Reasonable adjustments to provide equitable and inclusive assessment, screening and treatment of osteoporosis for adults with intellectual disabilities: A feasibility study.

BACKGROUND: People with intellectual disabilities are a high risk population for developing osteoporosis and fragility fractures, yet they experience barriers to accessing dual-energy x-ray absorptiometry (DXA) bone mineral density (BMD) screening and fracture assessment. Reasonable adjustments are a statutory requirement in the UK, but there is a paucity of evidence-based examples to assist their identification, implementation and evaluation. METHOD: Thirty adults with intellectual disabilities underwent DXA BMD screening and fracture risk assessment. Reasonable adjustments were identified and implemented. RESULTS: The presence of osteopenia or osteoporosis was detected in 23 out of 29 (79%) participants. Osteoporosis professionals report that 17 of 18 reasonable adjustments identified and implemented are both important and easy to implement. CONCLUSION: Adults across all levels of intellectual disabilities can complete DXA BMD screening with reasonable adjustments. Widely implementing these reasonable adjustments would contribute to reducing inequalities in health care for adults with intellectual disabilities.

Assessing Osteoporosis in the Young Adult.

Osteoporosis in the young adult is a relatively rare phenomenon, and its diagnosis needs careful assessment of the affected person. The emphasis in the assessment of bone health is gradually shifting from a simple quantitative assessment of bone mineral density to one that includes bone quality. This may be particularly important in the young adult, where the aetiological cause of osteoporosis may be a primary genetic condition or secondary to another chronic condition.

Medical training and the hospital at night: an oxymoron?

CONTEXT: Attempts to reduce doctors' working hours and streamline postgraduate medical training may mean junior doctors' out-of-hours experience is reduced. It is also proposed that, in the UK, compulsory clinical (Foundation Programme) competencies are to be accomplished in 1 year rather than 2 years as they are at present. This observational study was performed to examine the scope of opportunity available to junior doctors to achieve such competencies while working on a 'Hospital at Night' (H@N) team. METHODS: A database of electronic requests made to the H@N team was used to tabulate the number and type of tasks requested and to define differences between specialties, using local hospital admissions rates to contextualise the data. These requests were then compared with a list of compulsory clinical competencies to assess the scope of opportunity available to trainees to achieve these competencies when working on the H@N team. RESULTS: A total of 8268 referrals were made to our H@N team between 1 October 2007 and 31 January 2008 using the electronic Hospital Information System (HIS). The predefined, online HIS request list included eight of the 20 tasks that represent compulsory competencies and showed that on average there were 247 opportunities per week of night shifts to perform them. Medical wards generated more requests than surgical wards (4767 versus 3170) and afforded greater opportunity to attain compulsory competencies (139 opportunities/week versus 96 opportunities/week; extra requests could not be attributed to either medical or surgical wards as original request did not include ward number). CONCLUSIONS: The H@N initiative provides adequate opportunities for junior doctors to attain important clinical (Foundation) competencies. There appears to be sufficient opportunity to achieve these competencies within 1 year rather than the 2 years currently allowed in the UK Foundation Programme.

Refracture following fracture liaison service assessment illustrates the requirement for integrated falls and fracture services.

The Fracture Liaison Service (FLS) allows appropriate antiosteoporosis therapy to be targeted to potentially reduce future fracture risk. A proportion of these treated patients will still experience a further fracture. This work reviews the characteristics of these patients. Data were collated for patients >65 years old presenting to the South Glasgow FLS between January 2001 and August 2004. There were 2,489 patients who presented (incident fracture group), and 129 (5.2%) sustained an additional fracture (refracture group). Median age of the incident fracture group was 77.8 years vs. 80.6 years for the refracture group (P = nonsignificant). The refracture group was determined according to whether their incident fracture was hip (n = 47) or nonhip (n = 82). When the incident fracture was hip, a refracture was more likely to be a further hip fracture (chi(2) = 14.4, P = 0.002) and patients refractured sooner (median time to refracture 194 [range 10-1,134] days vs. 258 [range 6-1,081] days [nonhip]) (P = nonsignificant). In the refracture group, 76% of patients were already on osteoporosis treatment after their incident fracture. Patients over 65 years of age presenting to FLS who sustain an additional fracture are older; are likely to sustain another hip fracture after an incident hip fracture; often refracture early, particularly when the incident fracture is of the hip; and are often already on antiosteoporosis treatment. Therefore, it is important to identify these high-risk patients and offer a combined approach of prompt drug treatment through a systematic and specialist osteoporosis management team along with reducing any reversible falls risk factors.

