Showing papers by "Cyrus Cooper published in 2000"

Risk factors for the incidence and progression of radiographic knee osteoarthritis.

Abstract: Objective Preventive strategies against knee osteoarthritis (OA) require a knowledge of risk factors that influence the initiation of the disorder and its subsequent progression. This population-based longitudinal study was performed to address this issue. Methods Ninety-nine men and 255 women aged ≥55 years had baseline interviews and weight-bearing knee radiographs in 1990–1991. Repeat radiographs were obtained in 1995–1996 (mean followup duration 5.1 years, median age at followup 75.8 years). Risk factors assessed at baseline were tested for their association with incident and progressive radiographic knee OA by logistic regression. Results Rates of incidence and progression were 2.5% and 3.6% per year, respectively. After adjusting for age and sex, the risk of incident radiographic knee OA was significantly increased among subjects with higher baseline body mass index (odds ratio [OR] 18.3, 95% confidence interval [95% CI] 5.1–65.1, highest versus lowest third), previous knee injury (OR 4.8, 95% CI 1.0–24.1), and a history of regular sports participation (OR 3.2, 95% CI 1.1–9.1). Knee pain at baseline (OR 2.4, 95% CI 0.7–8.0) and Heberden's nodes (OR 2.0, 95% CI 0.7–5.7) were weakly associated with progression. Analyses based on individual radiographic features (osteophyte formation and joint space narrowing) supported differences in risk factors for either feature. Conclusion Most currently recognized risk factors for prevalent knee OA (obesity, knee injury, and physical activity) influence incidence more than radiographic progression. Furthermore, these factors might selectively influence osteophyte formation more than joint space narrowing. These findings are consistent with knee OA being initiated by joint injury, but with progression being a consequence of impaired intrinsic repair capacity.

Oral corticosteroids and fracture risk: relationship to daily and cumulative doses

Abstract: OBJECTIVE: This study examined the effects of daily and cumulative oral corticosteroid doses on the risk of fractures. METHODS: Information was obtained from the General Practice Research Database, which contains medical records of general practitioners in England and Wales. The study included 244 235 oral corticosteroid users and 244 235 controls. RESULTS: Patients taking higher doses (at least 7. 5 mg daily of prednisolone or equivalent) had significantly increased risks of non-vertebral fracture [relative rate (RR)=1.44, 95% confidence interval (CI) 1.34-1.54], hip fracture (RR=2.21, 95% CI 1.85-2.64) and vertebral fracture (RR=2.83, 95% CI 2.35-2.40) relative to patients using oral corticosteroids at lower doses (less than 2.5 mg per day). Fracture risk was also elevated among people with higher cumulative exposure to oral corticosteroids over the study period, but this effect was almost wholly removed by adjustment for daily dose, age, gender and other confounding variables. CONCLUSIONS: These findings suggest that the adverse skeletal effects of oral corticosteroids manifest rapidly and are related to daily dose. The level of previous exposure to oral corticosteroids was not a strong determinant of the risk of fracture. Preventive measures against corticosteroid-induced osteoporosis should therefore be instituted as soon after the commencement of glucocorticoid therapy as possible.

EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT)

