Prevalence of Low Bone Mass and Osteoporosis in Ireland: the Dual-Energy X-Ray Absorptiometry (DXA) Health Informatics Prediction (HIP) Project

Osteoporosis is a common disease that has a significant impact on patients, healthcare systems, and society. World Health Organization (WHO) diagnostic criteria for postmenopausal women were established in 1994 to diagnose low bone mass (osteopenia) and osteoporosis using dual-energy X-ray absorptiometry (DXA)-measured bone mineral density (BMD) to help understand the epidemiology of osteoporosis, and identify those at risk for fracture. These criteria may also apply to men ≥50 years, perimenopausal women, and people of different ethnicity. The DXA Health Informatics Prediction (HIP) project is an established convenience cohort of more than 36,000 patients who had a DXA scan to explore the epidemiology of osteoporosis and its management in the Republic of Ireland where the prevalence of osteoporosis remains unknown. In this article we compare the prevalence of a DXA classification low bone mass (T-score < -1.0) and of osteoporosis (T-score ≤ -2.5) among adults aged ≥40 years without major risk factors or fractures, with one or more major risk factors, and with one or more major osteoporotic fractures. A total of 33,344 subjects met our study inclusion criteria, including 28,933 (86.8%) women; 9362 had no fractures or major risk factors, 14,932 had one or more major clinical risk factors, and 9050 had one or more major osteoporotic fractures. The prevalence of low bone mass and osteoporosis increased significantly with age overall. The prevalence of low bone mass and osteoporosis was significantly greater among men and women with major osteoporotic fractures than healthy controls or those with clinical risk factors. Applying our results to the national population census figure of 5,123,536 in 2022 we estimate between 1,039,348 and 1,240,807 men and women aged ≥50 years have low bone mass, whereas between 308,474 and 498,104 have osteoporosis. These data are important for the diagnosis of osteoporosis in clinical practice, and national policy to reduce the illness burden of osteoporosis. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Surgical procedure prediction using medical ontological information

BACKGROUND AND OBJECTIVE

Predicting the duration of surgical procedures is an important step in scheduling operating rooms. Many factors have been shown to influence the duration of a procedure, in this research we aim to use medical ontological information to improve the predictions.

METHODS

This paper presents two methods for incorporating the medical information about a surgical procedure into the prediction of the duration of the procedure. The first method uses the Systematised Nomenclature of Medicine Clinical Terms to relate different procedures to each other. The second uses simple text fragments. The relationships between types of procedures are included in a regression model for the procedure duration. These methods are applied to data from New Zealand healthcare facilities and the accuracy of the estimations of the durations is compared. In addition a simulation of scheduling the procedures in an operating room is performed.

RESULTS

It is shown that both of the methods provide an improvement in the prediction of procedure durations. When compared to a traditional categorical encoding, the ontological information provides an improvement in the continuous ranked probability scores of the prediction of procedure durations from 18.4 min to 17.1 min, and from 25.3 to 21.3 min for types of procedures that are not performed very often.

CONCLUSIONS

Different methods for encoding medical ontological information in surgery procedure duration predictions are presented, and show an improvement over traditional models. The improvement in duration prediction is shown to improve the efficiency of scheduling in a simple simulation.

Role of Adipose Derived Stem Cells in Patients with Diabetic Foot Ulcers: Systematic Review and Meta-Analysis of Randomised Controlled Trials

Few studies to date have investigated the role of adipose derived stem cells (ADSCs) in patients with diabetic foot ulcers (DFU). We aimed to conduct a systematic search of the literature to explore the available evidence behind ADSCs application in patients with DFU to establish if it has any added benefit regarding healing rate and healing time in this cohort of patients. The PubMed and Embase databases were searched for eligible studies. Only randomised controlled trials which investigated the impact of ADSCs alone on the healing of DFU were considered eligible and were included for the review. Reported healing rates, time to healing and procedure related complications were collected and analysed. The initial search resulted in 160 papers. Following duplicate removal, 131 papers were screened for eligibility. Only four trials met the study criteria and were included for the final review and analysis. 97 out of 189 patients who were included in the four studies received ADSCs for treatment of DFU whereas the remaining 92 patients received standard measures (control). The median participant age was 62, predominantly male (72.5%). Complete healing was achieved in 83.5% (n  =  81) of patients in the ADSC group compared to 52% (n  =  48) for patients in the control group at 12 months (OR = 4.8, 95%CI  =  2.25 to 10.24, P < 0.0001). Mean healing time in the ADSC group ranged from 31 to 85 days whereas mean healing time in the control group ranged from 42 to 85 days (Pooled weighted mean difference  =  -10.832856, 95%CI  =  -22.44 to 0.77, P  =  0.0673). No significant procedure related complications were reported in either group. The use of ADSCs in patients with DFU appears to demonstrate improved healing rates. The procedure of ADSC harvest and administration appears to be safe based on the initial reports. Large, randomised trials are needed to establish its role in patients with diabetic foot wounds.

An overview of the management of osteoporosis in the aging female population

Osteoporosis is a systemic skeletal disease that is a cause of morbidity and mortality. It can affect all ages but most frequently postmenopausal women. It is a silent condition, however, osteoporotic fractures can lead to significant pain and disability. In this review article, we aim to review the clinical approach to the management of postmenopausal osteoporosis. We include risk assessment, investigations, and the various pharmacological and non-pharmacological options used in the treatment of osteoporosis. We have discussed the pharmacological options individually including their mechanism of action, safety profile, effects on bone mineral density and fracture risks, and duration of use. Potential new treatments are also discussed. The importance of sequence in the use of osteoporotic medicine is also highlighted in the article. An understanding of the different treatment options will hopefully help in the management of this very common and debilitating condition.