Setting up an osteoporosis fracture liaison service: background and potential outcomes.

A large evidence base now exists for treatment interventions that will reduce fracture risk. However, the key area of practice now is how to get this evidence base into clinical practice. All health-care systems are subject to financial constraints, and therefore it is important that all areas of clinical practice can demonstrate that they are able to deliver care in a cost-effective manner. It has become increasingly recognized within the area of osteoporosis that treatment interventions should be targeted at patients at the highest absolute risk of fracture in order to maximize the cost-effectiveness of the service. One key subgroup of patients who are at higher absolute fracture risk are patients who present with an incident fracture. Although it has long been recognized that this is a key group to be considered for investigation and intervention, it is also clear that any form of structured care for this group has not been developed. This chapter will review the background and practical aspects of running a fracture liaison service. This service addresses the issue of secondary prevention of fracture while also considering both the absolute risk of fracture and the absolute benefit of the intervention. Issues relating to the background evidence base underpinning the service as well as the practical issues relating to the actual running of a service are discussed. Some of the potential service outcomes are also reviewed.

The fracture liaison service: success of a program for the evaluation and management of patients with osteoporotic fracture.

INTRODUCTION: Fracture care often represents the first opportunity for clinical management of osteoporosis; however, many patients do not receive any evaluation after a fracture. In Glasgow, Scotland, fewer than 10% of fracture patients underwent bone mineral density (BMD) testing. In an effort to better meet the needs of fracture patients by providing routine assessment and, where necessary, treatment for osteoporosis after their fracture, a novel service (The Fracture Liaison Service) was designed and implemented in two separate National Health Service trusts in Glasgow. METHODS: An agreed-upon standard of care for men and women 50+ years of age with fractures was established in collaboration with orthopedic surgeons and primary care physicians. The Fracture Liaison Service assumes responsibility for fracture case-finding and for assessing and performing diagnostic evaluations (including axial DXA), and making specific treatment recommendations for the secondary prevention of osteoporotic fractures. RESULTS: During the first 18 months of operation, more than 4,600 patients with fractures of the hip, wrist, humerus, ankle, foot, hand, and other sites were seen by the Fracture Liaison Service's osteoporosis specialist nurses. Nearly three quarters of these patients were considered for BMD testing; treatment was recommended for approximately 20% of the patients without need for BMD testing. Overall, 82.3% of patients who had BMD testing were found to be osteopenic or osteoporotic at the hip or spine. CONCLUSIONS: The Fracture Liaison Service has successfully identified and evaluated most patients with fractures. Only those patients who declined were not evaluated. The ultimate success of the program will be measured by the subsequent fracture experience of these patients, but clear improvements in diagnosing and treating low bone mineral density in patients with fracture have already been demonstrated.

Metabolic, inflammatory and haemostatic effects of a low-dose continuous combined HRT in women with type 2 diabetes: potentially safer with respect to vascular risk?

BACKGROUND: Conventional hormone replacement therapy (HRT) containing conjugated equine oestrogen (CEE) and medroxyprogesterone acetate (MPA) increases triglyceride, C-reactive protein (CRP) and coagulation Factor VII concentrations, potentially explaining their increased coronary heart disease (CHD) and stroke risk. OBJECTIVE: To assess the metabolic effects of a continuous combined HRT containing 1 mg oestradiol and 0.5 mg norethisterone or matching placebo. DESIGN: Double-blind, randomized placebo-controlled trial. PATIENTS: Fifty women with type 2 diabetes. MEASUREMENTS: Classical and novel risk factors for vascular disease. RESULTS: Triglyceride concentration was not altered (P = 0.31, change in active arm relative to placebo) and low-density lipoprotein (LDL) cholesterol concentration declined 13% (P = 0.018). IL-6 concentration (mean difference -1.42 pg/ml, 95% CI: -2-55 to -0-29 IU/dl, P = 0.015), Factor VII (-32 IU/dl, -43 to -21 IU/l, P < 0.001) and tissue plasminogen activator antigen (by 13%, P = 0.005) concentrations fell, but CRP was not significantly altered (P = 0.62). Fasting glucose (P = 0.026) also declined significantly, but there are no significant effects on HBA1c, Factor IX or APC resistance. CONCLUSIONS: HRT containing 1 mg oestradiol and 0.5 mg norethisterone may avoid the adverse metabolic effects potentially implicated in the elevated CHD and stroke risk induced by conventional higher dose HRT. This type of preparation may therefore be more suitable than conventional HRT for women at elevated CHD risk such as those with type 2 diabetes. Large randomized controlled trials of such low dose preparations, powered for cardiovascular end points, are now needed.