Abstract: BACKGROUND—Osteoarthritis (OA) is the most common joint disease encountered throughout Europe. A task force for the EULAR Standing Committee for Clinical Trials met in 1998 to determine the methodological and logistical approach required for the development of evidence based guidelines for treatment of knee OA. The guidelines were restricted to cover all currently available treatments for knee OA diagnosed either clinically and/or radiographically affecting any compartment of the knee. METHODS—The first stage was the selection of treatment modalities to be considered. The second stage comprised a search of the electronic databases Medline and Embase using a combination of subject headings and keywords. All European language publications in the form of systematic reviews, meta-analyses, randomised controlled trials, controlled trials, and observational studies were included. During stage three all the relevant studies were quality scored. The summary statistics for validated outcome measures, when available, were recorded and, where practical, the numbers needed to treat and the effect size for each treatment were calculated. In the fourth stage key clinical propositions were determined by expert consensus employing a Delphi approach. The final stage ranked these propositions according to the available evidence. A second set of propositions relating to a future research agenda was determined by expert consensus using a Delphi approach. RESULTS—Over 2400 English language publications and 400 non-English language publications were identified. Seven hundred and forty four studies presented outcome data of the effects of specific treatments on knee OA. Quantitative analysis of treatment effect was possible in only 61 studies. Recommendations for the management of knee OA based on currently available data and expert opinion are presented. Proposals for a future research agenda are highlighted. CONCLUSIONS—These are the first clinical guidelines on knee OA to combine an evidence based approach and a consensus approach across a wide range of treatment modalities. It is apparent that certain clinical propositions are supported by substantial research based evidence, while others are not. There is thus an urgent need for future well designed trials to consider key clinical questions.

Health-related quality of life in postmenopausal women with low BMD with or without prevalent vertebral fractures.

Abstract: Fractures and subsequent morbidity determine the impact of established postmenopausal osteoporosis. Health-related quality of life (HRQOL) has become an important outcome criterion in the assessment and follow-up of osteoporotic patients. As part of the baseline measurements of the Multiple Outcomes of Raloxifene Evaluation (MORE) study, HRQOL was assessed in 751 osteoporotic (bone mineral density [BMD] T score > or = -2.5) women from Europe with or without vertebral fractures (VFX). This was done using the quality of life questionnaire of the European Foundation for Osteoporosis (QUALEFFO), Nottingham Health Profile (NHP) and the EQ-5D (former EuroQol). QUALEFFO contains questions in five domains: pain, physical function, social function, general health perception, and mental function. Each domain score and QUALEFFO total scores are expressed on a 100-point scale, with 0 corresponding to the best HRQOL. In comparison with patients without VFX, those with VFX were older (66.2 +/- 5.9 years vs. 68.8 +/- 6.3 years; p < 0.001), had higher prevalence of nonvertebral fractures (25% vs. 36%; p = 0.002), and higher QUALEFFO scores (worse HRQOL; total score, 26 +/- 14 vs. 36 +/- 17; p < 0.001). QUALEFFO scores increased progressively with increasing number of VFX, especially lumbar fractures (p < 0.001). Patients with a single VFX already had a significant increase in QUALEFFO scores (p < 0.05). Similar, though weaker, associations were seen for NHP and EQ-5D scores. This study confirms decreased HRQOL for patients with prevalent VFX. In osteoporotic patients, QUALEFFO scores change in relation to the number of VFX. QUALEFFO is suitable for clinical studies in patients with postmenopausal osteoporosis.

Use of oral corticosteroids in the United Kingdom

Abstract: Administration of oral corticosteroids is associated with the development of osteoporosis and an increased risk of fractures. However, the size of the treated sub-population who would benefit from preventive therapy remains uncertain. The objective of this study was to investigate the usage pattern of oral corticosteroids in a large sample representative of the general population in England and Wales. Information was obtained from the General Practice Research Database (GPRD) which contains medical records of general practitioners. Oral corticosteroid users were patients aged 18 years or older who received one or more prescriptions for oral corticosteroids. Over 1.6 million oral corticosteroid prescriptions were issued to the cohort of 244 235 oral corticosteroid users. At any point in time, oral corticosteroids were being used by 0.9% of the total adult GPRD population. The highest use (2.5%) was by people between 70 and 79 years of age. Respiratory disease was the most frequently recorded indication for oral corticosteroid treatment (40%). Patients with arthropathies were most likely to use long-term, continuous treatment, and patients with chronic obstructive pulmonary disease least likely (19.3% and 6.1%, respectively, used oral corticosteroids for more than 2 years). The overall use of bone-active medication (oestrogens, bisphosphonates, vitamin D, and calcitonin) during oral corticosteroid treatment was low (between 4.0% and 5.5%). The current population in the UK at risk of developing corticosteroid-induced fractures might be as large as 350 000. Identification of these patients will be important for implementing preventive strategies in a cost-effective manner.

