Management of glucocorticoid-induced osteoporosis

This review summarizes the available evidence-based data that form the basis for therapeutic intervention and covers the current status of glucocorticoid-induced osteoporosis (GIOP) management, regulatory requirements, and risk-assessment options. Glucocorticoids are known to cause bone loss and fractures, yet many patients receiving or initiating glucocorticoid therapy are not appropriately evaluated and treated. An European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis workshop was convened to discuss GIOP management and to provide a report by a panel of experts. An expert panel reviewed the available studies that discussed approved therapeutic agents, focusing on randomized and controlled clinical trials reporting on bone mineral density and/or fracture risk of at least 48 weeks' duration. There is no evidence that GIOP and postmenopausal osteoporosis respond differently to treatments. The FRAX algorithm can be adjusted according to glucocorticoid dose. Available antiosteoporotic therapies such as bisphosphonates and teriparatide are efficacious in GIOP management. Several other agents approved for the treatment of postmenopausal osteoporosis may become available for GIOP. It is advised to stop antiosteoporotic treatment after glucocorticoid cessation, unless the patient remains at increased risk of fracture. Calcium and vitamin D supplementation as an osteoporosis-prevention measure is less effective than specific antiosteoporotic treatment. Fracture end-point studies and additional studies investigating specific subpopulations (pediatric, premenopausal, or elderly patients) would strengthen the evidence base and facilitate the development of intervention thresholds and treatment guidelines.

Masticatory muscle disorders diagnostic criteria: the American Academy of Orofacial Pain versus the research diagnostic criteria/temporomandibular disorders (RDC/TMD)

In this study, relevant cases were retrospectively reviewed to identify patients who were diagnosed as suffering from myofascial pain only according to the research diagnostic criteria/temporomandibular disorders (RDC/TMD) criteria, in order to examine whether or not they could fulfil the American Academy of Orofacial Pain (AAOP) diagnostic criteria for TMD-related masticatory muscle disorders. One hundred and twenty-seven patients, diagnosed according to the RDC/TMD criteria as having myofascial pain with or without limited jaw opening only, were allocated to two groups according to their answers to the RDC/TMD 'jaw disability checklist'. The two groups were compared for Axis I and II data taken from the RDC/TMD questionnaire. Thirty-eight of the patients (29·9%) did not associate their symptoms with jaw functions (e.g. chewing and yawning). This group was characterised by increased range of motion (ROM) and older average age. The AAOP diagnostic criteria for TMD require pain on function in all subtypes of TMD-related muscle disorders. An association between pain and jaw function is common and research is needed to determine whether this should be categorised differently to muscle pain unrelated to jaw function. There may well be different pathophysiological mechanisms and consequently different management strategies for these two pain conditions.

Estimating vaccination coverage in the absence of immunisation registers--the German experience

Immunisation registers are regarded as an appropriate solution to measure vaccination coverage on a population level. In Germany, a decentralised healthcare system and data protection regulations constrain such an approach. Moreover, shared responsibilities in the process of immunisation and multiple providers form the framework for public health interventions on vaccination issues. On the national level, those interventions consist mainly of conceptualising immunisation strategies, establishing vaccination programmes, and issuing recommendations. This paper provides an overview on sources and methods for collecting appropriate coverage data at national level and their public health relevance in Germany. Methods of data collection and available information on immunisations are described for three approaches: school entrance health examination, population surveys and insurance refund claim data. School entrance health examinations allow regional comparisons and estimation of trends for a specific cohort of children and for all recommended childhood vaccinations. Surveys deliver population based data on completeness and timeliness of selected vaccinations in populations defined by age or socio-demographic parameters and on knowledge and attitudes towards vaccination. Insurance refund claim data inform continuously on immunisation status (e.g. of children aged two years) or on vaccination incidence promptly after new or modified recommendations. In a complex healthcare system, the German National Public Health Institute (Robert Koch Institute, RKI) successfully compiles coverage data from different sources, which complement and validate one another. With the German approach of combining different data sources in the absence of immunisation registers, it is possible to gain solid and reliable data on the acceptance of vaccination programmes and target groups for immunisation. This approach might be of value for other countries with decentralised healthcare systems.