21 ASSESSING SARCOPENIA, FRAILTY AND MALNUTRITION IN COMMUNITY-DWELLING DEPENDANT OLDER ADULTS – A HOME-BASED STUDY WITH AN UNDERREPRESENTED GROUP IN RESEARCH

Background

Sarcopenia, frailty, and malnutrition are known determinants of adverse health outcomes. Adults of advanced age, with functional dependency, socioeconomic disadvantage, or a need for home care, are expected to be at high risk of these conditions yet are likely to be underrepresented in research. We aimed to examine the feasibility and preliminary outcomes of conducting home-based assessments in this group.

Methods

Home-based health assessments were conducted among older adults (n= 31), in receipt of state-funded home care. Assessments included probable sarcopenia [hand-grip strength (HGS), chair rise-test and SARC-F case-finding tool] in line with the European Working Group on Sarcopenia in Older People 2 (EWGSOP2) guidelines, the Mini Nutritional Assessment (MNA), and the Clinical Frailty Scale (CFS).

Results

The study group was of mean age 83.2 ± 8.2 years, 74% female, 23% lived in socioeconomically disadvantaged areas, had comorbidities (n=30, 97%) and low physical activity (71%). We found that almost all met the criteria for probable sarcopenia (94%, 29/31), most were frail or vulnerable by CFA (97%, 30/31), and over a quarter were at risk of malnutrition (26%, n=8). In all participants, it was feasible to assess sarcopenia (by HGS and SARC-F, but not chair rise test), malnutrition (MNA), and frailty (CFS). Notably, in-home assessments required additional time, the adaptation of assessment tools, responsibility to address issues arising, including signposting to health services (36%, n=11), and navigating complex psychosocial environments; the latter was commonly observed in areas of socioeconomic disadvantage.

Conclusion

Assessing sarcopenia, frailty, and malnutrition in community-dwelling dependant older adults in-home was feasible, once potential challenges were considered. Moreover, our findings suggest that most participants were at risk of both sarcopenia and frailty, and over a quarter were at risk of malnutrition. This highlights a need for further research and proactive evidence-based multi-modal community interventions to support ageing in place.

National Audit of Criteria For Pre-Operative Sickle Cell Screening in Children

Aim We set out to identify the current practice in the anaesthesiology departments of Ireland's public hospitals that deliver paediatric anaesthesia with regard to pre-operative screening for sickle cell disease (SCD) and Sickle cell trait (SCT). Methods The Departments of Anaesthesiology at 14 public HSE-funded hospitals that deliver paediatric anaesthesia were contacted over a three month period in 2020. Any existing policies regarding pre-operative screening of paediatric patients for Sickle cell disease or trait were sought. Comparisons were made between any screening policies in place. Results A response was received from 11 of the 14 hospitals. Three out of 11 of the Anaesthesiology Departments have formal policies in place. The ethnicities identified for pre-operative screening varied across these three hospitals. Conclusion Despite a significant increase in the number of people of African, middle Eastern &amp; Indian descent living in Ireland in recent years, no neonatal screening programme for Sickle cell exists here, and no national policy exists with criteria to guide the practice of pre-operative screening of patients for SCD/SCT (trait). Our survey highlights a lack of standardisation in the approach to pre-operative sickle cell screening of children across Ireland's public hospital system. In view of the increasing multiculturalism in Ireland we recommend a national review of the merits of the introduction of developing a targeted national guideline for pre-operative screening for sickle cell in at-risk children.

18 months on: an interrupted time series analysis investigating the effect of COVID-19 on chlamydia and gonorrhoea testing and test positivity at the Gold Coast, Australia

BACKGROUND

STI rates have been reported as reduced during the height of the COVID-19 pandemic. Our study evaluates the number of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections recorded relative to the number of tests performed in 2017-2021, thus accurately depicting trends over time and evaluate the effect of COVID-19 restrictions since these were implemented in March 2020.

METHODS

Data was extracted from an electronic database of pathology and clinical records used at Gold Coast Sexual Health Service (GCSHS) in Queensland, Australia from January 2017 to October 2021. Poisson regression-based interrupted time series analyses were performed for number of tests performed and test positivity over the study period. The COVID-19 period was defined as starting from March 2020 when public health directives were implemented.

RESULTS

CT and NG testing dropped significantly in the month after COVID-19 restrictions were brought in, by 30% and 23% respectively. Over the 5year study period, the proportion of positive CT tests has consistently decreased by approximately 0.33% points per year (P≤0.001). The instigation of COVID-19 restrictions had no effect on this trend. The proportion of NG positive tests remained steady prior to COVID-19 (P=0.96) at approximately 3.5%, decreased immediately at the onset of COVID-19 restrictions to approximately 2.5% (P<0.001) and has remained at this level post-COVID restrictions (P=0.54). Testing at GCSHS continued to target gay and bisexual men, accounting for ≥50% of all tests performed.

CONCLUSION

Our study suggests that there has been a sustained reduction in test positivity of NG infections in the 18months since COVID-19 restrictions were implemented, and that this is not an artifact of reduced testing. It highlights the importance of maintaining health messaging including screening for sexually transmissible infections and maintaining access to services, which may include alternative models of care such as Telehealth, self-testing and collaboration between all sexual health service providers.

Conceptual design of the dual X-ray absorptiometry health informatics prediction system for osteoporosis care

Osteoporotic fractures are a major and growing public health problem, which is strongly associated with other illnesses and multi-morbidity. Big data analytics has the potential to improve care for osteoporotic fractures and other non-communicable diseases (NCDs), reduces healthcare costs and improves healthcare decision-making for patients with multi-disorders. However, robust and comprehensive utilization of healthcare big data in osteoporosis care practice remains unsatisfactory. In this paper, we present a conceptual design of an intelligent analytics system, namely, the dual X-ray absorptiometry (DXA) health informatics prediction (HIP) system, for healthcare big data research and development. Comprising data source, extraction, transformation, loading, modelling and application, the DXA HIP system was applied in an osteoporosis healthcare context for fracture risk prediction and the investigation of multi-morbidity risk. Data was sourced from four DXA machines located in three healthcare centres in Ireland. The DXA HIP system is novel within the Irish context as it enables the study of fracture-related issues in a larger and more representative Irish population than previous studies. We propose this system is applicable to investigate other NCDs which have the potential to improve the overall quality of patient care and substantially reduce the burden and cost of all NCDs.