Occupational physical activities and osteoarthritis of the knee

Abstract: Objective: to assess the risk of knee osteoarthritis (OA) associated with kneeling, squatting, and other occupational activities. Methods: we compared 518 patients who were listed for surgical treatment of knee OA and an equal number of control subjects from the same communities who were matched for sex and age. Histories of knee injury and occupational activities were ascertained at interview, height and weight were measured, and the hands were examined for Heberden's nodes. Data were analyzed by conditional logistic regression. Results: after adjustment for body mass index (BMI), history of knee injury, and the presence of Heberden's nodes, risk was elevated in subjects who reported prolonged kneeling or squatting (odds ratio [OR] 1.9; 95% confidence interval [95% CI] 1.3-2.8), walking >2 miles/day (OR 1.9; 95% CI 1.4-2.8), and regularly lifting weights of at least 25 kg (OR 1.7; 95% CI 1.2-2.6) in the course of their work. The risks associated with kneeling and squatting were higher in subjects who also reported occupational lifting, and appeared to interact multiplicatively with the risk conferred by obesity. People with a BMI of 30 kg/m2 whose work had entailed prolonged kneeling or squatting had an OR of 14.7 (95% CI 7.2-30.2), compared with subjects with a BMI Conclusion: there is now strong evidence for an occupational hazard of knee OA resulting from prolonged kneeling and squatting. One approach to reducing this risk may lie in the avoidance of obesity in people who perform this sort of work.

Back pain in Britain: comparison of two prevalence surveys at an interval of 10 years

Abstract: In Britain, as in many other countries, back pain is a major cause of disability, especially in adults of working age. During the decade to 1993, outpatient attendances for back pain rose fivefold, and the number of days of incapacity from back disorders for which social security benefits were paid more than doubled.1 It is unclear whether this represents an increase in the occurrence of diseases affecting the back or a change in people's behaviour when they have symptoms. To address this question we compared the prevalence of low back pain and associated disability in two postal surveys 10 years apart.

Factors Associated with Osteoarthritis of the Hip and Knee in Hong Kong Chinese: Obesity, Joint Injury, and Occupational Activities

Abstract: In 1998, a case-control study was conducted in Hong Kong on hospital patients with osteoarthritis of the hip (n = 138) and osteoarthritis of the knee (n = 658). Age- and sex-matched controls were recruited consecutively from general practice clinics in the same region. The following three risk factors were found to be associated with osteoarthritis of both the hip and the knee: first, a history of joint injury: for osteoarthritis of the hip, the odds ratio = 25.1 (95% confidence interval (CI): 3.5, 181) in men and 43.3 (95% CI: 11.7, 161) in women; for osteoarthritis of the knee, the odds ratio = 12.1 (95% CI: 3.4, 42.5) in men and 7.6 (95% CI: 3.8, 15.2) in women; second, climbing stairs frequently: for osteoarthritis of the hip, the odds ratio = 12.5 (95% CI: 1.5, 104.3) in men and 2.3 (95% CI: 0.6, 8.1) in women; for osteoarthritis of the knee, the odds ratio = 2.5 (95% CI: 1.0, 6.4) in men and 5.1 (95% CI: 2.5, 10.2) in women; third, lifting heavy weight frequently: for osteoarthritis of the hip, the odds ratio = 3.1 (95% CI: 0.7, 14.3) in men and 2.4 (95% CI: 1.1, 5.3) in women; for osteoarthritis of the knee, the odds ratio = 5.4 (95% CI: 2.4, 12.4) in men and 2.0 (95% CI: 1.2, 3.1) in women. In addition, subjects whose height and weight were in the highest quartile were at increased risk of osteoarthritis of the hip and knee, respectively (p < 0.05).

