way dentists interact and communicate with patients. The VIG sessions increased their awareness of the communication strategies they use with their patients and were perceived as neither uncomfortable nor threatening.

DISCUSSION

The VIG session was beneficial in this exploratory investigation because the dentists could identify when their interactions were most effective. Awareness of their non-verbal communication strategies and the need to adopt these behaviours frequently were identified as key benefits of this training approach. One dentist suggested that the video review method was supportive because it was undertaken by a behavioural scientist rather than a professional counterpart.

CONCLUSION

Some evidence supports the VIG approach in this specialist area of communication skills and dental training.

Cows Milk Allergy: A Cohort of Patients from a University Hospital

The study illustrates advantages of Fiberoptic Bronchoscopy, a new service started at St. Lukes General Hospital in patient care since April 2014. Retrospective review of Bronchoscopies and referrals to Tertiary care unit for Bronchoscopy, prior and after initiation of service at St. Lukes Hospital were studied. Total 106 procedures were performed out of which 103(98%) were for diagnostic purpose. Common Indications for bronchoscopy were functional airway assessment in 38 cases (35%) of chronic cough, 26 cases (24.8%) of suspected Malignancy. The average time taken for procedure was 15 + 1 minute with overall rate of complication recorded in 1 case (0.95%). 32(30%) inpatients were referred before Bronchoscopy services were started locally.15(14%) patients were referred for Endobronchial ultrasound (EBUS) after diagnostic procedure performed at St. Lukes Hospital. To conclude, Bronchoscopy is a safe procedure used for diagnosis of various Lung conditions. The services offered locally reduced the time and cost involved in referrals. The diagnostic Bronchoscopies performed for Malignancy at St. Lukes Hospital have rightly increased references for EBUS at Tertiary care Unit.

Search for patterns by combining cosmic-ray energy and arrival directions at the Pierre Auger Observatory

Energy-dependent patterns in the arrival directions of cosmic rays are searched for using data of the Pierre Auger Observatory. We investigate local regions around the highest-energy cosmic rays with [Formula: see text] eV by analyzing cosmic rays with energies above [Formula: see text] eV arriving within an angular separation of approximately 15[Formula: see text]. We characterize the energy distributions inside these regions by two independent methods, one searching for angular dependence of energy-energy correlations and one searching for collimation of energy along the local system of principal axes of the energy distribution. No significant patterns are found with this analysis. The comparison of these measurements with astrophysical scenarios can therefore be used to obtain constraints on related model parameters such as strength of cosmic-ray deflection and density of point sources.

Infants with FPIES to solid food proteins--chicken, rice and oats

We present two cases of Food Protein Induced Enterocolitis Syndrome (FPIES), a non-IgE mediated food hypersensitivity. FPIES induces severe vomiting 1.5-to-3 hours post ingestion of the offending food, and may be associated with diarrhoea, hypovolemic shock and acidosis. Avoidance of that food will lead to resolution of symptoms and prevents further episodes.

A phase II trial of dacomitinib, an oral pan-human EGF receptor (HER) inhibitor, as first-line treatment in recurrent and/or metastatic squamous-cell carcinoma of the head and neck

BACKGROUND

An open-label, multicenter, single-arm phase II trial was conducted to investigate the clinical activity of dacomitinib in recurrent/metastatic squamous-cell carcinoma of the head and neck (RM-SCCHN).

PATIENTS AND METHODS

Eligible patients were administered dacomitinib at 45 mg orally daily, in 21-day cycles. Primary end point was objective response rate.

RESULTS

Sixty-nine patients were enrolled with a median age of 62 years. Among response-evaluable patients, 8 [12.7%, 95% confidence interval (CI) 5.6% to 23.5%] achieved a partial response and 36 (57.1%) had stable disease, lasting ≥24 weeks in 9 patients (14.3%). The median progression-free survival (PFS) was 12.1 weeks and the median overall survival (OS) was 34.6 weeks. Most adverse events (AEs) were tolerable. The most common grade 3 or higher treatment-related AEs were diarrhea (15.9%), acneiform dermatitis (8.7%), and fatigue (8.7%). Treatment-related AEs led to at least one dose interruption in 28 (40.6%) patients and dose reductions in 26 (37.7%). Permanent treatment discontinuation occurred in 8 (11.6%) patients due to treatment-related AEs.

CONCLUSIONS

Dacomitinib demonstrated clinical activity in RM-SCCHN, and the primary end point of this study was met. The toxicity profile of this agent was generally manageable with dose interruptions and adjustments.

Cyclical vomiting syndrome in children: a prospective study

BACKGROUND

Cyclical vomiting syndrome (CVS) is a disorder that affects all ages and is characterized by episodes of severe nausea and vomiting with symptom-free intervals between episodes. The incidence in children is 3.15/100 000 children per year. Our objective was to evaluate the natural history of CVS and examine factors that predict symptom resolution.

METHODS

Thirty newly diagnosed children (mean 9.15 years, SD 3.31 range 3.5-15.7) were enrolled. All children had a follow-up interview at 3 months, 27/30 at 6 months, and 22/30 at 9 months.

KEY RESULTS

Following diagnosis of CVS, only 5/22(22.7%) children had no further episodes of vomiting at 9 months, whereas 17/22 (77.3%) continued to vomit. In the year prior to diagnosis, 15/30 (50%) children were admitted to hospital. Of the 22 children with follow-up for 9 months, only one child required hospital admission. Children who continued to vomit had higher internalizing scores on CBCL compared with those who stopped vomiting (P = NS). The Pediatric Quality-of-Life Score suggested those who continued to vomit had a poorer quality of life at diagnosis compared with those who stopped vomiting (P < 0.05).