255 A QUALITATIVE STUDY OF OLDER ADULTS’ EXPERIENCES OF EMBEDDING PHYSICAL ACTIVITY WITHIN THEIR HOME CARE SERVICES

Background

Physical activity programmes have been shown to improve older adults’ functional capacity, independence and quality of life. Research around structured exercise programmes has been completed in different groups of community-dwelling older people, however few studies have focused on the older population receiving formal home care. In a feasibility study, we embedded physical activity within older adults existing home care services through the ‘Care to Move’ (CTM) programme. The aim of this qualitative study is to explore older adults’ experiences of the CTM programme.

Methods

We conducted semi-structured telephone interviews with 13 older adults and one carer. Topics covered included participants overall experiences of the CTM programme, changes to their overall activity and participation, aspects of the programme that they liked or found valuable and issues that they found challenging. Interview transcripts were coded and analysed thematically to capture barriers and facilitators to programme delivery.

Results

Four themes emerged: i) ‘I’m feeling good about it’, ii) ‘safety and security is the name of the game’, iii) ‘we’re a team as it stands’, iv) ‘it’s [COVID] depressing for everybody at the moment’. Older adults identified benefits of CTM participation including improvements in physical and psychological wellbeing. However, frailty and multimorbidity influenced overall engagement. Participants expressed concerns around the logistics of programme delivery and competing healthcare assistant (HCA) interests. The broader role of HCA’s in supporting the CTM programme was highlighted as well as the emotional support that HCAs provided to older adults. HCA continuity was identified as a barrier to ongoing programme engagement. The impact of COVID on older adults physical and mental health negatively impacted programme delivery.

Conclusion

Our findings suggest that embedding the CTM programme within home support services is feasible. Restructuring of services, addressing HCA continuity, and adopting individual approaches to programme delivery may enhance the implementation of services.

199 EMBEDDING PHYSICAL ACTIVITY WITHIN HOME CARE SERVICES FOR OLDER ADULTS IN IRELAND—A QUALITATIVE STUDY OF BARRIERS AND FACILITATORS

Background

In Ireland, over 53,000 older adults are supported in their community by formal home support, amounting to an estimated 19 million care hours annually. There is a growing need to move beyond care, to more proactive approaches to maintain physical function. In a feasibility study, we delivered the ‘Care to Move’ (CTM) programme through existing home support services. The aim of the present qualitative study was to explore the experience and perceptions of Health Care Assistants (HCAs), who were trained in, and delivered the CTM programme.

Methods

We conducted semi-structured telephone interviews with 22 HCAs involved in the delivery of the programme among older adults [n = 35, mean age 82.8 (7.8) years]. Interview transcripts were coded and analysed thematically to capture barriers and facilitators to programme delivery.

Results

Barriers and facilitators were identified under three main themes i) the programme ii) the care setting, iii) the clients. Overall, there was a positive perception of the programme’s focus on ‘movement prompts and motivators’, the ‘fit’ within home support services, and the training provided. Practical challenges of limited time and the task-orientation nature of home support were reported as recurring barriers for CTM. Many HCAs commented on the value and perceived positive benefits of the programme for their clients. Though negative perceptions of older adult’s motivation or ability to engage with physical activity also emerged. Risk, such as injury or pain, was identified but was not a dominant theme.

Conclusion

Our preliminary findings suggest that embedding physical activity initiatives within home support services could be feasible. Restructuring of services, engaging HCAs, and moving beyond traditional ‘task-oriented' care models to more personalised proactive approaches may facilitate this initiative and support ageing in place.

Machine Learning Can Improve Clinical Detection of Low BMD: The DXA-HIP Study

BACKGROUND

Identification of those at high risk before a fracture occurs is an essential part of osteoporosis management. This topic remains a significant challenge for researchers in the field, and clinicians worldwide. Although many algorithms have been developed to either identify those with a diagnosis of osteoporosis or predict their risk of fracture, concern remains regarding their accuracy and application. Scientific advances including machine learning methods are rapidly gaining appreciation as alternative techniques to develop or enhance risk assessment and current practice. Recent evidence suggests that these methods could play an important role in the assessment of osteoporosis and fracture risk.

METHODS

Data used for this study included Dual-energy X-ray Absorptiometry (DXA) bone mineral density and T-scores, and multiple clinical variables drawn from a convenience cohort of adult patients scanned on one of 4 DXA machines across three hospitals in the West of Ireland between January 2000 and November 2018 (the DXA-Heath Informatics Prediction Cohort). The dataset was cleaned, validated and anonymized, and then split into an exploratory group (80%) and a development group (20%) using the stratified sampling method. We first established the validity of a simple tool, the Osteoporosis Self-assessment Tool Index (OSTi) to identify those classified as osteoporotic by the modified International Society for Clinical Densitometry DXA criteria. We then compared these results to seven machine learning techniques (MLTs): CatBoost, eXtreme Gradient Boosting, Neural network, Bagged flexible discriminant analysis, Random forest, Logistic regression and Support vector machine to enhance the discrimination of those classified as osteoporotic or not. The performance of each prediction model was measured by calculating the area under the curve (AUC) with 95% confidence interval (CI), and was compared against the OSTi.

