Comment on: NICE guidance does not tally with clinical practice--a district general experience: reply.
- SourceAvailable from: Swan Sim YeapRheumatology (Oxford, England) 09/2008; 47(11):1735; author reply 1736. · 4.24 Impact Factor
- Rheumatology (Oxford, England) 03/2008; 47(2):222-3. · 4.24 Impact Factor
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ABSTRACT: When subjects are selected on the basis of fall risk alone, therapies for osteoporosis have not been effective. In a prospective study of elderly subjects at high risk of falls, we investigated the influence of bone strength and fall risk on fracture. At baseline we assessed calcaneal bone ultrasound attenuation (BUA) as well as quantitative measures of fall risk in 2005 subjects in residential care. Incident falls and fractures were recorded (median follow-up 705 days). A total of 6646 fall events and 375 low trauma fracture events occurred. The fall rate was 214 per 100 person years and the fracture rate 12.1 per 100 person years. 82% of the fractures could be attributed to falls. Although fracture rates increased with decreasing BUA (incidence rate ratio 1.94 for lowest vs. highest BUA tertile, p<0.002), incident falls also affected fracture incidence. Subjects who fell frequently (>3.15 falls/per person year) were 3.35 times more likely to suffer a fracture than those who did not fall. Some fall risk factors such as balance were associated with the lowest fracture risk lowest in the worst performing group. Multivariate analysis revealed higher fall rate, history of previous fracture, lower BUA, lower body weight, cognitive impairment and better balance as significant independent risk factors for fracture. In the frail elderly, both skeletal fragility and fall risk including the frequency of exposure to falls are important determinants of fracture risk.Osteoporosis International 05/2007; 18(5):603-10. · 4.04 Impact Factor
Advance Access publication 30 August 2008
Comment on: NICE guidance does not tally with clinical
practice—a district general experience: reply
SIR, Many thanks for giving us the opportunity to comment on
the observations of Yeap  on our letter . His observations are
valid about BMD not being the best marker for osteoporosis. It is,
however, a flawed assumption that a prior fragility fracture is the
only marker for future fracture. We know that what is frequently
reported as a fragility fracture in the elderly might not be so .
Yeap advocates the recently published European guidance for the
management of osteoporosis in post-menopausal women, which
propose that treatment can be instigated after a fragility fracture,
with or without BMD assessment . This is pragmatic advice that
may be partly related to the limited provision of dual energy X-ray
Our data included all fragility fractures including hip, wrist,
vertebra and rib, while most of the data quoted in the literature is
based on vertebral and or hip fractures, but did not include all
Many studies have shown that BMD is still a good marker for
future fracture risk , and therefore finding a normal BMD in a
patient who has sustained a fracture should make us re-evaluate
the fracture and determine whether it was indeed low trauma.
Fractures themselves are sometimes due to a combination of
skeletal fragility and fall risk  and a possible unmeasured
confounder in our findings was fall risk. This was emphasized in
the European Prospective Osteoporosis Study . It could be
argued that falls risk should be assessed separately when new
guidelines are produced.
Disclosure statement: M.B. has received honoraria from Servier,
Proctor & Gamble and Merck and has received assistance for
attending meetings from Eli-Lilly and Novartis and funding for
rheumatology databases from Roche and Wyeth. All other
authors have declared no conflicts of interest.
S. ADIMULAM1, C. GREENBANK1, J. HALSEY1, M. BUKHARI1,2
1University Hospitals of Morecambe Bay NHS trust, The Royal
Lancaster Infirmary, Lancaster and2Clinical Sciences, University
of Liverpool, Liverpool, UK
Accepted 31 July 2008
Correspondence to: M. Bukhari, University Hospitals of
Morecambe Bay NHS trust, The Royal Lancaster Infirmary,
Ashton Road, Lancaster LA1 4RP, UK.
1 Yeap S. Comment on: NICE guidance does not tally with clinical practice—a
district general experience. Rheumatology. Advance Access published August 19,
2 Adimulam S, Halsey J, Greenbank C, Bukhari M. NICE guidance does not tally
with clinical practice—a district general experience. Rheumatology 2008;47:222–3.