CONCLUSIONS & INFERENCES

Making a positive diagnosis of CVS and providing families with information is very important in the management of CVS. Although 75% of children reported regular episodes of vomiting 9 months after diagnosis, there was a significant reduction in the frequency and severity of symptoms in addition to a marked reduction in the use of medical services.

Rapid rise in incidence of Irish paediatric inflammatory bowel disease

AIMS

To describe the change in incidence of paediatric inflammatory bowel disease (IBD) observed at the National Centre for Paediatric Gastroenterology, Hepatology and Nutrition, and to determine whether the presenting disease phenotype and disease outcomes have changed during the past decade.

METHODS

The annual incidence of IBD in Irish children aged <16 years was calculated for the years 2000-2010. Two subsets of patients, group A (diagnosed between 1 January 2000 and 31 December 2001), and group B (diagnosed between 1 January and 31 December 2008) were phenotyped according to the Paris Classification. Phenotype at diagnosis and 2-year follow-up were then compared.

RESULTS

406 new cases of IBD were identified. The incidence was 2.5/100 000/year in 2001, 7.3 in 2008 and 5.6 in 2010, representing a significant increase in the number of new cases of Crohn's disease (CD) and ulcerative colitis (UC). There were 238 cases of CD; 129 of UC; and 39 of IBD unclassified. Comparing groups A and B, no differences were found in disease location at diagnosis or, for CD, in its behaviour.

CONCLUSIONS

There has been a substantial and sustained increase in the incidence of childhood UC and CD in Ireland over a relatively short period of time. However, disease phenotype at diagnosis has not changed. At 2 years follow-up, CD appears to progress less frequently than in some neighbouring countries. These variations remain unexplained. Prospective longitudinal studies will help to elucidate further the epidemiology of childhood IBD.

Prevalence and concurrence of anxiety, depression and fatigue over time in multiple sclerosis

BACKGROUND

Anxiety, depression and fatigue are commonly reported by persons with multiple sclerosis (PwMS).

OBJECTIVES

We estimated the prevalence of each factor in a representative sample of PwMS, and in subgroups defined by age, sex and disease duration, at cohort entry and over time. We further examined whether and how these factors clustered together.

METHODS

A population-based longitudinal cohort of 198 PwMS was followed 6-monthly for 2.5 years. The Hospital Anxiety and Depression Scale (HADS) was used to measure anxiety (cut-point >7) and depression (>7) and the Fatigue Severity Scale (FSS) to measure fatigue (≥5).

RESULTS

At cohort entry, prevalence of anxiety was 44.5% (95%CI 37-51%), depression 18.5% (95%CI 12.6-23.4%), and fatigue 53.7% (95%CI 47-61%). Fatigue was more common in males than females (RR 1.29, p=0.01), with attenuation of the effect after adjustment for Expanded Disability Status Scale (adjusted RR 1.18, p=0.13). Prevalence of anxiety (but not depression or fatigue) decreased by 8.1% per year of cohort observation (RR 0.92, 95%CI 0.86-0.98, p=0.009), with the effect more pronounced in women (14.6%, RR 0.85, 95%CI 0.79-0.93, -<0.001) than men (2.6%, RR 1.03, 95%CI 0.90-1.17, p=0.77). There was no apparent seasonal variation in the prevalence of any of the three factors (p>0.05). All three factors occurred contemporaneously at cohort entry in a higher proportion of the cohort than expected by chance (p<0.001).

CONCLUSIONS

Anxiety, depression and fatigue are common in PwMS and tend to cluster together. The findings are important for clinical management of PwMS and to the exploration of possible shared causal biological pathways.

Pedometer determined ambulatory activity and bone mass: a population-based longitudinal study in older adults

In this large population-based study, walking was assessed twice yearly for a week, each time by pedometer, had consistent clinically important associations with hip areal bone mineral density (aBMD) in both sexes which appears most important in those over 65 years of age suggesting that walking becomes more important with increasing age.

INTRODUCTION

Walking is advocated as a preventative strategy for osteoporosis but the evidence is conflicting in females and lacking in males. The aim of this population-based longitudinal study in community dwelling older people (n=875) was to determine the association between pedometer determined ambulatory activity (PAA) and bone mass.

METHODS

Bone mass was assessed as aBMD at the hip and spine using dual X-ray absorptiometry. Steps per day were measured using pedometers for 1 week on four occasions at least 6 months apart. Data were analysed using linear mixed models.

RESULTS

At baseline, PAA was positively associated with hip aBMD. An age interaction was present with steps having a stronger association for those aged over 65 years. Longitudinally, the effect of steps on hip aBMD was constant, but not additive over time. For those over 65 years, the difference in hip aBMD between the lowest and highest steps quartiles ranged from 3.1% to 9.4%. With regard to the spine, the relationship between daily steps and spine aBMD was modified by sex. For males; there was no significant relationship between steps and spine aBMD. However, for females, higher steps were associated with higher spine aBMD with the effect being constant over time but not additive. There was no evidence of a threshold effect.

CONCLUSION

In conclusion, pedometer-determined ambulatory activity has consistent clinically important associations with hip aBMD in both sexes which appears most important in those over 65 years of age. The associations for spine aBMD were both weaker and inconsistent suggesting site specificity.