RESULTS

A cohort of 13,577 adults aged ≥40 yr at the age of their first scan was identified including 11,594 women and 1983 men. 2102 (18.13%) females and 356 (17.95%) males were identified with osteoporosis based on their lowest T-score. The OSTi performed well in our cohort in both men (AUC 0.723, 95% CI 0.659-0.788) and women (AUC 0.810, 95% CI 0.787-0.833). Four MLTs improved discrimination in both men and women, though the incremental benefit was small. eXtreme Gradient Boosting showed the most promising results: +4.5% (AUC 0.768, 95% CI 0.706-0.829) for men and +2.3% (AUC 0.833, 95% CI 0.812-0.853) for women. Similarly MLTs outperformed OSTi in sensitivity analyses-which excluded those subjects taking osteoporosis medications-though the absolute improvements differed.

CONCLUSION

The OSTi retains an important role in identifying older men and women most likely to have osteoporosis by bone mineral density classification. MLTs could improve DXA detection of osteoporosis classification in older men and women. Further exploration of MLTs is warranted in other populations, and with additional data.

Utility of Osteoporosis Self-Assessment Tool as a Screening Tool for Osteoporosis in Irish Men and Women: Results of the DXA-HIP Project

Many algorithms have been developed and publicised over the past 2 decades for identifying those most likely to have osteoporosis or low BMD, or at increased risk of fragility fracture. The Osteoporosis Self-assessment Tool index (OSTi) is one of the oldest, simplest, and widely used for identifying men and women with low BMD or osteoporosis. OSTi has been validated in many cohorts worldwide but large studies with robust analyses evaluating this or other algorithms in adult populations residing in the Republic of Ireland are lacking, where waiting times for public DXA facilities are long. In this study we evaluated the validity of OSTi in men and women drawn from a sampling frame of more than 36,000 patients scanned at one of 3 centres in the West of Ireland. 18,670 men and women aged 40 years and older had a baseline scan of the lumbar spine femoral neck and total hip available for analysis. 15,964 (86%) were female, 5,343 (29%) had no major clinical risk factors other than age, while 5,093 (27%) had a prior fracture. Approximately 2/3 had a T-score ≤-1.0 at one or more skeletal sites and 1/3 had a T-score ≤-1.0 at all 3 skeletal sites, while 1 in 5 had a DXA T-score ≤-2.5 at one or more skeletal sites and 5% had a T-score ≤-2.5 at all 3 sites. OSTi generally performed well in our population with area under the curve (AUC) values ranging from 0.581 to 0.881 in men and 0.701 to 0.911 in women. The performance of OSTi appeared robust across multiple sub-group analyses. AUC values were greater for women, proximal femur sites, those without prior fractures and those not taking osteoporosis medication. Optimal OSTi cut-points were '2' for men and '0' for women in our study population. OSTi is a simple and effective tool to aid identification of Irish men and women with low BMD or osteoporosis. Use of OSTi could improve the effectiveness of DXA screening programmes for older adults in Ireland.

876 A Sweeping Success – Management of Type 1A Endoleak Using A Chimney Graft Technique

Endoleak is a recognised complication after Endovascular Abdominal Aortic Aneurysm Repair (EVAR). In the setting of a rapidly expanding aneurysm – time is of the essence. Perfusion of the renal arteries, superior mesenteric artery (SMA) and coeliac artery must be maintained. To facilitate this a customised fenestrated endograft may be used or a chimney endovascular aortic repair (CHEVAR).

A 78-year-old female initially underwent EVAR in 2016 for a ruptured 6.9cm AAA. She made a good recovery at that time. She was enlisted in a surveillance programme. Her most recent duplex showed an aneurysmal sac of 10cm with associated type 1A endoleak. Given these findings waiting for a fenestrated graft posed an unacceptable delay. She underwent a CHEVAR with bilateral axillary and right femoral access. She had chimney stents deployed in the renal arteries and SMA with aortic cuff extension proximally. Her completion angiogram showed good proximal seal with patent stents. She was unexpectedly unstable post-operatively and had a CT scan which revealed a re-ruptured aneurysm. She was treated in ICU and recovered well. Repeat imaging showed good flow in all 4 grafts with no endoleak.

This case demonstrates the challenges of managing endoleak post EVAR and the importance of robust surveillance and appropriate, timely treatment.

P110 Sex differences in hand osteoarthritis symptoms and function

Background/Aims 

There is currently no consensus regarding sex-related differences in pain intensity and functional abilities among patients with hand osteoarthritis (OA). In this study we determine sex-related differences in pain intensity and functional ability among patients with hand OA, as assessed by a self-report questionnaire and by performance-based tests.

Methods 

Using the AUSCAN tool for symptom and functional assessment of hand OA with dynamometry we prospectively accessed patients meeting the ACR criteria for hand osteoarthritis. Using this analysis, assessments of pain and function were compared in male and female patients. The outcome measures included self-reported pain measures, functional assessment and dynamometry measures.

Results 

The study population included 106 patients (90 females and 16 males) with a mean age of males 48.44 (7.48) and females 52.67 (9.43). All patients with symptomatic hand osteoarthritis meeting ACR Criteria. When accessing difference between sexes, men were found to be significantly heavier (p = 0.003) and have greater grip and pinch strength.As part of function and pain assessments there was a significant correlation between difficulty with fine motor skills such as difficulty doing buttons, difficulty when doing jewellery, or peeling vegetables associated with pain when turning objects e.g. doorknobs, taps and faucets for men in comparison to women. Difficulty in these fine motor skills also correlated with stiffness on wakening and pain on lifting heavy objects regardless of sex. A Mann-Whitney U test was run on 106 participants to determine if there were differences in pain or functional scores between males and females. This reviled Median score for males () and females () was statistically significantly different,There were sex differences noted in the correlation associated with pain with rotational movements e.g. turning objects and functional difficulty with fine motor movements including difficulty when doing up buttons ( Males r(14) = -0.109, p = 0.698, Females r(88) =0.489, p = &lt;0.01 value.= ), difficulty when doing jewellery ( Males r(14) =-0.265, p = 0.339.= Females r(88) = 0.570, p = &lt;0.01) , difficulty peeling vegetables ( Males r(14) = -0.207, p = 0.458 Females r(88) = 0.519, &lt;0.01 )

