[Cost-effectiveness analysis of fracture liaison services in Catalonia]

OBJECTIVE

To assess the cost-effectiveness of Fracture Liaison Service (FLS) compared to the standard of care for secondary prevention of fragility fractures form the perspective of the Catalan Health Service.

METHODS

Cost-utility assessment through a Markov model that simulated disease progression of a patients' cohort candidates to initiate antiosteoporotic treatment after a fragility fracture. A time horizon of 10 years and a 6-month duration per cycle was established. Clinical, economics and quality of life parameters were obtained from the literature and derived from four Catalan FLS. The Catalan Health Service perspective was adopted, considering direct health costs expressed in 2022 euros. A 3% discount rate was applied on costs and outcomes. Uncertainty was assessed through multiple sensitivity analyses.

RESULTS

Compared to the standard of care, FLS would promote antiosteoporotic initiation and persistence, reducing the incidence and mortality associated with subsequent fragility fractures. This incremental clinical benefit was estimated at 0.055 years and 0.112 quality-adjusted life years (QALYs) per patient. A higher cost (€1,073.79 per patient) was estimated, resulting into an incremental cost-utility ratio of €9,602.72 per QALYs gained. The sensitivity analyses performed were consistent, corroborating the robustness and conservative approach of the base-case.

CONCLUSIONS

The introduction of FLS for the secondary prevention of FF would represent a cost-effective strategy from the Catalan Health Service perspective.

Simplified risk-prediction for benchmarking and quality improvement in emergency general surgery. Prospective, multicenter, observational cohort study

BACKGROUND AND AIMS

Emergency General Surgery (EGS) conditions account for millions of deaths worldwide, yet it is practiced without benchmarking-based quality improvement programs. The aim of this observational, prospective, multicenter, nationwide study was to determine the best benchmark cutoff points in EGS, as a reference to guide improvement measures.

METHODS

Over a 6-month period, 38 centers (5% of all public hospitals) attending EGS patients on a 24-h, 7-days a week basis, enrolled consecutive patients requiring an emergent/urgent surgical procedure. Patients were stratified into cohorts of low (i.e., expected morbidity risk <33%), middle and high risk using the novel m-LUCENTUM calculator.

RESULTS

A total of 7258 patients were included; age (mean ± SD) was 51.1 ± 21.5 years, 43.2% were female. Benchmark cutoffs in the low-risk cohort (5639 patients, 77.7% of total) were: use of laparoscopy ≥40.9%, length of hospital stays ≤3 days, any complication within 30 days ≤ 17.7%, and 30-day mortality ≤1.1%. The variables with the greatest impact were septicemia on length of hospital stay (21 days; adjusted beta coefficient 16.8; 95% CI: 15.3 to 18.3; P < .001), and respiratory failure on mortality (risk-adjusted population attributable fraction 44.6%, 95% CI 29.6 to 59.6, P < .001). Use of laparoscopy (odds ratio 0.764, 95% CI 0.678 to 0.861; P < .001), and intraoperative blood loss (101-500 mL: odds ratio 2.699, 95% CI 2.152 to 3.380; P < .001; and 500-1000 mL: odds ratio 2.875, 95% CI 1.403 to 5.858; P = .013) were associated with increased morbidity.

CONCLUSIONS

This study offers, for the first time, clinically-based benchmark values in EGS and identifies measures for improvement.

Vertebral fractures are increased in rheumatoid arthritis despite recent therapeutic advances: a case-control study

Prevalence and risk factors of vertebral fractures in postmenopausal RA women were assessed in 323 patients and compared with 660 age-matched women. Of patients, 24.15% had at least one vertebral fracture vs.16.06% of controls. Age, glucocorticoids and falls were the main fracture risks. Vertebral fractures were associated with disease severity.

INTRODUCTION

There is little quality data on the updated prevalence of fractures in rheumatoid arthritis (RA) that may have changed due to advances in the therapeutic strategy in recent years. This study was aimed at analysing the prevalence and risk factors of vertebral fractures in postmenopausal women with RA and comparing it with that of the general population.

METHODS

We included 323 postmenopausal women diagnosed with RA from 19 Spanish Rheumatology Departments, randomly selected and recruited in 2018. Lateral radiographs of the thoracic and lumbar spine were obtained to evaluate morphometric vertebral fractures and the spinal deformity index. We analysed subject characteristics, factors related to RA, and fracture risk factors. The control group consisted of 660 age-matched Spanish postmenopausal women from the population-based Camargo cohort.

RESULTS

Seventy-eight (24.15%) RA patients had at least one vertebral fracture. RA patients had increased fracture risk compared with controls (106 of 660, 16.06%) (p = 0.02). Logistic regression analysis showed that age (OR 2.17; 95% CI 1.27-4.00), glucocorticoids (OR 3.83; 95% CI 1.32-14.09) and falls (OR 3.57; 95% CI 1.91-6.86) were the independent predictors of vertebral fractures in RA patients. The subgroup with vertebral fractures had higher disease activity (DAS28: 3.15 vs. 2.78, p = 0.038) and disability (HAQ: 0.96 vs. 0.63, p = 0.049), as compared with those without vertebral fractures.

CONCLUSION

The risk of vertebral fracture in RA is still high in recent years, when compared with the general population. The key determinants of fracture risk are age, glucocorticoids and falls. Patients with vertebral fractures have a more severe RA.

OP0323 INCIDENCE OF CLINICAL FRAGILITY FRACTURES IN POSTMENOPAUSAL WOMEN WITH RHEUMATOID ARTHRITIS. A MULTICENTRIC CASE-CONTROL STUDY

Background:

Incidence of clinical fractures in rheumatoid arthritis (RA) is not as well-known as hip or vertebral fracture incidence.

Objectives:

1. To estimate the incidence of clinical fragility fractures in a population of postmenopausal women diagnosed with RA and compare it with that of the general population; 2. To analyze the risk factors for fracture.

Methods:

330 postmenopausal women with RA from 19 Spanish Rheumatology Departments, randomly selected from the registry of RA patients in each center. The control group consisted of 660 Spanish postmenopausal women from the Camargo Cohort. Clinical fractures during the previous 5 years were recorded. Assessed risk factors for fracture were: sociodemographic characteristics, BMD and variables related to RA.