Epidemiology of osteoporotic fractures.

Abstract: Osteoporosis constitutes a major public health problem through its association with age-related fractures. These fractures typically occur at the hip, spine and distal forearm. It has been estimated that the lifetime risk of a hip fracture in white women is 17.5%, with a comparable risk in men of 6%. Hip fractures lead to an overall reduction in survival of about 15% (relative or observed/expected survival at 5 years of 0.83), and the majority of excess deaths occur within the first 6 months following the fracture. Such fractures are also associated with considerable morbidity. Although all vertebral deformities do not come to clinical attention, the lifetime risk of clinically diagnosed vertebral fractures is about 15% in white women. Vertebral fractures tend to be associated with back pain and kyphosis, and also with an impairment of survival, though this is likely to be due to clustering of comorbidity. About one-quarter of clinically diagnosed vertebral deformities result in hospitalization.

The use of a large pharmacoepidemiological database to study exposure to oral corticosteroids and risk of fractures: validation of study population and results

Abstract: Purpose - The objective of this study was an evaluation of the sensitivity of findings of the relationship between oral corticosteroid use and the risk of fracture. We found in earlier work that the risk of fracture was significantly higher during oral corticosteroid treatment, with increases of 61% in hip and 160% in vertebral fractures.Methods - Information was obtained from the General Practice Research Database which contains medical records of general practitioners in the UK. The study included 244,235 oral corticosteroid users and 244,235 controls.Results - The validation of fracture cases showed that the hip fractures, as recorded in the GPRD, were confirmed by the GP on the questionnaire in 90.7% of the cases and by discharge summary in 86.5%. The relative rate of non-vertebral fracture during oral corticosteroid use did not vary substantially between patients with different diseases, age, or gender. The sensitivity analysis, modifying the type of analysis or inclusion of patients, did not materially change the findings.Conclusions - We found a high level of validity of the GPRD with respect to hip and vertebral fractures. The sensitivity analysis indicated internal validity and consistency of the findings on fracture risks of oral corticosteroid therapy. Copyright (c) 2000 John Wiley & Sons, Ltd.

Medical management of osteoarthritis

Abstract: Osteoarthritis is a common, chronic, musculoskeletal disorder. Symptomatic osteoarthritis, particularly of the knee and hip, is the most common cause of musculoskeletal disability in elderly people. In the Western world it ranks fourth in health impact among women and eighth among men.1 Given this high prevalence, therapeutic approaches to treatment will have to be shared between primary and secondary care. A range of non-surgical interventions has been proposed as components of such a therapeutic strategy. #### Summary points Osteoarthritis is a major cause of pain and disability in Western populations The prevalence of osteoarthritis necessitates a “shared care” approach to management between general practitioners and hospital specialists Several non-surgical interventions to alleviate pain and disability in lower limb osteoarthritis are now available: Non-pharmacological measures (education, social support, physiotherapy, and occupational therapy) Pharmacological measures (simple analgesics, non-steroidal anti-inflammatory drugs, COX-2 inhibitors, topical non-steroidal anti-inflammatory drugs, and capsaicin) Intra-articular therapy: corticosteroids, hyaluronic acid derivatives, and tidal irrigation These interventions have been evaluated to varying degrees, but they can be incorporated into an algorithm for the management of osteoarthritis #### Therapeutic options in osteoarthritis ##### Non-pharmacological treatment Education (patient and spouse or family) Social support (telephone contact) Physiotherapy (aerobic exercises, muscle strengthening, and patellar strapping) Occupational therapy (aids and appliances, joint protection) Weight loss Acupuncture Transcutaneous electrical nerve stimulation (TENS) ##### Pharmacological treatment Simple analgesia Non-steroidal anti-inflammatory drugs COX-2 inhibitors (cyclo-oxygenase-2 selective non-steroidal anti-inflammatory drugs) Topical (non-steroidal anti-inflammatory drugs, capsaicin) Chondroprotective agents ##### Intra-articular treatment Corticosteroids Hyaluronans Tidal irrigation Systematic reviews and controlled clinical trials were located through Medline and BIDS 1991-9, searching under the key words: osteoarthritis; guidelines; glucosamine; capsaicin; physiotherapy, occupational therapy, acupuncture, drug therapy, education, intra-articular injection, heat, cold, rehabilitation, epidemiology, therapy. When available, the most recent reviews or meta-analyses are cited; if not available, individual controlled trials were included and methodological shortcomings discussed. We did not perform assessments of quality of individual reviews. Semiquantitative estimates …