Conclusion 

The results demonstrate the presence of sex differences in patients suffering from hand osteoarthritis self-reported functional ability and pain scales. These differences indicate the need for further studies to explore the mechanisms of hand OA and to understanding the specific impact of gender on the development and progression of disease. With further understanding we can obtain the proper strategy to provide better individualised treatment. It also highlights that rehabilitation programs should consider these differences and each patients’ performance limitations in order to address the specific needs of each individual patient. In doing so, improved pain and functional status will improve morbidity in hand OA

Disclosure 

B. Dinneen: None. D. Heath: None. M. Ghaffar: None. M. O'Sullivan: None. C. Silke: None. B. Whelan: None.

The Irish dual-energy X-ray absorptiometry (DXA) Health Informatics Prediction (HIP) for Osteoporosis Project

PURPOSE

The purpose of the Irish dual-energy X-ray absorptiometry (DXA) Health Informatics Prediction (HIP) for Osteoporosis Project is to create a large retrospective cohort of adults in Ireland to examine the validity of DXA diagnostic classification, risk assessment tools and management strategies for osteoporosis and osteoporotic fractures for our population.

PARTICIPANTS

The cohort includes 36 590 men and women aged 4-104 years who had a DXA scan between January 2000 and November 2018 at one of 3 centres in the West of Ireland.

FINDINGS TO DATE

36 590 patients had at least 1 DXA scan, 6868 (18.77%) had 2 scans and 3823 (10.45%) had 3 or more scans. There are 364 unique medical disorders, 186 unique medications and 46 DXA variables identified and available for analysis. The cohort includes 10 349 (28.3%) individuals who underwent a screening DXA scan without a clear fracture risk factor (other than age), and 9947 (27.2%) with prevalent fractures at 1 of 44 skeletal sites.

FUTURE PLANS

The Irish DXA HIP Project plans to assess current diagnostic classification and risk prediction algorithms for osteoporosis and fractures, identify the risk predictors for osteoporosis and develop novel, accurate and personalised risk prediction tools, by using the large multicentre longitudinal follow-up cohort. Furthermore, the dataset may be used to assess, and possibly support, multimorbidity management due to the large number of variables collected in this project.

Economic assessment of Holstein-Friesian dairy cows of divergent Economic Breeding Index evaluated under seasonal calving pasture-based management

The objective of this study was to investigate the economic performance of 2 genetic groups (GG) of Holstein-Friesian dairy cows of divergent Economic Breeding Index (EBI), evaluated within 3 contrasting spring-calving pasture-based feeding treatments (FT). The study was a simulated economic appraisal, using the Moorepark Dairy Systems Model, a stochastic budgetary simulation model integrating biological data obtained from a 4-yr experiment conducted from 2013 to 2016. The 2 divergent GG were (1) high EBI representative of the top 5% nationally (elite) and (2) EBI representative of the national average (NA). The 3 FT were reflective of slight restriction to generous feeding. The elite GG had the lowest replacement rate, and therefore had lower replacement costs and an older and more productive parity structure. The elite GG consistently had higher sales of milk (on average +3% or +18,370 kg of milk) and milk solids (milk fat plus protein yield; +8.7% or +4,520 kg) compared with the NA GG across the 3 FT scenarios. Milk income was consequently greater for elite versus NA (on average +9.5% or +€21,489) cows. Livestock sales were greater (on average +13.2% or +€4,715) for NA compared with elite cows. Baseline net farm profit and net profit/ha at a base milk price of 29.5 cents per liter (3.3% protein and 3.6% fat) were on average €31,156, and €772 greater for elite compared with NA cows across the 3 FT. Greater profitability achieved with elite cows in each of the FT investigated demonstrated the adaptability of high-EBI cows across different levels of feeding intensities in seasonal pasture-based feeding systems. Sensitivity analysis of varying milk price and concentrate cost did not result in a reranking of GG for farm profit. This study clearly demonstrates the power of a suitably constructed genetic-selection index together with a well-considered breeding program to deliver genetics capable of favorable change to farm physical performance and profit over a relatively short duration.

P131 Patients with hand osteoarthritis have a long duration of symptoms and significant pain scores at the time of referral to rheumatology services

Background

Osteoarthritis is the most common arthritic condition worldwide affecting 9.6% of men and 18% of women aged &gt;60 years with an Irish prevalence &gt;50 years of age is 17.3% for women and 9.4% for men. It can occur in any joint but is most common in the hip, knee and spine. It is also prevalent in the hand and can lead to significant pain and disability. The aim of this study was to examine the pattern and severity of hand osteoarthritis in patients referred to a regional rheumatology service.

Methods

Consecutive patients seen in general rheumatology clinics of all ages and gender who had confirmed diagnosis of hand osteoarthritis based on the ACR criteria were recruited (patients with RA, psoriatic arthritis, gout and haemochromatosis were excluded). All gave written informed consent to participate and had a single assessment performed including demographic details, symptom assessment using the AUSCAN Osteoarthritis Hand Index. In addition, measures of functional ability, grip strength and pincer strength were performed in the OT department. All patients also had an up to date hand X-ray performed. For the purposes of this paper we will report the initial assessments including the demographic details and pain scores.

Results

103 consecutive patients were included in this analysis. M:F ratio 1:5.25. Mean age was 66.13 years. Mean duration of symptoms 74.63 months (8-422). At assessment the mean pain scores (0-10 VAS) were 4.53 (at rest), 6.09 (when gripping), 6.06 (when lifting) and 6.42 (when turning objects). The mean tender joint count was 7.14 and the mean score for objective soft tissue swelling in the joints was 1.36.

Subject Average VAS (0-10) Pain Score at presentation by Gender

Conclusion

From these analyses, we can see that patients are referred very late with no one being seen within 6 months of symptoms onset. This is despite patients having pain scores which are comparable to those with inflammatory arthritis and in a small minority evidence of soft tissue swelling in joints at the time of presentation. In addition, it is noticeable that men are under-represented in the cohort of referred patients based on estimates of prevalence.