Results:

Median age of RA patients was 64 yrs. vs. 63 yrs. in controls (ns). Evolution of the disease was 8 yrs. 78% and 76% had RF and ACPA+, respectively. 69% of patients were in remission or low activity. 85% had received glucocorticoids and methotrexate and 40% at least one biological DMARD. We identified 105 fractures (87 fragility and 18 traumatic) in 75 patients. Fifty-four patients and 47 controls had at least one major fracture (MF) (p< 0.001). Incidence of MF was 3.55 per 100 patient-year in patients and 0.72 in controls. Risk factors for MF in RA patients were age, previous fracture, parental hip fracture, postmenopausal period, hip BMD and cumulative dose of glucocorticoids. In controls, risk factors were age, age at menopause and lumbar BMD.

Among RA-associated factors, MFs were associated with erosions, disease activity and disability. Previous fracture in RA patients was a strong risk for MF (HR: 10.37 [95% CI: 2.95-36.41]).

Conclusion:

Between 3 and 4 of every 100 postmenopausal women with RA have a major fracture per year, four times more than the general population. Disease activity and disability associated with RA, the cumulative dose of glucocorticoids and mainly previous fracture are associated with the development of fragility fractures.

References:

None

Acknowledgments:

Funded in part by ISCIII (PI18/00762) that included FEDER funds from the EU.

Disclosure of Interests:

Carmen Gómez Vaquero: None declared, Jose Manuel Olmos: None declared, J. Luis Hernández: None declared, Dacia Cerda: None declared, Cristina Hidalgo: None declared, JA Martínez López: None declared, Luis Marcelino Arboleya Rodríguez: None declared, Javier Aguilar del Rey: None declared, Silvia Martinez Pardo: None declared, Inmaculada Ros: None declared, Xavier Surís: None declared, Dolors Grados Canovas: None declared, Chesús Beltrán Audera: None declared, Evelyn Suero-Rosario: None declared, Inmaculada Gómez Gracia: None declared, Asunción Salmoral: None declared, Irene Martín-Esteve: None declared, Helena Florez: None declared, Antonio Naranjo Grant/research support from: amgen, Consultant of: UCB, Speakers bureau: AMGEN, Santos Castañeda: None declared, Soledad Ojeda Speakers bureau: AMGEN, LILLY, GEBRO, S García Carazo: None declared, Alberto García-Vadillo: None declared, Laura López Vives: None declared, À Martínez-Ferrer: None declared, Helena Borrell Paños: None declared, Pilar Aguado: None declared, Raul Castellanos-Moreira: None declared, Cristian Tebé: None declared, Núria Guañabens: None declared

FRI0528 INDICATORS OF EFFECTIVENESS AFTER 6 YEARS OF FOLLOW-UP OF PATIENTS IN THE FLS DR. NEGRIN

Background:

Data on the effectiveness of FLS in the medium and long term in Spain are needed

Objectives:

To analyze the indicators of long-term persistence to treatment, refracture and mortality in our Fracture Liaison Service (FLS)

Methods:

Throughout 2019, the medical records of patients with an indication of treatment to prevent new fractures whose baseline visit took place between 2012 and 2014 were reviewed. The data included those of the baseline visit (age, sex, type of index fracture, FRAX scale and DXA results) and for the follow-up (death and date, refracture including revision of spine x-rays - it was considered only the first refracture and, in the case of several fractures the most serious was chosen-, prescribed treatment, persistence of treatment trough electronic prescription on the date of review or death, and MPR or proportion of days covered by treatment).

Results:

399 patients were included, 335 of them women (84%), mean age 73.8 years (range 51-93) and average follow-up of 6 years (range 5.5-7 years).

Baseline visit.- The average FRAX was 15 and 7 for major fracture and femoral fracture respectively. DXA was normal in 22 patients (5.5%), osteopenia in 143 (35.8%) and osteoporosis in 234 (58.6%). 78 patients (19.5%) had a previous fragility fracture.

Type of fracture index: femur 126 (31.5%), forearm 119 (29.8%), humerus 76 (19%), vertebra 24 (6%), others 54 (13.5%). 80 patients (20%) had received prior treatment for osteoporosis.

Follow-up.- The persistence of treatment was assessed in 394 patients; 245 patients (62%) were prescribed a treatment on the most recent date, 200 (51%) with MPR≥80%. When analyzing patients with prescribed treatment, in 176 cases (72%) it was a bisphosphonate in a sustained manner, in 23 cases (9%) a bisphosphonate was prescribed and subsequently changed to denosumab, while in 45 cases (18%) it was initiated and maintained denosumab.

71 of 397 patients presented a new fracture (17.8%). The type of incident fracture was as follows: femur in 24 patients (34%), vertebra in 20 patients (28%), forearm in 9 patients (12%) and other fractures in 18 patients (25%). Refracture occurred in 9 patients in the first year, 16 in 2nd, 12 in the 3rd, 9 in 4th, 14 in 5th, 6 in 6th and 3 in 7th year. The persistence of treatment with MPR≥80% was similar in patients with and without refracture (52 vs 51%). The average baseline age and FRAX for major fracture in the fractured and non-fractured were 75 vs. 73 years (p = 0.10) and 17 vs. 14 respectively (p <0.01).

92 patients (23%) died, 25% of them in the two years that followed the baseline visit and 61% in the following 4 years. The persistence of treatment was 37% in those who died and 69% in those who remained alive (p <0.01).

Conclusion:

After an average of 6 years after the assessment in an FLS, the persistence of treatment was 62% (MPR≥80% in 51%), the mortality was 23% and the percentage of refractured patients was 17%.

Disclosure of Interests:

Antonio Naranjo Grant/research support from: amgen, Consultant of: UCB, Speakers bureau: AMGEN, Amparo Molina Speakers bureau: AMGEN, STADA, Cristina Sepúlveda: None declared, Francisco Rubiño: None declared, Soledad Ojeda Speakers bureau: AMGEN, LILLY, GEBRO

AB1180 THE EVOLUTION OF AN FLS IN SEARCH OF EXCELLENCE: THE EXPERIENCE OF GRAN CANARIA

Background:

The implementation of an FLS in the Spanish public health system is not an easy task since there are no official plans for the incorporation of personnel dedicated to the unit

Objectives:

To expose the consolidation and improvement of an FLS after its implementation as well as the problems that have arisen over time.