The Southampton examination schedule for the diagnosis of musculoskeletal disorders of the upper limb

Abstract: OBJECTIVES Following a consensus statement from a multidisciplinary UK workshop, a structured examination schedule was developed for the diagnosis and classification of musculoskeletal disorders of the upper limb. The aim of this study was to test the repeatability and the validity of the newly developed schedule in a hospital setting. METHOD 43 consecutive referrals to a soft tissue rheumatism clinic (group 1) and 45 subjects with one of a list of specific upper limb disorders (including shoulder capsulitis, rotator cuff tendinitis, lateral epicondylitis and tenosynovitis) (group 2), were recruited from hospital rheumatology and orthopaedic outpatient clinics. All 88 subjects were examined by a research nurse (blinded to diagnosis), and everyone from group 1 was independently examined by a rheumatologist. Between observer agreement was assessed among subjects from group 1 by calculating Cohen9s κ for dichotomous physical signs, and mean differences with limits of agreement for measured ranges of joint movement. To assess the validity of the examination, a pre-defined algorithm was applied to the nurse9s examination findings in patients from both groups, and the sensitivity and specificity of the derived diagnoses were determined in comparison with the clinic9s independent diagnosis as the reference standard. RESULTS The between observer repeatability of physical signs varied from good to excellent, with κ coefficients of 0.66 to 1.00 for most categorical observations, and mean absolute differences of 1.4°–11.9° for measurements of shoulder movement. The sensitivity of the schedule in comparison with the reference standard varied between diagnoses from 58%–100%, while the specificities ranged from 84%–100%. The nurse and the clinic physician generally agreed in their diagnoses, but in the presence of shoulder capsulitis the nurse usually also diagnosed shoulder tendinitis, whereas the clinic physician did not. CONCLUSION The new examination protocol is repeatable and gives acceptable diagnostic accuracy in a hospital setting. Examination can feasibly be delegated to a trained nurse, and the protocol has the benefit of face and construct validity as well as consensus backing. Its performance in the community, where disease is less clear cut, merits separate evaluation, and further refinement is needed to discriminate between discrete pathologies at the shoulder.

Occupational lifting is associated with hip osteoarthritis: a Japanese case-control study.

Abstract: OBJECTIVE: Hip osteoarthritis (OA) is a frequent cause of pain and disability in Western countries, but the disorder is less common in Japan. A case-control study in Britain found obesity, hip injury, and occupational lifting to be associated with hip OA among men and women. However, there are few epidemiological studies concerning factors associated with hip OA in Japan. We performed a comparable case-control study of the disorder in Japan, and contrasted the findings with those from Britain. METHODS: The study was carried out in 2 health districts in Wakayama Prefecture, Japan. Cases were men and women aged > or = 45 years listed for total hip arthroplasty due to OA over one year, and who did not have an established cause of secondary OA (e.g., rheumatoid arthritis, ankylosing spondylitis). For each case, a control was selected randomly from the general population and was individually matched to the case for age, sex, and district of residence. Cases and controls were interviewed with a structured questionnaire about medical history, physical activity, socioeconomic factors, and occupation. Measurements were made of height and weight. RESULTS: One hundred fourteen cases (103 women, 11 men) were compared with 114 controls. We found no relationship between obesity and hip OA (OR = 1.0, 95% CI 0.5-1.9; highest vs lowest thirds of distribution of body mass index). There was, however, a statistically significant association between occupational lifting and hip OA, such that regular lifting of 25 kg in the individual's first job (OR = 3.6, 95% CI 1.3-9.7) or of 50 kg in their main job (OR = 4.0, 95% CI 1.1-14.2) was associated with increased risk of hip OA. These associations remained after adjustment for potential confounding variables. In contrast, those subjects who spent > 2 h each day sitting during their first job were significantly less likely to have the disorder (crude OR = 0.5, 95% CI 0.3-0.9). This association also remained statistically significant after adjustment for potential risk factors. CONCLUSION: Our findings support the hypothesis that occupational physical activity, particularly the lifting of very heavy loads in the workplace at regular intervals, predisposes to hip OA in both Britain and Japan. The lack of association between obesity or hand involvement and hip OA in Japan suggests that the contribution of constitutional and mechanical risk factors to this disorder might differ in different populations. However, attention to manual handling in the workplace would appear an important aspect of preventive strategies against hip OA in Western and Oriental populations.

