Improving trends in glucocorticoid-induced osteoporosis management: 2002 to 2006

OBJECTIVE

In 2002 we undertook an audit of GIO (glucocorticoid-induced osteoporosis) management in the outpatient clinics of our university teaching hospital and found a wide variation in practice and considerable under-treatment of patients. We re-audited our practice in 2006.

METHODS

A retrospective chart audit was undertaken over a 4-month period of 3,475 patients attending the 3 medical specialty outpatient clinics that were originally audited in 2002. All glucocorticoid (GC) users over the past 6 months were identified. Demographic data and treatment details were extracted, and findings were compared with the previous audit.

RESULTS

Two hundred and fifty-three (7%) patients were identified to be taking GC vs. 104 (2%) in 2002. GIO risk was documented in 71% (179) (p < 0.001) of the charts vs. 13% (19) in the previous audit. In 2002, 56% (58) were on some form of bone protection [53% (55) on Ca/vitamin D and 29% (30) on a bisphosphonate] whereas in 2006 the figures were 86% (219), 82% (207) and 57% (144), respectively. DXA scanning was performed in 32% (82) of our patients in 2006. Nonetheless, considerable variation in practice was still seen, with prescription rates for anti-resorptive therapy varying from 24%-70% and those for Ca/vitamin D supplements ranging from 15%-95% for different services. For the highest risk patients, the prescription rates by specialty ranged from 36%-72% for anti-resorptive therapy and 76%-95% for Ca/vitamin D supplements.

CONCLUSION

Over 4 years, major improvements in GIO management have taken place in our institution, with almost a doubling of the prescription of bone protectants. However, there still remains a considerable variation in individual practices and an under-utilisation of DXA scanning. We believe that these overall, encouraging findings can be generalized to similar institutions elsewhere.

AA amyloidosis in psoriatic arthritis

BACKGROUND

Amyloidosis is an extremely rare complication of psoriatic arthritis (PsA) and is associated with a poor prognosis. We report a case of amyloidosis secondary to severe PsA in a young patient and the course of his disease over a 13-year period of aggressive immunosuppression.

METHODS

Diagnosis of renal amyloidosis was made on biopsy: multi-agent immunosuppressive therapy was continued with stabilisation of renal function.

RESULTS

Marked deterioration in renal function subsequently occurred following a reduction in cyclosporin A (CyA) dose and repeat biopsy confirmed worsening amyloidosis.

CONCLUSION

This case report emphasises the need for aggressive control of the inflammatory response in secondary amyloidosis.

Current management of corticosteroid-induced osteoporosis: variations in awareness and management

BACKGROUND

Guidelines for the prevention of corticosteroid-induced osteoporosis (CIO) have been widely published. There are no guidelines on the use of gastro-protectants with corticosteroids (CS).

AIMS

To determine whether patients receiving CS therapy are evaluated and treated for osteoporosis risk, how management varied by steroid dose and diagnosis, and how many patients received gastro-protection.

METHODS

A retrospective audit of 4,350 patients presenting to four medical specialities.

RESULTS

One hundred and fifty-one patients prescribed CS were identified. Indications for CS therapy included renal transplantation (32%) and asthma/respiratory diseases (23%), inflammatory arthritis/vasculitis (32%) and inflammatory bowel disease/auto-immune hepatitis/other (13%). Risk of osteoporosis was mentioned in 13% of charts. The prescription rates for bone protection agents varied from 69% to 4% according to the medical speciality attended. Gastro-protectants were prescribed for 44% of patients.

CONCLUSION

There are large variations among medical specialties both in the prescription of gastro-protectant agents and in the use of measures to prevent CIO. Simpler guidelines could facilitate rational prescribing in these patients.

Forefoot deformity, pain, and mobility in rheumatoid and nonarthritic subjects

OBJECTIVE

To evaluate how painful metatarsal arthritis affects foot and ankle mechanics and mobility.

METHODS

We studied 16 symptomatic forefeet in 10 patients with rheumatoid arthritis (RA) and compared them with 14 asymptomatic forefeet in 7 nonarthritic subjects. RA limbs with significant disease at other locations were excluded. We measured pain and deformity of the foot using a visual analog scale and a modified articular index. A video based 3 dimensional gait analysis system and force platform were used to collect data on subjects walking barefoot at a self-selected pace according to an established protocol. Mobility level was quantified using the Sickness Impact Profile (SIP) ambulation subscale.

RESULTS

We observed considerable pain and deformity of the forefeet of RA subjects. During gait, motion and force measures revealed that RA subjects significantly (p < 0.005) delayed and reduced forefoot loading, which minimized use of the foot as a rigid level for push off. As a result, stride lengths were shorter and gait was slower compared to nonarthritic subjects. SIP scores revealed that these changes in gait resulted in moderate disability in RA subjects (p=0.05).

CONCLUSION

Impairments of the forefoot due to RA include pain and deformity, which produce characteristic stance phase abnormalities in foot function, a slow walking speed, and moderate disability.

A technique to evaluate foot function during the stance phase of gait

A technique to measure foot function during the stance phase of gait is described. Advantages of the method include its three-dimensional approach with anatomically based segment coordinate systems. This allows variables such as ground reaction forces and center of pressure location to be expressed in a local foot coordinate system, which gives more anatomical meaning to the interpretation of results. Application of the measurement technique to case examples of patients with rheumatoid arthritis demonstrated its ability to discriminate normal from various levels of pathological function. Future studies will utilize this technique to study the impact of pathology and treatment on foot function.