Methods:

The health program for secondary fracture prevention was implemented in 2012. Initially worked with the same staff assigned to the Rheumatology service, since 2016 we have a part-time support nurse. Patients are identified from the emergency registry and, more recently, from patients admitted for hip fracture and treated in a monographic osteoporosis clinic. The baseline visit consists of consultation with the nurse, DXA and bone metabolism analytics. Falling patients are referred to a fall prevention school. Most patients are referred to their primary care physician to start a treatment.

Results:

Of the 2,416 patients attended the baseline visit, 30% were forearm fractures, 27% hip, 20% humerus, 10% spine and 11% other fractures. In comparison to 2012, in 2019 the monthly average of patients has doubled, increased the number of hip and spine fractures, and increased the percentage of captured patients (Table). In spite of consolidating the unit, getting a support nurse for the admitted patients and establishing a solid alliance with primary care, it is pending the involvement of Primary Care Nurses and start first prescription at the hospital.

Table.

Comparison of the first year with the last year of implementation of our FLS.

20122019Mean monthly number of fractures, N2242Type of fracture: forearm/hip/spine, %37/20/628/40/11Captured patients of elegible, %5777Delay in weeks until first visit to FLS, median1412Patient origin: emergency list/inpatient/outpatient, %100/0/059/31/9DXA performed, %10061Referral to fall prevention school, %026Criteria to start a treatment, %6790*Referral to the osteoporosis clinic, %377

*We apply the 2019 recommendations of the Spanish Society of Rheumatology

Conclusion:

We present the achievements made by our FLS along 8 years and the difficulties within the Spanish public health system.

Disclosure of Interests:

Antonio Naranjo Grant/research support from: amgen, Consultant of: UCB, Speakers bureau: AMGEN, Amparo Molina Speakers bureau: AMGEN, STADA, Cristina Sepúlveda: None declared, Candelaria Torres: None declared, Fabiola Santana: None declared, Francisco Rubiño: None declared, Rubén López: None declared, Soledad Ojeda Speakers bureau: AMGEN, LILLY, GEBRO

Best Practice Framework of Fracture Liaison Services in Spain and their coordination with Primary Care

The coordination of Fracture Liaison Services (FLS) with Primary Care (PC) is necessary for the continuity of care of patients with fragility fractures. This study proposes a Best Practice Framework (BPF) and performance indicators for the implementation and follow-up of FLS-PC coordination in clinical practice in Spain.

PURPOSE

To develop a BPF for the coordination of FLS with PC in Spain and to improve the continuity of care for patients with fragility fractures.

METHODS

A Steering Committee selected experts from seven Spanish FLS and related PC doctors and nurses to participate in a best practice workshop. Selection criteria were an active FLS with an identified champion and prior contact with PC centres linked to the hospital. The main aim of the workshop was to review current FLS practices in Spain and their integration with PC. A BPF document with processes, tools, roles, and metrics was then generated.

RESULTS

Spanish FLS consists of a multidisciplinary team of physicians/nurses but with low participation of other professionals and PC staff. Evaluation and treatment strategies are widely variable. Four desired standards were agreed upon: (1) Effective channels for FLS-PC communication; (2) minimum contents of an FLS clinical report and its delivery to PC; (3) adherence monitoring 3 months after FLS baseline visit; and (4) follow-up by PC. Proposed key performance indicators are (a) number of FLS-PC communications, including consensus protocols; (b) confirmation FLS report received by PC; (c) medical/nursing PC appointment after FLS report received; and (d) number of training sessions in PC.

CONCLUSIONS

The BPF provides a comprehensive approach for FLS-PC coordination in Spain, to promote the continuity of care in patients with fragility fractures and improve secondary prevention. The implementation of BPF recommendations and performance indicator tracking will benchmark best FLS practices in the future.

Greenhouse gas, water, and land footprint per unit of production of the California dairy industry over 50 years

Food production including dairy has been associated with environmental impacts and resource use that has been steadily improving when adjusted per unit of product. The objective of this study was to conduct a cradle-to-farm gate environmental impact analysis and resource inventory of the California dairy production system to estimate the change in greenhouse gas emissions and water and land use over the 50-yr period between 1964 and 2014. Using a life cycle assessment according to international standards and the Food and Agriculture Organization of the United Nations guidelines, we analyzed contributions from dairy production in California to global environmental change. Production of 1 kg of energy- and protein-corrected milk (ECM) in California emitted 1.12 to 1.16 kg of CO₂ equivalents (CO₂e) in 2014 compared with 2.11 kg of CO₂e in 1964, a reduction of 45.0 to 46.9% over the last 50 yr, depending on the model used. Greater reductions in enteric methane intensity (i.e., methane production per kilogram of ECM) were observed (reduction of 54.1 to 55.7%) compared with manure GHG (reduction of 8.73 to 11.9%) in 2014 compared with 1964. This was mainly because manure management in the state relies on lagoons for storage, which has a greater methane conversion factor than solid manure storage. Water use intensity was reduced by 88.1 to 89.9%, with water reductions of 88.7 to 90.5% in crop production, 55.3 to 59.2% in housing and milking, and 52.4 to 54% in free water intake. Improved crop genetics and management have contributed to large efficiencies in water utilization. Land requirements for crop production were reduced by 89.4 to 89.7% in 2014 compared with 1964. This was mainly due to dramatic increases in crop yields in the last 50 yr. The increases in milk production per cow through genetic improvements and better nutrition and animal care have contributed to reductions in greenhouse gas emissions and land and water usage when calculated per unit of production (intensity) basis.

Genetic structure of the Canarian palm tree (Phoenix canariensis) at the island scale: does the 'island within islands' concept apply to species with high colonisation ability?