3 Bergstro ¨m U, Bjo ¨rnstig U, Stenlund H, Jonsson H, Svensson O. Fracture
mechanisms and fracture pattern in men and women aged 50 years and older: a
study of a 12-year population-based injury register, Umea ˚, Sweden. Osteoporos Int
4 Kanis JA, Burlet N, Cooper C et al. European guidance for the diagnosis and
management of osteoporosis in postmenopausal women. Osteoporos Int 2008;
5 Nevitt MC, Cummings SR, Stone KL et al. Risk factors for a first-incident radiographic
vertebral fracture in women > or¼65 years of age: the study of osteoporotic
fractures. J Bone Miner Res 2005;20:131–40.
6 Sambrook PN, Cameron ID, Chen JS et al. Influence of fall related factors
and bone strength on fracture risk in the frail elderly. Osteoporos Int 2007;18:603–10.
7 Kaptoge S, Benevolenskaya LI, Bhalla AK et al. Low BMD is less predictive
than reported falls for future limb fractures in women across Europe: results from the
European Prospective Osteoporosis Study. Bone 2005;36:387–98.
Advance Access publication 2 September 2008
Comment on: Serum leptin and ghrelin correlate with
disease activity in ANCA-associated vasculitis
SIR, The results of the study by Ku ¨ mpers et al.  on leptin and
ghrelin levels in systemic vasculitis are unexpected according to
current understanding of the action of these hormones in
rheumatic disease, but all the more interesting for that reason.
However, the authors state in their discussion that serum leptin
levels are decreased in RA, in contrast to the findings they present
in systemic vasculitis. In fact, the situation is far from clear, and
the study by Popa et al. , which they quote, did not in fact find a
significant difference between RA and control subjects, but
instead did detect a negative correlation between markers of
inflammation and leptin within the RA group.
Of the nine studies (seven in English) that have examined serum
leptin levels in RA patients as compared with healthy controls
published in the last 10yrs, one found serum leptin levels to be
lower in RA, six (including Popa et al.’s study) found no significant
difference and two found higher levels. Even the correlation with
disease activity is not established; at least eight studies have found
no relationship between leptin levels and inflammatory markers in
RA, three recently published papers have actually suggested a
positive relationship [3–5] and anti-TNF-? therapy in RA appears
to leave the levels unchanged .
Leptin is a fascinating peptide, which provides a tantalizing link
between adipose tissue and inflammation. The lack of clarity even
in observational studies, however, shows just how far we have to
go to understand its role in rheumatic disease.
Disclosure statement: The author has declared no conflicts of
D. J. ARMSTRONG1
1Department of Rheumatology, Altnagelvin Hospital,
Accepted 15 July 2008
Londonderry BT47 6SB, UK. E-mail: email@example.com
1 Ku ¨mpers P, Horn R, Brabant G et al. Serum leptin and ghrelin correlate with disease
activity in ANCA-associated vasculitis. Rheumatology 2008;47:484–7.
2 Popa C, Netea MG, Radstake TR, van Riel PL, Barrera P, van der Meer JW. Markers
of inflammation are negatively correlated with serum leptin in rheumatoid arthritis.
Ann Rheum Dis 2005;64:1195–8.
3 Targon ´ska-Stepniak B, Majdan M, Dryglewska M. Leptin serum levels in rheumatoid
arthritis patients: relation to disease duration and activity. Rheumatol Int
4 Ljung L, Olsson T, Engstrand S, Wa ˚llberg-Jonsson S, So ¨derberg S, Rantapa ¨a ¨-
Dahlqvist S. Interleukin-1 receptor antagonist is associated with both lipid
metabolism and inflammation in rheumatoid arthritis. Clin Exp Rheumatol
5 Lee SW, Park MC, Park YB, Lee SK. Measurement of the serum leptin level could
6 Ha ¨rle P, Sarzi-Puttini P, Cutolo M, Straub RH. No change of serum levels of leptin
and adiponectin during anti-tumour necrosis factor antibody treatment with
adalimumab in patients with rheumatoid arthritis. Ann Rheum Dis 2006;65:970–1.
1736Letters to the Editor
by guest on October 14, 2011