Disclosures

M. Ghaffar None. M. O'Sullivan None. C. Silke None. B. Whelan None.

Creating new guidelines on how best to treat foot symptoms in people with EB

Epidermolysis bullosa (EB) is a complex rare condition that affects the skin and many parts of the body. Those born with EB have skin so fragile they are called 'butterfly children', their skin is quite simply as fragile as the wing of a butterfly. In the UK it is estimated that there are more than 5,000 people living with EB and 500,000 worldwide. Little clinical guidance for care existed until DEBRA International started a programme to develop clinical practice guidelines (CPGs). There were no previous guidelines and few published studies on foot care in EB so treatment decisions were largely based on individual opinion and experience. The panel - made up of clinical experts and people living with EB representing Australia, the UK, and the USA - aimed to describe foot problems in people of all ages with EB, and summarise current evidence and management. The authors used a logical podiatric (foot) care literature review focussed on patients with EB. The authors found that the evidence in this area was limited but several interventions (treatments) currently practised by podiatrists show positive outcomes. The study allowed the group to make recommendations on how to treat foot and nail disorders in patients with EB. Furthermore, the authors concluded that further research is needed. This is a summary of the study: Foot care in epidermolysis bullosa: evidence-based guideline.

An Evaluation of the Hybrid Model for Predicting Surgery Duration

The degree of accuracy in surgery duration estimation directly impacts on the quality of planned surgical lists. Model selection for the prediction of surgery duration requires technical expertise and significant time and effort. The result is often a collection of viable models, the performance of which varies across different strata of the surgical population. This paper proposes a prediction framework to be used after a comprehensive model selection process has been completed for surgery duration prediction. The framework produces a partition of the surgical cases and a "hybrid model" that allocates different predictors from the collection of viable models to different parts of the surgical population. The intention is a flexible prediction process that can reassign models and adapt as surgical processes change. The framework is tested via a simulation study, and its utility is demonstrated by predicting surgery durations for Ear, Nose and Throat surgeries in a New Zealand hospital. The results indicate that the hybrid model is effective, performing better than standard model selection in two of the three simulation studies, and marginally worse when the selected model was the true underlying process.

Reproductive efficiency and survival of Holstein-Friesian cows of divergent Economic Breeding Index, evaluated under seasonal calving pasture-based management

The objective of the current study was to examine phenotypic fertility performance and survival, and to gain insight into underlying factors that may contribute to greater fertility performance in 2 divergent genetic groups (GG) of Holstein-Friesian, selected using the Irish Economic Breeding Index (EBI). The GG were evaluated across 3 spring calving pasture-based feeding treatments (FT) over 4 yr. The 2 divergent GG were (1) high EBI; representative of the top 5% nationally (elite), and (2) EBI representative of the national average (NA). In each year, 90 elite and 45 NA cows were randomly allocated to 1 of 3 FT: control, lower grass allowance, and high concentrate. No interaction between GG and FT was observed for any of the measures of fertility investigated. The elite cows achieved significantly greater pregnancy rate to first service (+14.9 percentage points), and significantly greater pregnancy rates after 21, 42, and 84 d of breeding (+17.3, +15.2, and +9.6 percentage points, respectively) compared with NA. The number of services per cow was fewer for elite (1.57) compared with NA (1.80). The interval from mating start date to pregnancy was significantly shorter for elite cows compared with NA. The elite cows maintained greater mean body condition score than NA throughout the study (2.91 vs. 2.72), and had greater body condition score at calving, artificial insemination, and drying off compared with NA. The elite cows had greater mean circulating concentrations of insulin-like growth factor-1 compared with NA. No significant effect was observed of GG on commencement of luteal activity, or progesterone profile variables. Greater survival to the start of fifth lactation was observed for elite cows. The elite cows were 43% less likely to be culled than NA by the beginning of the fifth lactation. The results highlight the success of the Economic Breeding Index to deliver reproductive performance and longevity consistent with industry targets across a range of seasonal pasture-based FT. The results also clearly demonstrate the potential of appropriate genetic selection to reverse negative fertility trends incurred during previous decades of selection for milk production alone.

Foot care in epidermolysis bullosa: evidence-based guideline

This guideline was designed to provide service providers and users with an evidence-based set of current best practice guidelines for people and their families and carers, living with epidermolysis bullosa (EB). A systematic literature review relating to the podiatric care of patients with EB was undertaken. Search terms were used, for which the most recent articles relating to podiatric treatment were identified from as early as 1979 to the present day, across seven electronic search engines: MEDLINE, Wiley Online Library, Google Scholar, Athens, ResearchGate, Net and PubFacts.com. The Scottish Intercollegiate Guidelines Network (SIGN) methodology was used. The first guideline draft was analysed and discussed by clinical experts, methodologists and patients and their representatives at four panel meetings. The resulting document went through an external review process by a panel of experts, other healthcare professionals, patient representatives and lay reviewers. The final document will be piloted in three different centres in the U.K. and Australia. Following an EB community international survey the outcomes indicated six main areas that the community indicated as a priority to foot management. These include blistering and wound management, exploring the most suitable footwear and hosiery for EB, management of dystrophic nails, hyperkeratosis (callus), maintaining mobility and fusion of toes (pseudosyndactyly). The evidence here is limited but several interventions currently practised by podiatrists show positive outcomes.

Reducing Implant Infection in Orthopaedics (RIIiO): Results of a pilot study comparing the influence of forced air and resistive fabric warming technologies on postoperative infections following orthopaedic implant surgery

BACKGROUND

Active warming during surgery prevents perioperative hypothermia but the effectiveness and postoperative infection rates may differ between warming technologies.