Oceanic islands are dynamic settings that often promote within-island patterns of strong population differentiation. Species with high colonisation abilities, however, are less likely to be affected by genetic barriers, but island size may impact on species genetic structure regardless of dispersal ability. The aim of the present study was to identify the patterns and factors responsible for the structure of genetic diversity at the island scale in Phoenix canariensis, a palm species with high dispersal potential. To this end, we conducted extensive population sampling on the three Canary Islands where the species is more abundant and assessed patterns of genetic variation at eight microsatellite loci, considering different within-island scales. Our analyses revealed significant genetic structure on each of the three islands analysed, but the patterns and level of structure differed greatly among islands. Thus, genetic differentiation fitted an isolation-by-distance pattern on islands with high population densities (La Gomera and Gran Canaria), but such a pattern was not found on Tenerife due to strong isolation between colonised areas. In addition, we found a positive correlation between population geographic isolation and fine-scale genetic structure. This study highlights that island size is not necessarily a factor causing strong population differentiation on large islands, whereas high colonisation ability does not always promote genetic connectivity among neighbouring populations. The spatial distribution of populations (i.e. landscape occupancy) can thus be a more important driver of plant genetic structure than other island, or species' life-history attributes.

High sensitivity C-reactive protein in systemic lupus erythematosus: relation to disease activity, clinical presentation and implications for cardiovascular risk

Measurement of high sensitivity C-reactive protein (hs-CRP), has been used in the assessment of disease activity in numerous rheumatic conditions including systemic lupus erythematosus (SLE). However, the utility of hs-CRP measurement in patients with lupus is uncertain. This study examined if hs-CRP can be used to assess disease activity, severity and cardiovascular risk in SLE. Serum samples from 601 visits of 213 SLE patients and 134 controls were analysed for hs-CRP by nephelometry. Detailed demographic data were obtained from all subjects and medication history and key laboratory parameters were collected. Disease activity was assessed using the SLEDAI. High sensitivity CRP was not associated with disease activity (SLEDAI), number of ACR SLE criteria or presence of any particular organ involvement. hs-CRP levels were significantly correlated with standard cardiovascular risk factors including body weight ( P = 0.0002), hypertension ( P = 0.001), and apolipoprotein A-I ( P < 0.0001). Interestingly an inverse correlation was seen between hs-CRP levels and antimalarial use ( P = 0.0018). Our results suggest that measurement of hs-CRP, though not valuable as marker of disease activity in SLE may be of some use in the assessment of cardiovascular risk. We speculate that antimalarials may help to reduce cardiovascular risk in patients with SLE.

Two-year adherence to treatment and associated factors in a fracture liaison service in Spain

A fracture liaison service in Spain is able to maintain 73 % of the patients on antiresorptive 2 years after the fracture.

INTRODUCTION

The purpose of this study was to evaluate the 2-year effectiveness of a program for the secondary prevention of fractures.

METHODS

Fragility fractures in patients over 50 attending the emergency room in our centre are captured by the recruitment system of a secondary prevention program. The unit is attended by a nurse, coordinated by two rheumatologists and with the collaboration of primary care consisted of a training program and annual meetings. The outcome of the program was analysed 2 years after implementation, including: (1) percentage of attendees/eligible; (2) percentage of attendees who start treatment with antiresorptive; (3) percentage of patients who retain treatment after 6, 12, 18 and 24 months; and (4) factors associated to adherence.

RESULTS

After 2 years of implementation, the program detected 1674 patients with fracture, of whom 759 finally entered the program (57 % of eligible). After 3 months, 82 % of patients prescribed an antiresorptive started treatment. After a year, 52 % of the patients in the program, 72 % of those of a prescribed treatment, were taking antiresorptives. Adherence at 24 months among those who had prescribed anti-fracture drugs was 73 %. Factors associated with adherence at 12 months were female sex (76 vs 45 %; p = 0.01) and previous treatment with antiresorptive (86 vs 68 %; p = 0.02).

CONCLUSIONS

In Spain, a program designed to prevent secondary fragility fractures based on the collaboration between primary care and rheumatology seems effective in terms of recruitment of patients and adherence to treatment in the mid/long-term.

A pilot study of tandem high-dose chemotherapy with stem cell rescue as consolidation for high-risk neuroblastoma: Children's Oncology Group study ANBL00P1

Increasing treatment intensity has improved outcomes for children with neuroblastoma. We performed a pilot study in the Children’s Oncology Group (COG) to assess feasibility and toxicity of a tandem myeloablative regimen without total body irradiation (TBI) supported by autologous CD34 selected peripheral blood stem cells. Forty-one patients with high-risk neuroblastoma were enrolled; eight patients did not receive any myeloablative consolidation procedure, and seven received only one. Two patients out of 41 (4.9%) experienced transplant-related mortality. CD34 selection was discontinued after subjects were enrolled due to serious viral illness. From the time of study enrollment, the overall 3-year event-free survival (EFS) and overall survival (OS) were 44.8±9.6% and 59.2±9.2% (N=41). These results demonstrate that tandem transplantation in the cooperative group setting is feasible and support a randomized comparison of single versus tandem myeloablative consolidation with PBSC support for high-risk neuroblastoma.

A 40-month multicentre, randomised placebo-controlled study to assess the efficacy and carry-over effect of repeated intra-articular injections of hyaluronic acid in knee osteoarthritis: the AMELIA project

Objective

AMELIA (OsteoArthritis Modifying Effects of Long-term Intra-articular Adant) was designed to compare against placebo the efficacy and safety of repeated injections of hyaluronic acid (HA) and its effect on disease progression over 40 months.

Methods

A multicentre, randomised, patient and evaluator-blinded, controlled study in 306 patients fulfilling American College of Rheumatology criteria for knee osteoarthritis, radiological grades II–III (Kellgren–Lawrence) and joint space width ≥2 mm. Patients received four cycles of five intra-articular HA or placebo injections with a follow-up of 6 months after the first and second cycles, and 1 year after the third and fourth cycles. Osteoarthritis Research Society International (OARSI) 2004 responder criteria were used to assess efficacy. The consumption of rescue medication was a secondary outcome. Adverse events were recorded for safety purposes.

Results

At the 40-month visit significantly more patients responded to HA compared with placebo (OARSI 2004, p=0.004). The number of responders to HA increased through the study, whereas those to placebo did not change. Significant differences were also found in favour of HA for each individual component of the OARSI 2004. No safety problems were recorded.