Risk perception and information-seeking behaviour during the 2009/10 influenza A(H1N1)pdm09 pandemic in Germany

During the influenza A(H1N1)pdm09 pandemic in 2009/10, a total of 13 consecutive surveys were carried out of the general population in Germany to monitor knowledge, attitude and behaviour concerning the disease and vaccination against pandemic influenza in real time. In total, 13,010 persons aged 14 years or older were interviewed by computer-assisted telephone techniques between November 2009 and April 2010. During the peak of the pandemic, only 18% of participants stated that they perceived the risk of pandemic influenza as high; this proportion fell to 10% in January 2010. There was a significant difference in information-seeking behaviour among population subgroups concerning the disease and vaccine uptake. However, in all subgroups, conventional media sources such as television, radio and newspapers were more frequently used than the Internet. While the majority of participants (78%) felt sufficiently informed to make a decision for or against vaccination, overall vaccination coverage remained low. Among those who decided against vaccination, fear of adverse events and perception that the available vaccines were not sufficiently evaluated were the most frequently stated reasons. Such mistrust in the vaccines and the perceived low risk of the disease were the main barriers that contributed to the low vaccination coverage in Germany during the pandemic.

Risk perception and information-seeking behaviour during the 2009/10 influenza A(H1N1)pdm09 pandemic in Germany

During the influenza A(H1N1)pdm09 pandemic in 2009/10, a total of 13 consecutive surveys were carried out of the general population in Germany to monitor knowledge, attitude and behaviour concerning the disease and vaccination against pandemic influenza in real time. In total, 13,010 persons aged 14 years or older were interviewed by computer-assisted telephone techniques between November 2009 and April 2010. During the peak of the pandemic, only 18% of participants stated that they perceived the risk of pandemic influenza as high; this proportion fell to 10% in January 2010. There was a significant difference in information-seeking behaviour among population subgroups concerning the disease and vaccine uptake. However, in all subgroups, conventional media sources such as television, radio and newspapers were more frequently used than the Internet. While the majority of participants (78%) felt sufficiently informed to make a decision for or against vaccination, overall vaccination coverage remained low. Among those who decided against vaccination, fear of adverse events and perception that the available vaccines were not sufficiently evaluated were the most frequently stated reasons. Such mistrust in the vaccines and the perceived low risk of the disease were the main barriers that contributed to the low vaccination coverage in Germany during the pandemic.

Bruxism, oral parafunctions, anamnestic and clinical findings of temporomandibular disorders in children

The reported prevalence of temporomandibular disorders (TMD) present during childhood and adolescence ranges between 7% and 68%. The range of the reported prevalence of sleep bruxism in children is also wide. The purpose of the current study was threefold: (i) determine the prevalence of oral parafunctions, sleep bruxism and of anamnestic and clinical findings of TMD among Israeli children with primary or mixed dentition; (ii) to establish whether the parafunctional activities are associated with anamnestic and clinical findings of TMD in this population and (iii) to examine the possible impact of stressful life events on the prevalence of bruxism, oral parafunctions, and anamnestic and clinical findings of TMD in children. A total of 244 children (183 girls and 61 boys) aged 5-12 years were included in the study. Each participant underwent a full TMD examination. Parents, in collaboration with their children, completed a questionnaire on TMD symptoms, oral parafunctions and stressful life events in their children's life. Most participants (78·8%) reported at least one oral habit. Of these, only 'jaw play' was associated with TMD anamnestic and clinical findings. Stressful life events were associated only with the performance of multiple oral habits. These findings indicate that the performance of oral parafunctions is commonplace during childhood, with younger children exhibiting fewer oral parafunctions than adolescents. Stressful life events are related with an increase in the performance of multiple oral parafunctions in children but the later are not necessarily associated with anamnestic and clinical findings of TMD in the paediatric population.

Biomarkers and personalised medicine in rheumatoid arthritis: a proposal for interactions between academia, industry and regulatory bodies

Rheumatoid arthritis (RA) is one of the most appropriate conditions for the application of personalised medicine as a high degree of heterogeneity has been recognised, which remains to be explained. Such heterogeneity is also reflected in the large number of treatment targets and options. A growing number of biologics as well as small molecules are already in use and there are promising new drugs in development. In order to make the best use of treatment options, both targeted and non-targeted biomarkers have to be identified and validated. To this aim, new rules are needed for the interaction between academia and industry under regulatory control. Setting up multi-centre biosample collections with clear definition of access, organising early, possibly non-committing discussions with regulatory authorities, and defining a clear route for the validation, qualification and registration of the biomarker-drug combination are some of the more critical areas where effective collaboration between the drug industry, academia and regulators is needed.