AIM

To establish the recruitment and data management strategies needed for a full trial comparing postoperative infection rates associated with forced air warming (FAW) versus resistive fabric warming (RFW) in patients aged >65 years undergoing hemiarthroplasty following fractured neck of femur.

METHODS

Participants were randomized 1:1 in permuted blocks to FAW or RFW. Hypothermia was defined as a temperature of <36°C at the end of surgery. Primary outcomes were the number of participants recruited and the number with definitive deep surgical site infections.

FINDINGS

A total of 515 participants were randomized at six sites over a period of 18 months. Follow-up was completed for 70.1%. Thirty-seven participants were hypothermic (7.5% in the FAW group; 9.7% in the RFW group). The mean temperatures before anaesthesia and at the end of surgery were similar. For the primary clinical outcome, there were four deep surgical site infections in the FAW group and three in the RFW group. All participants who developed a postoperative infection had antibiotic prophylaxis, a cemented prosthesis, and were operated under laminar airflow; none was hypothermic. There were no serious adverse events related to warming.

CONCLUSION

Surgical site infections were identified in both groups. Progression from the pilot to the full trial is possible but will need to take account of the high attrition rate.

Intake, efficiency, and feeding behavior characteristics of Holstein-Friesian cows of divergent Economic Breeding Index evaluated under contrasting pasture-based feeding treatments

The objective of the current study was to explore differences in dry matter intake, intake capacity, production efficiency, energy balance, and grazing behavior, of 2 divergent genetic groups (GG) of lactating Holstein-Friesian, selected using the Irish Economic Breeding Index (EBI). The GG were evaluated across 3 spring calving pasture-based feeding treatments (FT) over 3 yr. The 2 divergent GG were (1) high EBI, representative of the top 5% nationally (elite), and (2) EBI representative of the national average (NA). In each year 90 elite and 45 NA cows were randomly allocated to 1 of 3 FT: control, lower grass allowance, and high concentrate. Although FT did affect animal performance, there were few notable incidences of GG × FT interaction. The elite cows expressed lower daily milk yield (-1 kg) compared with NA. Elite cows did, however, express higher daily concentrations of milk fat (+3.7 g/kg) and protein (+2.1 g/kg) compared with NA. Daily yield of milk solids and net energy of lactation (NE_L) was similar for both GG. Body weight (BW) was greater for NA (+13 kg) compared with elite, whereas mean body condition score was greater (+0.14) for elite compared with NA. Intake did not differ significantly between GG. Intake capacity, expressed as total dry matter intake/100 kg of BW, was greater with elite compared with NA. Production efficiency expressed as yield of milk solids per 100 kg of BW was greater with elite compared with NA, although milk solids/total dry matter intake did not differ between GG. Expressed as NE_L as a proportion of net energy intake minus net energy of maintenance (NE_L/NE_I - NE_M) and NE_I/milk solids kg, indicated a slight reduction in the utilization of ingested energy for milk production with elite compared with NA. This is, however, suggested as favorable as it manifested as a more positive energy balance with elite compared with NA and so is likely to enhance robustness, increase longevity, and increase overall lifetime efficiency. Noteworthy was a consistent numerical trend toward more intense grazing activity with elite compared with NA cows, exhibited in the numerically greater grazing time (+19 min) and total number of bites per day (+2,591).

Milk production of Holstein-Friesian cows of divergent Economic Breeding Index evaluated under seasonal pasture-based management

The objective of this study was to validate the effect of genetic improvement using the Irish genetic merit index, the Economic Breeding Index (EBI), on total lactation performance and lactation profiles for milk yield, milk solids yield (fat plus protein; kg), and milk fat, protein, and lactose content within 3 pasture-based feeding treatments (FT) and to investigate whether an interaction exists between genetic group (GG) of Holstein-Friesian and pasture-based FT. The 2 GG were (1) extremely high EBI representative of the top 5% nationally (referred to as the elite group) and (2) representative of the national average EBI (referred to as the NA group). Cows from each GG were randomly allocated each year to 1 of 3 pasture-based FT: control, lower grass allowance, and high concentrate. The effects of GG, FT, year, parity, and the interaction between GG and FT adjusted for calving day of year on milk and milk solids (fat plus protein; kg) production across lactation were studied using mixed models. Cow was nested within GG to account for repeated cow records across years. The overall and stage of lactation-specific responses to concentrate supplementation (high concentrate vs. control) and reduced pasture allowance (lower grass allowance vs. control) were tested. Profiles of daily milk yield, milk solids yield, and milk fat, protein, and lactose content for each week of lactation for the elite and NA groups within each FT and for each parity group within the elite and NA groups were generated. Phenotypic performance was regressed against individual cow genetic potential based on predicted transmitting ability. The NA cows produced the highest milk yield. Milk fat and protein content was higher for the elite group and consequently yield of solids-corrected milk was similar, whereas yield of milk solids tended to be higher for the elite group compared with the NA group. Milk lactose content did not differ between GG. Responses to concentrate supplementation or reduced pasture allowance did not differ between GG. Milk production profiles illustrated that elite cows maintained higher production but with lower persistency than NA cows. Regression of phenotypic performance against predicted transmitting ability illustrated that performance was broadly in line with expectation. The results illustrate that the superiority of high-EBI cattle is consistent across diverse pasture-based FT. The results also highlight the success of the EBI to deliver production performance in line with the national breeding objective: lower milk volume with higher fat and protein content.

Premolar Double Teeth in a Group of Irish Orthodontic Referrals

This is a report of gemination type premolar double teeth in patients who were referred for orthodontic consultation in the Eastern Health Board, Ireland. Prevalence was low (0.06%) with just three patients presenting with this dental anomaly. The premolar double teeth involving two maxillary and one mandibular premolar are illustrated. 