Prevalence of Raynaud's phenomenon in Great Britain and its relation to hand transmitted vibration: a national postal survey

Abstract: Objectives—To assess the prevalence of Raynaud’s phenomenon in the general population of Great Britain and to estimate the proportion and number of cases attributable to hand transmitted vibration (HTV). Methods—A questionnaire was posted to a random sample of 22 194 adults of working age. Information was collected on the lifetime prevalence of finger blanching, smoking habits, and occupational and leisure time exposures to HTV. Associations with risk factors were explored by logistic regression, with odds ratios converted into prevalence ratios (PRs). Results—Among the 12 907 respondents, 1835 (14.2%) reported finger blanching at some time, including 1529 (11.8%) in whom symptoms were induced by cold, and 597 (4.6%) in whom the blanched area was also clearly demarcated. Prevalences were higher in women than men. Around one fifth of cases (2% of respondents) had consulted a doctor about their symptoms. By comparison with men who had never been exposed to HTV, the PR for cold induced blanching in those exposed only at work was 2.0 (95% CI 1.7 to 2.3), and in men exposed both at work and in leisure it was 2.5 (95% CI 2.1 to 3.1). Higher risks were found in men who consulted a doctor about cold induced blanching, among whom 37.6% of cases were estimated to arise from exposure to HTV. The estimated number of cases attributable to HTV nationally was 222 000 in men who reported extensive blanching (blanching aVecting at least eight of the digits or 15 phalanges). Similar patterns of risk were found in women, but the attributable proportion was much lower (5.3% in cases consulting a doctor). Conclusions—Raynaud’s phenomenon is common in the general population. Many cases are attributable to HTV,especially in men, emphasising the public health importance of this common occupational hazard. (Occup Environ Med 2000;57:448‐452)

Health impact of pain in the hip region with and without radiographic evidence of osteoarthritis: a study of new attenders to primary care

Abstract: OBJECTIVES—To assess the health impact of hip pain at the time of first presentation to primary care, and the influence on this of radiographic evidence of osteoarthritis. SUBJECTS AND METHODS—Cross sectional survey of 195 patients (63 male, 132 female), aged 40 years and over, presenting with a new episode of hip pain, recruited from 35 general practices across the UK. Health status at presentation was determined by a structured questionnaire on symptoms, healthcare use, and health related quality of life (SF-36). Pelvic radiographs were assessed blindly for hip osteoarthritis using standard scoring systems. RESULTS—The overall impact on health was substantial. Before their first consultation, three quarters of patients needed analgesics, half used topical creams or ointments, and one in eight used a walking stick. Most of these impact measures were, however, unrelated to the degree of radiographic change, though use of a walking stick was increased in those with the most severe damage. Health status, as judged by the SF-36, was also impaired for measures of physical function and pain, but the impact on the "mental health", "general health", and "vitality" dimensions was small. There was a weak relation between the SF-36 scores and radiographic change, with many domains unrelated to the severity of radiographic damage. CONCLUSIONS—This study is the first to show the therapeutic impact and pattern of impairment in health status resulting from hip pain at the time of first presentation to the healthcare services. Unlike many regional pain syndromes seen in primary care, such as back pain, hip pain does not impact on wider aspects of quality of life, such as general health status, mental health, or vitality. Furthermore, any impact of hip pain in this group is not markedly influenced by the degree of structural damage. Further follow up is required to determine whether such damage influences the persistence of any adverse impact.