Conclusions

The results of AMELIA offer pioneer evidence that repeated cycles of intra-articular injections of HA not only improve knee osteoarthritis symptoms during the in-between cycle period but also exert a marked carry-over effect for at least 1 year after the last cycle. In this respect, it is not possible to establish if this carry-over effect reflects true osteoarthritis remission or just a modification of the disease's natural course.

ClinicalTrials.gov number, NCT00669032

Secondary prevention program for osteoporotic fractures and long-term adherence to bisphosphonates

Our purpose was to assess the impact of a secondary prevention program for osteoporotic fractures in patients with fragility fracture and to determine its effect on long-term compliance with bisphosphonate treatment. Persistence with bisphosphonate use was 71%. Attending follow-up visits was the only variable significantly associated with adherence to bisphosphonates.

INTRODUCTION

The aim of this study is to assess the impact a secondary prevention program for osteoporotic fractures in a prospective cohort of patients with at least one fragility fracture and to determine the effect of this intervention on long-term compliance with bisphosphonate treatment.

METHODS

All patients older than 50 years with a fragility fracture attended at the emergency department over a 2-year period were appointed for a clinical visit through a telephone call. Two follow-up controls at 4 and 12 months were scheduled. After a mean of 4 years, a telephone survey was conducted to assess compliance with treatment.

RESULTS

Of 683 eligible patients, 380 (55.6%) were visited at the hospital. Previous treatment with bisphosphonates was recorded in 17.9% of patients. DXA scan was considered normal in 61 patients and revealed osteopenia in 184 and osteoporosis in 135. Pharmacological treatment was indicated in 90% of patients (alendronate in 76%). Among 241 patients who participated in the survey, eight patients had new fractures (four were on treatment with bisphosphonates and four had discontinued treatment). Of 187 patients in which bisphosphonates were prescribed at the initial visit, 133 (71.1%) continued using bisphosphonates. Attendance of scheduled visits was associated with adherence to bisphosphonates (odds ratio, 3.33; 95% confidence interval, 2.99-3.67).

CONCLUSIONS

The efficacy of the program to recruit patients was 55%. In patients visited at the hospital, treatment with bisphosphonates increased from 17.9% to 76%. Persistence with bisphosphonate use after a mean of 4 years was 71%. Attending follow-up visits was significantly associated with adherence to bisphosphonates.

Limited value of ultrasound assessment in patients with poor outcome after carpal tunnel release surgery

OBJECTIVE

To determine the value of ultrasonography in the assessment of patients with idiopathic carpal tunnel syndrome (CTS) and poor outcome after carpal tunnel release.

METHODS

A total of 88 consecutive patients with CTS (104 hands) underwent open surgical release of the median nerve. Ultrasound (US) examination was performed blind to any patient's data. The median nerve area at tunnel inlet and outlet, the retinaculum distance, and the flattening ratio were measured. The main outcome variable was the patient's overall satisfaction using a five-point Likert scale (1 = worse, 2 = no change, 3 = slightly better, 4 = much better, 5 = cured) at 3 months postoperatively. Pre- and postoperative ultrasonographic findings in relation to clinical outcome were analysed.

RESULTS

Improvement (scores 4 or 5 on the Likert scale) was recorded in 75 hands (72%). After carpal tunnel release, the cross-sectional area at tunnel inlet decreased from a mean of 14.2 to 13.3 mm2 in the group with clinical improvement and also from a mean of 12.5 to 11.6 mm2 in the group with no change or slight improvement. No significant changes in the cross-sectional area at tunnel outlet, retinaculum distance, and flattening ratio were observed.

CONCLUSION

Reduction of the median nerve cross-sectional area at tunnel inlet at 3 months after carpal tunnel release was similar in patients reporting cure or great improvement and in those with slight or no improvement. Ultrasonography is of limited value in assessment of patients with poor outcome after median nerve release.

Smokers and non smokers with rheumatoid arthritis have similar clinical status: data from the multinational QUEST-RA database

OBJECTIVES

To analyse clinical severity/activity of rheumatoid arthritis (RA) according to smoking status.

METHODS

The QUEST-RA multinational database reviews patients for Core Data Set measures including 28 swollen and tender joint count, physician global estimate, erythrocyte sedimentation rate (ESR), HAQ-function, pain, and patient global estimate, as well as DAS28, rheumatoid factor (RF), nodules, erosions and number of DMARDs were recorded. Smoking status was assessed by self-report as 'never smoked', 'currently smoking' and 'former smokers'. Patient groups with different smoking status were compared for demographic and RA measures.

RESULTS

Among the 7,307 patients with smoking data available, status as 'never smoked,' 'current smoker' and 'former smoker' were reported by 65%, 15% and 20%. Ever smokers were more likely to be RF-positive (OR 1.32;1.17-1.48, p<0.001). Rheumatoid nodules were more frequent in ever smokers (OR 1.41;1.24-1.59, p<0.001). The percentage of patients with erosive arthritis and extra-articular disease was similar in all smoking categories. Mean DAS28 was 4.4 (SD 1.6) in non-smokers vs. 4.0 (SD 1.6) in those who had ever smoked. However, when adjusted by age, sex, disease duration, and country gross domestic product, only ESR remained significantly different among Core Data Set measures (mean 31.7mm in non-smokers vs. 26.8mm in ever smoked category).

CONCLUSIONS

RA patients who had ever smoked were more likely to have RF and nodules, but values for other clinical status measures were similar in all smoking categories (never smoked, current smokers and former smokers).

Establishment of a pediatric liver transplantation program: experience with 100 transplantation procedures

OBJECTIVE

To analyze the primary factors that influence the development and consolidation of a pediatric liver transplantation program.

PATIENTS AND METHODS

This was a retrospective study of 100 liver transplantation procedures performed in 84 pediatric patients between May 1990 and November 2007. The male-female ratio was 40:60. Mean (SD) age was 5 years (40 patients were younger than 2 years); cold ischemia time was 7.10 (3.1) hours; surgery time was 5.2 (2.2) hours; and time on the waiting list for transplantation was 75 (range, 1-1012) days. Indications for transplantation included cholestatic disease (43%), acute hepatic failure (AHF; 34%), metabolic disorders (14%), and cirrhosis (9%). Transplanted organs included 3 split grafts, 29 partial grafts, and 8 living-donor grafts.