Change in perceived stress and 2-year change in cognitive function among older adults: The Irish Longitudinal Study on Ageing

Prolonged or severe stress can adversely affect older adults' cognitive function, but population-based studies investigating this relationship over time are rare. Previous studies have largely focused on stress either evaluated at a single time point or linked to specific life events. This study aimed to investigate whether a change in perceived stress over 2 years predicts a change in cognitive performance over the same time period in a population-based sample of older adults. Data from the first 2 waves of The Irish Longitudinal Study on Ageing were analyzed. Five thousand and seventy adults aged 50 and older completed the 4-item Perceived Stress Scale and measures of verbal fluency, immediate and delayed word recall 2 years apart. A first differences regression model revealed that the change in stress over 2 years was inversely associated with a change in immediate word recall performance, even after adjustment for change in possible confounders (B = -0.030, 95% CI [-.056, -.004], p < .05). No association was observed for delayed recall or verbal fluency performance. Change in perceived stress is inversely correlated with change in immediate recall, even over a short period. Stress modifying interventions could potentially reduce the risk of cognitive decline associated with ageing.

High performance InAs/InP quantum dot 34.462-GHz C-band coherent comb laser module

We have developed an InAs/InP quantum dot (QD) C-band coherent comb laser (CCL) module with actively stabilized absolute wavelength and power, and channel spacing of 34.462 GHz with ± 100 ppm accuracy. The total output power is up to 46 mW. The integrated average relative intensity noise (RIN) values of the lasing spectrum and a filtered single channel at 1540.19 nm were -165.6 dB/Hz and -130.3 dB/Hz respectively in the frequency range from 10 MHz to 10 GHz. The optical linewidth of the 45 filtered individual channels between 1531.77 nm to 1543.77 nm ranged from 850 kHz to 2.16 MHz. We have also analyzed the noise behaviors of each individual channel.

Primary Renal Carcinoid - A Case Report

Carcinoid tumours in the abdomen are uncommon, but typically occur in the gastrointestinal tract. Primary renal carcinoid is an extremely rare tumour, poorly described in the literature. We describe an unusual case where an atypical renal mass on imaging led to a preoperative diagnosis of renal carcinoid on imaging guiding biopsy.

Virtual Reality (VR) Technology: Empowering Managers to Reduce and Eliminate Accessibility Barriers for People with Autism Spectrum Disorders

Barriers to accessibility are defined as 'factors in a person's environment that, through their absence or presence, limit functioning and create disability' [1]. There are four elements that are incorporated into this term which includes: physical environment, lack of assistive technology, attitudes of others and the lack of or restrictive services, systems and policies [1]. These barriers to accessibility are present for 13% of the Irish population. Many initiatives have been developed and implemented for people with physical disabilities; however, people with intellectual disabilities (ID) remain invisible. This invisible population accounts for 9.7% of our population or 75% of the population of people with disabilities [2]. Thus, it is imperative that we commence to implement Universal Design (UD) approaches that increase accessibility and empower the invisible to become visible. One such invisible group that holds substantial potential to bring immense value to companies is that of people with Autism Spectrum Disorders (ASD) [3]. ASD currently impacts 1 in 68 people worldwide with this figure growing annually at a rate of 10-17% [4]. 80% of people with ASD are either unemployed or underemployed; this can be attributed to barriers to accessibility [5]. Two of the most common barriers to accessibility experienced by those with ASD are environmental and attitudes of others [6,7]. These barriers have the potential to be overcome through the use of Virtual Reality (VR) technology to provide training and education to managers. VR technology is being used to empower managers to reduce these barriers, increase accessibility and develop inclusive environments and cultures. VR technology can be used to empower managers to recognise and reduce the barriers facing those with ASD. VR is a catalyst for managers to be able to identify the environmental barriers facing people with ASD within a work environment. This solution also provides them with the skills necessary to commence making adaptations to the environment to reduce or eliminate these barriers. The use of this technology and paradigm shift brings many benefits for the individual and the company. A mixed method approach has been used for the purposes of data collection. The tools that were utilised were interviews with HR managers and people with ASD; and surveys were circulated to HR managers, senior managers, Chief Executive Officers and people with ASD. The results of these were positive and clearly verified that there is a need to empower managers to increase accessibility within their organisations.

Long-term safety and efficacy of biosimilar infliximab among patients with inflammatory arthritis switched from reference product

Purpose

To evaluate the efficacy and safety of the biosimilar infliximab in adult patients with inflammatory arthritis switched from reference product in our center.

Patients and methods

In April 2014, patients attending our rheumatology service for infliximab infusions were switched from reference product to the biosimilar infliximab following consent and hospital approval.

Results

Around 34 patients with inflammatory arthritis were switched from reference product to biosimilar infliximab in 2014: 50% female, mean age 55 years (standard deviation=12.9), mean disease duration 14.79 years (9.7), median duration on infliximab 57 months, and two-thirds on oral disease-modifying antirheumatic drugs. There was no difference in efficacy or safety in the first 6 months of therapy. By the end of 2015, the mean follow-up on biosimilar infliximab was 15.8 (standard deviation=6.3) months. Our results showed no significant difference in Health Assessment Questionnaire score, patient global assessment of disease activity, number of disease flares, or the medication dose between the originator and the biosimilar infliximab. However, reported pain and C-reactive protein values were significantly higher during the longer follow-up period (p=0.043, 0.001 respectively). There was no significant difference in the number of adverse events or infusion reactions during follow-up periods. Only five (14.7%) patients discontinued the biosimilar infliximab.

Conclusion

Our patients experienced similar efficacy and safety for managing their arthritis with the biosimilar infliximab as the reference product infliximab, but at a much lower cost.

Fractured root tips during dental extractions and retained root fragments. A clinical dilemma?

Root tip fracture can occur during the extraction of teeth. The clinician must then decide to either leave the root fragment in situ, or to attempt its removal. A similar decision is made when retained root fragments are found incidentally on oral radiographs. The prevalence of retained root fragments is reported as 11-37%. This article aims to highlight the risk benefit matrix of the removal or retention of retained root fragments, in light of the present evidence base.