[Overview and assessment of available data sources to determine incidence of vaccine preventable diseases, vaccination coverage, and immune status in Germany]

The surveillance of vaccine preventable diseases and vaccination coverage is necessary in order to deliver epidemiological data with respect to national vaccination recommendations and control targets. The data available on the incidence of vaccine preventable diseases, vaccination coverage, and immune status of the population are fragmentary and do not allow the epidemiological situation to be fully assessed. Although the majority of vaccine preventable diseases are under surveillance nationwide (by statutory reporting or sentinel surveillance), data are not available for some diseases. In addition, data on vaccination coverage are not collected centrally. Nationwide data on vaccination coverage are only available for children at school entry. Use of secondary data such as data from health insurance companies or associations of statutory health insurance physicians provides an opportunity to close gaps in knowledge and to improve the surveillance of vaccine preventable diseases.

[Current vaccination coverage and immunization gaps of children and adolescents in Germany]

Available data show increasing vaccination coverage of children and adolescents in recent years in Germany. Vaccination coverage of children against diphtheria, tetanus, polio and haemophilus influenzae Type b is high. Vaccination gaps exist for pertussis, hepatitis B and for the second measles, mumps and rubella doses. Coverage is still insufficient to achieve effective herd immunity and measles elimination. Data from the representative German Health Interview and Examination Survey for Children and Adolescents reveal that vaccination of infants is markedly delayed compared to recommendations of the German Standing Committee on Vaccination (STIKO). Particularly older children and adolescents are often not fully vaccinated or are even unvaccinated. A high proportion is missing the recommended booster doses against diphtheria, tetanus, pertussis and polio. Vaccination compliance especially regarding completeness and timeliness is lower in western than eastern Germany, as well as in children of vaccine sceptics and foreign-born children. More comprehensive surveillance of vaccination coverage and adverse events following immunization as well as the implementation of a national immunization plan focussing on closure of immunization gaps could lead to improved vaccination coverage.

247 ASSOCIATIONS BETWEEN HEAT SHOCK PROTEIN 70 GENETIC POLYMORPHISMS AND CALVING RATES OF BRAHMAN-INFLUENCED COWS

Stress proteins and their genetic polymorphisms have been associated with decreased male and female fertility. Our objectives were to 1) identify single nucleotide polymorphisms (SNP) located in the promoter region of the bovine heat shock protein 70 (Hsp70) gene and 2) evaluate associations between Hsp70 SNP and calving rates of multiparous Brahman-influenced cows (n = 99). Genomic DNA was extracted from the buffy coats of EDTA- treated whole blood. Primers HSP-Pro749F (GCCAGGAAACCAGAGACAGA) and HSP-Pro1268R (CCTACGCAGGAGTAGGTGGT) were used for PCR amplification of a 539-base segment of the bovine Hsp70 promoter (GenBank accession number M98823). Eleven single nucleotide polymorphisms were detected: 8 transitions (G1013A, n = 2; G1045A, n = 8; C1069T, n = 4; A1096G, n = 14; G1117A, n = 12; T1134C, n = 7; C1154G, n = 11; andT1204C, n = 56), 2 transversions (A1125C, n = 53; and G1128T, n = 51), and 1 deletion at base position 895 (n = 37). Within an SNP, calving percentages were compared by chi-square analysis. Concentrations of Hsp70 and Julian date were analyzed by ANOVA, with each SNP represented as the main effect in the model. Cows that were homozygous for the minor allele at both transversion (A1125C and G1128T) sites had lower (P < 0.05) calving rates when compared with cows that were homozygous for the primary allele (48 v. 75%). Homozygous and heterozygous deletion of cytosine at base 895 resulted in lower (P < 0.05) calving percentages than homozygous cytosine cows (8, 50, 82%; respectively). In addition, DD cows had the latest (P < 0.05) Julian calving date. Eighteen Hsp70 promoter haplotypes were deduced, and 7 of those haplotypes (n = 37) included the deletion at base 895. Thirty-two cows had the haplotype consistent with the sequence deposited at GenBank, and the remaining 30 cows had an SNP other than the deletion. Cows with the deletion haplotypes had greater (P < 0.05) serum Hsp70 concentrations and lower (P < 0.05) calving rates (5.1, 4.7, and 3.5 MSE 0.5 ng mL-1; and 35, 78, and 87%; respectively, for Deletion, No, and Yes). Furthermore, cows with the deletion haplotypes had the latest (P < 0.05) Julian calving date (85, 77, and 73 d, respectively, for Deletion, No, and Yes). Our results suggest that the promoter region of the bovine Hsp70 gene is polymorphic and might be useful in selecting cows with greater fertility.