Arthritis in patients with psoriasis treated with gamma-interferon

We observed 3 patients with psoriasis who developed arthritis during treatment of psoriatic skin disease with intramuscular recombinant human gamma-interferon (IFN-gamma). Symptoms primarily involved the hands, feet, shoulders, and neck. One patient had acute plantar fasciitis. Routine laboratory studies were unrevealing. Patients presented with symptoms initially between the 10th and 12th weeks of treatment and the arthritis resolved after cessation of IFN-gamma. One patient was subsequently retreated with IFN-gamma for 4 weeks and had a temporary recurrence of arthritis with an associated rise and fall of his articular index.

Rehabilitation dimensions of AIDS: a review

With the spread of human immunodeficiency virus (HIV) infection and of the acquired immune deficiency syndrome (AIDS), many rehabilitation professionals are faced with new challenges. This report covers two basic problems that are becoming common in rehabilitation practice: the management of the patient who suffers from disability resulting from HIV infection or AIDS, and the management of the traditional rehabilitation patient who may coincidentally be infected with HIV. Common manifestations of HIV infection and associated secondary infections and neoplasms are discussed, as well as are the complications of current medical treatments. This report also explores specific neurologic and musculoskeletal disorders and the fatigue associated with AIDS. In addition, potential approaches to rehabilitation management are evaluated, and consideration is given to the management of the asymptomatic HIV carrier. The differences between HIV infection in adults and children are explored, and the social implications of HIV rehabilitation are discussed. After consideration of the basic pathophysiology of infection and the modes of transmission, the significance and ethics of serologic testing are examined, and the concept of universal precautions is described. The paper concludes with a discussion of the use of safe sex practices by the disabled population.

Experience with rehabilitation in the acquired immunodeficiency syndrome

Patients with the acquired immunodeficiency syndrome (AIDS) represent a novel referral population for rehabilitation services. Limited information about the rehabilitation needs of individuals with human immunodeficiency virus infection is available. We reviewed 51 consecutive patients with AIDS referred to a rehabilitation consult service. Common problems encountered included generalized deconditioning (27%) and neurologic dysfunction (45%). Neurologic presentations were diverse and included hemiparesis, diffuse cognitive dysfunction and dementia, myelopathy, myopathy and peripheral neuropathy. Other patients were referred for wound care as well as the management of the local effects of Kaposi's sarcoma, various musculoskeletal syndromes and new onset blindness. Problems identified included impaired mobility (76%), difficulty with self-care (57%), impaired cognition (29%) and uncontrolled pain (37%). Among the rehabilitation interventions utilized were therapeutic exercise (73%), gait aids (45%), bathroom and safety equipment (45%), orthotics (29%), vocational counseling (4%), pain management (29%) and whirlpool treatments (10%). Five patients were too ill or refused treatment. We conclude that AIDS patients referred for rehabilitation have a wide variety of physical deficits, demonstrate a considerable degree of functional impairment and may require multiple rehabilitation interventions.

AIDS

This chapter gives a concise overview of the Acquired Immunodeficiency Syndrome (AIDS), with special emphasis on clinical aspects relevant to rehabilitation professionals. AIDS is a novel form of an acquired immune deficit now known to be caused by the recently recognized Human Immunodeficiency Virus (HIV). Symptoms result from the direct effects of the virus on the immune system and the nervous system, which appear to be the primary targets. Much of the morbidity and mortality, however, is caused by opportunistic infections which occur in patients unable to mobilize the appropriate immune defenses against them. Characteristic, but previously rare, neoplasms also occur due to a failure of immune regulation. Improved medical care, however, has changed AIDS from a rapidly fatal disease to one where survival may be prolonged. The rehabilitation setting, the physical disability caused by AIDS, along with the psychosocial and economic impact of the disease on the patient have become increasingly important. Fatigue, decreased endurance, weight loss, edema, blindness and swallowing difficulties may all contribute to functional impairment. Neurological involvement is frequent and may cause dementia, hemiplegia, spastic paraparesis, painful neuropathies and proximal or distal muscle weakness. The clinical features and functional impact of these symptoms on the patient with AIDS is discussed, and the appropriate rehabilitation interventions outlined. Psychosocial and vocational issues are addressed as they pertain to the different clinical presentations.

The relationship of pain and deformity of the rheumatoid foot to gait and an index of functional ambulation

We evaluated the relationships among pain, structural deformity of the foot, 4 variables of gait, and an index of functional ambulation in 31 patients with rheumatoid arthritis. We saw significant correlations between the ambulation index and all gait variables (p less than 0.005). For the group as a whole, pain in the foot did not correlate with structural deformity. However, when patients were grouped according to the relative preponderance of pain or deformity and duration of disease, we found correlations between the sites of pain and deformity. Pain in the lower extremity, and the knee or hindfoot separately, showed correlations with functional ambulation. Foot deformity did not correlate with functional ambulation at all. Foot pain correlated well with velocity and especially stride length (p less than 0.005), and not as well with cadence and double stance time. Fewer correlations were seen between foot deformity and gait. In general, hindfoot disease was associated with greater impairment of gait and mobility than forefoot disease.

Fistulous rheumatism

Fistulous rheumatism is an unusual complication of rheumatoid arthritis. We have reported the first case of fistulous rheumatism to involve a major joint and have reviewed the literature on this subject.

Coexistent gout and septic arthritis: a report of two cases and literature review

Two cases of coexistent gout and septic arthritis are presented. The known increased incidence of joint injections in patients with rheumatoid arthritis is contrasted with the relative rarity of this complication in persons with gouty arthritis. The reason for this dichotomy is not clear but it is suggested that an important factor may be the more episodic nature of the gouty process. For patients presenting with acute arthritis the possible concurrence of sepsis and gout should be considered.