Does location of vertebral deformity within the spine influence back pain and disability

Abstract: OBJECTIVE—Vertebral deformity is associated with back pain and disability. The aim of this analysis was to determine whether location within the spine influences the strength of association between vertebral deformity, back pain and disability. METHODS—Men and women aged 50 years and over were recruited from population registers in 30 European centres. Subjects were invited for an interviewer administered questionnaire, and for lateral spinal radiographs. The questionnaire included questions about back pain, general health and functional ability. The spinal radiographs were evaluated morphometrically and vertebral deformity defined according to the McCloskey-Kanis method. RESULTS—756 (11.7%) men and 885 (11.8%) women had evidence of one or more vertebral deformities. Among women with a single deformity, after adjusting for age and centre, those with a lumbar deformity were more likely than those with a thoracic deformity to report back pain, both currently (OR=1.4; 95% CI 1.0, 2.0) and in the past year (OR=1.5; 95% CI 1.0, 2.3). No association was observed in men. Among women with two deformities, those with adjacent deformities were more likely than those with non-adjacent deformities to report poor general health (OR=2.2; 95%CI 0.9, 5.6), impaired functional ability (OR=1.9; 95%CI 0.8, 4.7) and current back pain (OR=2.1; 95%CI 0.9, 4.9), though none of these associations were statistically significant. By contrast, among men, non-adjacent deformities were associated with impaired functional ability compared with those with adjacent deformities. CONCLUSION—Location within the spine influences the strength of association between self reported health factors and vertebral deformity.

Comparison of the European and USA practice guidelines for Osteoporosis.

Abstract: The European Foundation for Osteoporosis and Bone Disease (EFFO), the Royal College of Physicians, the European Community and the National Osteoporosis Foundation of the USA (NOF) have recently published guidelines for the diagnosis and management of osteoporosis. All adopt case-finding strategies but the conceptual approach between the European and North American guidelines differs fundamentally. This gives rise to differences in the populations identified for assessment and treatment.

An investigation of the diagnostic value of bilateral femoral neck bone mineral density measurements.

Abstract: This paper describes a study to assess the clinical value of bilateral femoral neck bone mineral density (BMD) measurements. Although a range of factors will determine clinical decisions, the classification of the site with the lowest T-score is likely to have significant bearing on the management of a patient. While it is common practice to measure BMD at the lumbar spine and a single neck of femur, knowledge of the BMD of the second femur may also be of diagnostic value. Using dual-energy X-ray absorptiometry, BMD of the lumbar spine and right and left femoral neck was measured in a group of 2372 white, Caucasian women (mean age +/- SD, 56.6 +/- 13.9 years) routinely referred for bone densitometry. Analysis of the measurements showed a significant (p = 0.02) but small difference between the mean BMD of the right (0.840 +/- 0.152 g/cm2) and left (0.837 +/- 0.150 g/cm2) femoral neck. Further investigation of femur scans revealed 79 (3.3%) patients in whom one side was osteoporotic while the other side and spine were normal or osteopenic using the World Health Organization diagnostic criteria in combination with manufacturer's reference data. Patients in whom the femoral neck BMD measurements differed by less than the precision error of the system were then excluded. This left only 51 (2.2%) patients, that is 29 (1.2%) for right femur and spine scan and 22 (0.9%) for left femur and spine scan, in whom knowledge of both femoral neck BMD measurements could have altered the classification of the lowest site assessed to osteoporotic. These data suggest that there is only a small benefit from performing bilateral femoral neck BMD measurements. Since BMD measurements are only one of a range of factors considered as part of a patient's management, it is suggested that the extra time, cost and radiation dose associated with measurement of the second femur may not be justified.