RESULTS

Mean graft survival was 70.4%, 59.2%, and 58.1% at 1, 3, and 5 years, respectively. Factors that influenced graft outcome were age younger than 2 years; surgery time more than 6 hours; and AHF vs cholestatic disease, metabolic disorders, and cirrhosis. There were no significant differences in long-term (51% vs 59%) and short-term (71% vs 70%) graft survival between procedures performed in 1990-1998 compared with those performed in 1999-2007; however, there was a higher percentage (P = .005) of recipients at high risk (age younger than 2 years or with AHF) in the later period. All data were consistent with those of the European Liver Transplant Registry 2007.

CONCLUSIONS

A pediatric liver transplantation program can be established by a group experienced in liver transplantation.

The MobiSan approach: informal settlements of Cape Town, South Africa

Pook se Bos informal settlement and the Cape Town Water & Sanitation Services Department are partnering on an urban sanitation project with a Dutch Consortium consisting of Lettinga Associates Foundation (LeAF), Landustrie Sneek and Vitens-Evides International. The aim of the project is to improve the basic sanitation services provided in informal settlements through the implementation of the MobiSan approach. The approach consists of a communal Urine-Diversion and Dehydration Toilet (UDDT) built in a former sea shipping container. The system is independent of water, electricity or sewerage connection and it is maintained by full-time community caretakers who also act as hygiene promoters. The project seeks to link sanitation services with hygiene promotion in informal settlements while enhancing user satisfaction and reducing costs in providing basic sanitation services. This paper describes the preliminary experiences and lessons learnt during the implementation and evaluation of the MobiSan prototype and discusses its potential for replication. The MobiSan has proved to be an appropriate option by means of dealing successfully with shallow groundwater table, land availability and high settlement densities. In addition it has been demonstrated to be cost-competitive in terms of operating cost compared to chemical toilets.

Usefulness of clinical findings, nerve conduction studies and ultrasonography to predict response to surgical release in idiopathic carpal tunnel syndrome

OBJECTIVES

To assess the usefulness of clinical findings, nerve conduction studies and ultrasonography performed by a rheumatologist to predict success in patients with idiopathic carpal tunnel syndrome (CTS) undergoing median nerve release.

METHODS

Ninety consecutive patients with CTS (112 wrists) completed a specific CTS questionnaire and underwent physical examination and nerve conduction studies. Ultrasound examination was performed by a rheumatologist who was blind to any patient's data. Outcome variables were improvement >25% in symptoms of the CTS questionnaire and patient's overall satisfaction (5-point Likert scale) at 3 months postoperatively. Success was defined as improvement in both outcome variables. Receiver operating characteristics (ROC) curves and logistic regression analyses were used to assess the best predictive combination of preoperative findings.

RESULTS

Success was achieved in 63% of the operated wrists. Utility parameters and area under the ROC curve (AUC) for individual findings was poor, ranging from 0.481 of the nerve conduction study to 0.634 of the cross-sectional area at tunnel outlet. Logistic regression identified the preoperative US parameters as the best predictive variables for success after 3 months. The best predictive combination (AUC=0.708) included a negative Phalen maneuver, plus absence of thenar atrophy, plus less than moderately abnormalities on nerve conduction studies plus a large maximal cross-sectional area along the tunnel by ultrasonography.

CONCLUSION

Although cross-sectional area of the median nerve was the only predictor of success after three months of surgical release, isolated preoperative findings are not reliable predictors of success in patients with idiopathic CTS. A combination of findings that include ultrasound improves prediction.

Factors involved in the progress of preclinical atherosclerosis associated with systemic lupus erythematosus: a 2-year longitudinal study

Objectives

To assess the changes in carotid intima-media thickness (IMT) and the associated risks factors in patients with low severity systemic lupus erythematosus (SLE).

Methods

Common carotid IMT measurements were obtained by ultrasound from 101 patients with SLE at an interval of 2 years. Cardiovascular risk factors, disease activity, accumulated damage, severity (Katz index) and biochemical parameters (including high sensitivity C-reactive protein, interleukin 6, C3a, C4a, C5a and homocysteine) were also assessed. Multiple linear regression was used to assess the effect of these variables on the end IMT measurement (eIMT) adjusted to the baseline measurement (bIMT).

Results

The cohort comprised 94.1% women, with a mean age at entry of 41.5 years and a mean disease duration of 12.1 years. An increase of 0.078 mm in IMT was detected over 2 years, from a mean bIMT of 0.37 mm to a mean eIMT of 0.44 mm (p<0.001). When adjusted for the bIMT, multiple linear regression identified bIMT, age at diagnosis, homocysteine, C3 and C5a as risk factors for IMT progression.

Conclusions

IMT significantly increases over 2 years in patients with SLE. Age, baseline IMT, C3, C5a anaphylatoxin and homocysteine are all associated risk factors, supporting a role for complement and homocysteine in the early stages of premature SLE-associated atherosclerosis.

Disparities in rheumatoid arthritis disease activity according to gross domestic product in 25 countries in the QUEST-RA database

OBJECTIVE

To analyse associations between the clinical status of patients with rheumatoid arthritis (RA) and the gross domestic product (GDP) of their resident country.

METHODS

The Quantitative Standard Monitoring of Patients with Rheumatoid Arthritis (QUEST-RA) cohort includes clinical and questionnaire data from 6004 patients who were seen in usual care at 70 rheumatology clinics in 25 countries as of April 2008, including 18 European countries. Demographic variables, clinical characteristics, RA disease activity measures, including the disease activity score in 28 joints (DAS28), and treatment-related variables were analysed according to GDP per capita, including 14 "high GDP" countries with GDP per capita greater than US$24,000 and 11 "low GDP" countries with GDP per capita less than US$11,000.

RESULTS

Disease activity DAS28 ranged between 3.1 and 6.0 among the 25 countries and was significantly associated with GDP (r = -0.78, 95% CI -0.56 to -0.90, r(2) = 61%). Disease activity levels differed substantially between "high GDP" and "low GDP" countries at much greater levels than according to whether patients were currently taking or not taking methotrexate, prednisone and/or biological agents.