Classifying degenerative joint disease by the RDC/TMD and by panoramic imaging: a retrospective analysis

The purposes of the study were to evaluate the utility of diagnosing degenerative joint disease (DJD) by the clinical finding of coarse crepitus alone, without supporting imaging studies, as defined by the RDC/TMD, and to evaluate the contribution of panoramic radiography as an aid in the diagnosis of DJD. A retrospective analysis of 372 consecutive patients with TMD was conducted. Their panoramic radiographs were evaluated for the extent of their contribution to the final diagnosis. Panoramic radiography was of no diagnostic value in 94.4% of the cases when the group was considered as a whole. When patients diagnosed with DJD were considered separately, panoramic radiography was completely sufficient for reaching the final diagnosis in 20.0% of the cases. In almost 90% of these patients, however, the clinical examination did not support the diagnosis of DJD (no coarse crepitus was found). This raises some doubts about the effectiveness of the clinical examination according to the RDC/TMD and about the utility of panoramic radiography in the definitive diagnosis of DJD, because both techniques have low accuracy (11.1% and 20%, respectively). The present study supports the current recommendations that panoramic radiography should not be ordered routinely to assess DJD, but still it is first choice when any dental problem is suspected. Further additional imaging (computerized tomography, magnetic resonance imaging) should be considered only if there is reason to expect that the findings might affect diagnosis and management. This study adds to recent criticisms of the clinical validity of the RDC/TMD, with regard to DJD.

EULAR evidence-based recommendations for the diagnosis of hand osteoarthritis: report of a task force of ESCISIT

Objectives:

To develop evidence-based recommendations for the diagnosis of hand osteoarthritis (OA).

Methods:

The multidisciplinary guideline development group, representing 15 European countries, generated 10 key propositions regarding diagnosis using a Delphi consensus approach. For each recommendation, research evidence was searched for systematically. Whenever possible, the sensitivity, specificity and likelihood ratio (LR) were calculated; relative risk and odds ratios were estimated for risk factors for hand OA. Quality of evidence was categorised using the European League Against Rheumatism (EULAR) hierarchy, and strength of recommendation was assessed by the EULAR visual analogue scale.

Results:

Diagnostic topics included clinical manifestations, radiographic features, subgroups, differential diagnosis, laboratory tests, risk factors and comorbidities. The sensitivity, specificity and LR varied between tests depending upon the cut-off level, gold standard and controls. Overall, no single test could be used to define hand OA on its own (LR <10) but a composite of the tests greatly increased the chance of the diagnosis. The probability of a subject having hand OA was 20% when Heberden nodes alone were present, but this increased to 88% when in addition the subject was over 40 years old, had a family history of nodes and had joint space narrowing in any finger joint.

Conclusion:

Ten key recommendations for diagnosis of hand OA were developed using research evidence and expert consensus. Diagnosis of hand OA should be based on assessment of a composite of features.

[The use of the panoramic radiograph for diagnosis of temporomandibular joint disorders (TMD)--comparison to other imaging techniques]

The panoramic radiograph is the most commonly used radiographic technique for initial evaluation and diagnosis of temporomandibular joint disorders (TMD). The purpose of this article is to highlight the principles of interpretation and limitations of the panoramic radiograph as an imaging technique of the temporomandibular joint. The indications for selecting the most suitable imaging technique for various TMD diagnoses are presented in accordance with the most recent position paper of the American Academy of Oral and Maxillofacial Radiology.

Universal immunisation with human papillomavirus (HPV) vaccine among females aged 12-17 recommended in Germany

In March 2007, vaccination against human papillomavirus (HPV) was added to the recommended routine immunisation schedule in Germany. Primary immunisation is recommended for females aged 12 to 17.