The prevalence of sensorineural symptoms attributable to hand-transmitted vibration in Great Britain: a national postal survey.

Abstract: Background: Exposure to hand-transmitted vibration (HTV) can cause sensorineural symptoms in the upper limb, but its impact has not previously been assessed in the general population. Methods: To investigate, we mailed a questionnaire about exposures to HTV, finger blanching and sensory symptoms (numbness or tingling) in the upper limbs to a population sample comprising 21,201 working-aged men and women selected at random from the age-sex registers of 34 British general practices, and a further 993 randomly selected from the pay records of the armed services. Associations were explored using multiple logistic regression models to adjust for confounding, with the resultant odds ratios converted into prevalence rate ratios (PRs). Results: Of 12,907 respondents, 2,607 (20.2%) reported sensory symptoms in the upper limb during the past week. Sensory symptoms were more prevalent in those with blanching, and were commonly associated with exposure to HTV, especially in men. In comparison with men who had never been exposed to HTV, the PR in men exposed both at work and in leisure was 2.2 (95% CI 1.9-2.4). Associations were found even in those who had never blanched. Conclusions: Sensorineural symptoms in the upper limbs are common. HTV is an important risk factor for such complaints in the general population.

Sensory Neural Processing in Work-related Upper Limb Disorders

Abstract: Pain in the upper limb is a common complaint in adults, and is often attributed to or exacerbated by occupational activities. In many patients there is no demonstrable pathology in the neck or arm to account for the symptom, and this has prompted the hypothesis that such cases might arise through abnormal neural processing of sensory information with a lowering of pain thresholds. In this paper we review the evidence in support of this theory and suggest directions for future research.

Congenital varicella syndrome diagnosed by polymerase chain reaction--scarring of the spinal cord, not the skin.

Abstract: A term infant with congenital varicella syndrome (CVS) is reported. Monoplegia of the left arm and paraplegia were present with no evidence of dermatomal skin scarring. Following death at 12 days of age, autopsy documented severe atrophy and gliosis of the spinal cord. Testing for varicella-zoster virus by the polymerase chain reaction method on brain tissue was positive. This case extends the current understanding of the clinical and pathological features of CVS.

Osteoporosis services in secondary care: a UK survey.

Abstract: A 1994 survey indicated that only 13 health authorities in the UK were purchasing access to dual X-ray absorptiometry (DXA), the most accurate measure of osteoporosis risk. By 1998 the number of centres (including private facilities providing DXA) was 161. All these were sent a questionnaire concerning their activities. 124 (77%) responded, and the survey found that DXA machines operate, on average, for only 3.6 days a week. Funding of and access to diagnostic services for osteoporosis varies greatly. There is clear scope for greater efficiency in the use of existing DXA machines and more equitable access to diagnostic services is required for effective management of osteoporosis.

The spectrum of inflammatory rheumatic disorders.

Abstract: Classification of the inflammatory rheumatic disorders is challenging. They represent a heterogeneous group of conditions, mostly of unknown aetiology. However, a uniform language is essential in facilitating clinical and epidemiological research and, therefore, several different approaches have evolved by which we can classify these diseases. One way in which inflammatory arthropathies are frequently distinguished is by the number of joints affected at presentation. Therefore, this chapter will discuss the differential diagnosis of a monoarthropathy and polyarthropathy. The epidemiology of many of the less common inflammatory disorders is poorly elucidated, but the current knowledge, together with its strengths and weaknesses, will be discussed. Finally, we will describe the overall burden of the musculoskeletal disorders in the community, and then highlight the role of the rheumatologist in the management of these disabling conditions.