CONCLUSIONS

The clinical status of patients with RA was correlated significantly with GDP among 25 mostly European countries according to all disease measures, associated only modestly with the current use of antirheumatic medications. The burden of arthritis appears substantially greater in "low GDP" than in "high GDP" countries. These findings may alert healthcare professionals and designers of health policy towards improving the clinical status of patients with RA in all countries.

Model for end-stage liver disease can predict very early outcome after liver transplantation

Postoperative Model for End-stage Liver Disease (MELD) values have never been assessed to predict very early (<1 week) death after liver transplantation (OLT). We retrospectively reviewed 275 consecutive OLTs performed in 252 recipients reported in a prospective database. We calculated the MELD score (pre-MELD) and consecutive postoperative MELD (post-MELD) scores computed daily during the first postoperative week and on days 15 and 30 after OLT. Post-MELD scores from nonsurviving recipients displayed on a scatterplot of immediate probability of death were adjusted to the best goodness-of-fit curve, and, finally, depicted graphically as a receiver operating characteristic (ROC) curve. Nonsurviving recipients showed higher post-MELD scores: day 1: 23.5 versus 16.6 (P = .05); day 3: 25.1 versus 12.5 (P = .000); day 5: 25.7 versus 11.8 (P = .000); and day 7: 22.1 versus 10.2 (P = .000). Overall comparisons were performed using a time-dependent general linear regression model, revealing higher post-MELD scores for nonsurviving recipients, irrespective of postoperative time (P = .002). The best goodness-of-fit curve was displayed when adjusting to a theoretical exponential regression curve calculated as follows: Probability of dying within the first week (%) = 3.36 x e(0.079 x (post-MELD)) (r = .89; P = .000). The area under the ROC curve was 0.783 (95% confidence interval, 0.630-0.935; P = .001). The model had a positive predictive value of 82.3%, a negative predictive value of 33.1%, and an accuracy of 79.2%. In conclusion, this study corroborated the suggestion that the MELD score may serve as a reliable tool to assess very early death after OLT.

Contribution of marginal donors to liver transplantation for hepatitis C virus infection

The use of marginal liver donors can affect the outcomes of liver transplantation in patients with hepatitis C virus (HCV) infection. There are no firm conclusions about which donor criteria are important for allocation of high-risk grafts to recipients with HCV cirrhosis. We performed 120 consecutive liver transplantations for HCV infection between 1995 and 2005. Marginal donor criteria were considered to be: age >70 years, macrovesicular steatosis >30%, moderate-to-severe liver preservation injury, high inotropic drug dose (dopamine >15 microg/kg/min; epinephrine, norepinephrine, or dobutamine at any doses), peak serum sodium >155 mEq/L, any hypotensive episode <60 mm Hg and >1 hour, cold ischemia time >12 hours, ICU hospitalization >4 days, bilirubin >2 mg/dL, AST and/or ALT >200 UI/dL. Graft survival with donors showing these marginal criteria was compared with optimal donors using Kaplan-Meier analysis and the log-rank test. Independent predictors of survival were computed with the Cox proportional hazards model. Fifty-six grafts (46%) were lost during follow-up irrespective of the Model for End-Stage Liver Disease (MELD) scores of the recipients in each category. Upon univariate analysis, grafts with moderate-to-severe steatosis (P = .012), those with severe liver preservation injury (P = .007) and prolonged cold ischemia time (P = .0001) showed a dismal prognosis at 1, 3, and 5 years. Upon multivariate analysis, fat content (P = .0076; OR = 4.2) and cold ischemia time >12 hours (P = .034; OR = 7.001) were independent predictors of graft survival. Among HCV recipients, marginal liver donors worked similar to those from "good" donors, except for those with fatty livers >30%, especially when combined with a prolonged cold ischemia time.

What is the diagnostic value of ultrasonography compared to physical evaluation in patients with idiopathic carpal tunnel syndrome?

OBJECTIVE

Our hypothesis is that sonography performed by the rheumatologist in patients with suspected carpal tunnel syndrome (CTS) has higher diagnostic value compared to physical evaluation.

METHODS

Adult patients with suspected idiopathic CTS, defined by sensory symptoms over the distribution of the median nerve with or without positive results with the Phalen and/or the Tinel's maneuvers were included. The diagnosis of CTS was indicated by typical symptoms daily for at least 3 months and a positive nerve conduction study. One rheumatologist unaware of the clinical and electrodiagnostic results performed an ultrasound examination of the median nerve for the area ranging from the inlet to the outlet of the carpal tunnel. Mean cross-sectional area at each level, flattening ratio and bowing of flexor retinaculum were obtained.

RESULTS

Sixty-eight patients with 105 affected wrists were examined. Tinel's and Phalen's signs had a closer sensitivity (73% and 67% respectively) and specificity (40% and 30% respectively). The best swelling nerve cut-off by sonography was 9.7 mm2 at the tunnel inlet, with a sensitivity of 86%, a specificity of 48% and accuracy of 77%. A 100% positive predictive value was reached with a cross-sectional area of 13 mm2, involving 33 hands (31% of the whole sample). Maximal cross sectional area and the measurement of flexor retinaculum had an accuracy of 72% and 73% respectively. Combination of physical maneuvers and sonography not yielded more accuracy than cross-sectional area itself.

CONCLUSION

In patients with clinical history of idiopathic CTS and positive nerve conduction study, sonography performed by the rheumatologist has higher diagnostic value than physical maneuvers.

Randomized clinical trial of the effect of intravenous fluid administration on hormonal and renal dysfunction in patients with obstructive jaundice undergoing endoscopic drainage

BACKGROUND

Renal dysfunction in patients with biliary obstruction is associated with extracellular water depletion. This study examined the effect of preoperative saline infusion before biliary drainage on hormonal and renal functional derangements in patients with obstructive jaundice.

METHODS

In a randomized study, 49 patients with malignant obstructive jaundice were investigated at baseline, on the day of drainage, and at 24 h, 72 h and 7 days after internal endoscopic biliary drainage. Patients were randomized to receive (n = 22) or not to receive (n = 27) 3000 ml normal saline intravenously for 24 h before drainage. Variables analysed included extracellular water volume, creatinine clearance, and serum levels of aldosterone, renin, atrial natriuretic peptide (ANP), vasopressin and albumin.

RESULTS

Preoperative saline infusion produced a rise in creatinine clearance, diuresis, ANP concentration and extracellular water volume but this did not translate into better recovery of renal function after operation. Drainage produced a fall in creatinine clearance in all patients, but hormonal and renal function had recovered by 2 days after restoration of bile flow, independently of preoperative hydration.

CONCLUSION

Fluid administration expands the extracellular water compartment before drainage but fails to improve renal function after drainage. Definitive improvement in endocrine and renal function requires the restoration of bile flow into the duodenum.

Prevalence and associated factors of anterior atlantoaxial luxation in a nation-wide sample of rheumatoid arthritis patients

OBJECTIVE

To estimate the prevalence of anterior atlantoaxial subluxation (AAS) in patients with rheumatoid arthritis (RA), and to analyse its association with disease markers.

METHODS

Cross-sectional analysis of a cohort of RA patients randomly selected from the clinical registries of 34 centres. AAS, defined as an atlantoaxial displacement in cervical spine X-rays greater than 3 mm on flexion films, was actively searched for. Bivariate and multivariate analysis was performed to examine its association with clinical, functional, and treatment variables.

RESULTS

AAS was found in 88 out of 736 patients with available cervical radiographs, (prevalence and 95% confidence interval [CI]: 12% [9.7-14.2]). The presence of AAS was highly associated with a Larsen score (0-150) over 50 (OR and 95% CI: 5.31 [2.68-10.55]), RA duration of more than 10 years (4.48 [2.70-7.44]), disease onset before age 50 (4.15 [2.42-7.12]), eye involvement (3.93 [1.63-9.46]), and previous RA related surgery (3.90 [2.46-6.19]). No association was found with rheumatoid factor. Multivariate analysis showed that a disease onset before the age of 50, the number of previous DMARD, and, above all, a Larsen score greater than 50 were important independent factors associated with AAS. There is a 33% increased risk for AAS every 10 units up in the Larsen score.

CONCLUSION

AAS is frequent in RA patients, particularly in those with markers of erosive disease.

Abnormal sonographic findings in the asymptomatic arthritic shoulder

OBJECTIVE

To assess the diagnostic value of ultrasonography (US) in the evaluation of arthritic shoulder joints, especially in painless shoulders.

METHODS

US examinations were performed in 57 consecutive patients with rheumatoid arthritis (114 shoulders) and in 32 controls (32 shoulders), using a 7.5 MHz linear probe and a standardized study protocol. US findings were compared with clinical, laboratory, and radiological data to find any relationship.

RESULTS

Abnormal sonographic findings were found in 80 shoulders (70%); the most common were lesions in the supraspinatus tendon (38%), subacromial-subdeltoid bursitis (29%), bone erosions of the humeral head (20%), glenohumeral joint ellusion (19%), and biceps tendinitis (13%). Although US abnormalities were most frequent in patients with painful shoulders or abnormal findings on physical examination or radiography, a high rate of alterations was found in asymptomatic shoulders (51%), in normal shoulders on physical examination (44%) and in normal shoulders on radiographic assessment (61%). Differences of US findings in relation to time of evolution of rheumatoid arthritis, patient's age, and radiographic stage in hand and/or wrist joints were not found.

CONCLUSION

US abnormalities in the shoulder joint are frequent in rheumatoid arthritis, both in patients with and without shoulder complaints as well as in patients with normal findings on physical examination.

Improved cardiac function in patients with obstructive jaundice after internal biliary drainage: hemodynamic and hormonal assessment

OBJECTIVE

To investigate myocardial function in patients with obstructive jaundice before and after internal biliary drainage.

SUMMARY BACKGROUND DATA

Increased plasma levels of atrial natriuretic peptide (ANP) have been found in patients with biliary obstruction.

METHODS

Thirteen patients with newly diagnosed obstructive jaundice and no previous heart, lung, or renal disease were studied using a Swan-Ganz catheter. Hemodynamic measurements were taken before and 4 days after internal biliary drainage. Levels of ANP and brain natriuretic peptide (BNP) were obtained and liver function tests were also determined.

RESULTS

Plasma levels of ANP and BNP were increased twofold to fourfold in the basal state and declined after biliary drainage. Independent variables predicting left ventricular systolic work were total bilirubin concentrations, duration of jaundice, and BNP. In addition, bilirubin concentrations correlated with pulmonary vascular resistance, mean arterial pulmonary pressure, and right ventricular systolic work. Internal biliary drainage resulted in an improvement in left ventricular systolic work. A correlation was found between decreasing ANP concentrations and increasing cardiac output.

CONCLUSIONS

Increased plasma levels of natriuretic peptides in patients with obstructive jaundice may reflect a subclinical myocardial dysfunction correlating with the degree of jaundice. After internal biliary drainage, there is a measurable improvement of cardiac function.

Anorexia and the effect of internal biliary drainage on food intake in patients with obstructive jaundice

BACKGROUND

Anorexia is a frequent finding in patients with biliary obstruction (BO). This study investigates the role of biochemical and hormonal factors in the pathogenesis of reduced food intake in BO and the effects of internal biliary drainage.

STUDY DESIGN

Sixty-two patients with BO were prospectively investigated. Transaminases, amylase, cholecystokinin, secretin, bile acids, tumor necrosis factor-alpha, and endotoxin were determined at admission. Caloric intake was quantified by a controlled diet. In a subset of 27 patients, studies were repeated after internal biliary drainage.

RESULTS

Sixty-six percent of patients had spontaneous food intakes below the estimated caloric requirements. Serum bilirubin, alkaline phosphatase, and cholecystokinin plasma levels were independent predictor factors for calorie intake (p = 0.0001). After internal biliary drainage, cholestasis parameters and cholecystokinin concentrations decreased significantly; this was associated with an improvement of spontaneous food intake in both benign and malignant biliary obstruction (p < 0.01 and p < 0.05, respectively).

CONCLUSIONS

Decreased food intake in BO was associated with the degree of obstruction and with increased cholecystokinin plasma levels. Biliary drainage improved biochemical and food intake derangements.