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CPD: Collaboration Matters: Irish DXA Annual Meeting

60 Second Summary: The recent Irish DXA Meeting themed – “Collaboration Matters” – took place at the University of Galway on May 10th and 11th with a variety of speakers from government, university staff, HIQA, China, Ireland, Taiwan, Singapore, UK, and the USA’.

The meeting was opened by Ms. Catherine Connolly. She acknowledged that Ireland has one of the highest prevalences of osteoporosis in the world and admitted that she was both startled by some of the recent figures and surprised that a national osteoporosis programme has yet to be put in place.

Mr. Fergal Lynch gave an excellent presentation on “Why Health Policy Matters” and how health policy is formed. He noted the theme of the meeting and agreed it is a critical part of the journey. He noted the Irish figures, and gave an outline of the journey for a national cancer programme and how it now delivers much better outcomes for patients but is not perfect.

Professor Gerard Boron, Tallaght University Hospital provided a brief but excellent overview of the biochemical basis of bone mineral density. He outlined the structure of bone and bone biochemistry, the factors which affect it and finished with a couple of unusual cases to highlight the clinical and biochemical assessment and some of the factors involved.

The last session of the day commenced with a presentation on the importance of the “Least significant change” (LSC) by Nurse Susan van der Kamp and what it means. In essence it is a measure of consistent, also known as the coefficient of variation with a 95% confidence interval and an important scientific step to understanding the consistency of measurements.

AUTHOR: Professor John J Carey & Dr Attracta Brennan, University of Galway

Professor John J Carey is a consultant physician in Medicine and Rheumatology, and Clinical lead in DXA, osteoporosis and fracture liaison services, at Galway University Hospitals, and Professor in Medicine at the University of Galway, Galway, Ireland.

Dr. Attracta Brennan is a lecturer in the School of Computer Science at the University of Galway. Her research interests span a number of areas, including: healthcare analytics, adaptive learning systems, game based learning, socio-technical systems to support older people, AR/VR and medical informatics.

Collaboration Matters: Irish DXA Annual Meeting

The recent Irish DXA Meeting themed – “Collaboration Matters” – took place at the University of Galway on May 10th and 11th with a variety of speakers from government, university staff, HIQA, China, Ireland, Taiwan, Singapore, UK and the USA.

The meeting was opened by Ms. Catherine Connolly, Leas Ceann Comhairle for the Dail. In a beautiful confluence of Gaeilge and English, she gave attendees a ‘céad mile failte go Gaillimh’. She acknowledged that Ireland has one of the highest prevalences of osteoporosis in the world and admitted that she was both startled by some of the recent figures and surprised that a national osteoporosis programme has yet to be put in place. She noted this disease affects around 1 in 3 women and 1 in 4 men aged 60 years and older, resulting in approximately 50,000 fractures annually. She emphasised that if we are to impact waiting times, trolley numbers and the lives of patients with this disease, then a national programme has to be a priority.

Following the address by Ms. Connolly, a patient shared her personal experience of having osteoporosis; she gave an eloquent but heart-breaking presentation titled “my story”. She recalled how she was sent to the emergency room with fractures in her back, only to be sent home ‘because there was nothing we could do’. All she was given for the pain was Panadol! She suffered needlessly for several months, and today is no longer the person she once was. She spoke about how osteoporosis doesn’t just shatter bones, it shatters lives. Despite having other illnesses, being familiar with the healthcare system and adhering very strictly to a healthy diet, regular exercise and her prescribed medication, she still ended up with eight spinal fractures. She saw an expert who noted that it was one of the worst cases that he had ever seen. She has since listened regularly to podcasts and, as a patient finds it difficult to accept that four things which could have benefitted her are not available in Galway for public patients:

  1. Shorter waiting times for MRI and DXA scans with modern technology;
  2. Access to bone turnover markers to monitor her treatment;
  3. Access to a team of experts to manage her acute fracture pain;
  4. Access to Romosozumab which is an excellent option for those who need it.

This speaker’s eloquent presentation had a profound impact on all present.

Next, Mr. Fergal Lynch gave an excellent presentation on “Why Health Policy Matters” and how health policy is formed. He noted the theme of the meeting, agreeing that it is a critical part of the journey. He discussed the Irish statistics, and outlined the journey in the development of a national cancer programme, which now delivers much better outcomes for patients, although it is not perfect. He emphasised the importance of working together, speaking to politicians and understanding their priorities, in addition to involving patients, researchers as well as expert clinicians and health professionals. He highlighted the critical role of the patient voice in driving changes and the value of international expertise and experience in leading to change.

Mr. Lee O’Hora from HIQA followed, outlining the role of HIQA in ensuring compliance with regulations for the use of ionizing medical radiation. He gave a very clear and concise overview of the regulations, the responsibilities of those undertaking procedures and the role of HIQA He explained to the audience that he was not there to punish people but to ensure that inspected organisations had clear policies and practices in place in order to adhere to the legislation thereby protecting patients and with respect to DXA, the staff and members of the public, although this would fall under the E.P.A. in many instances. He stressed that he was very impressed overall with the processes and the level of dedication he encountered, praising many of the excellent services which are in place. He also highlighted some concerns where further clarity is desirable with regard to legislation, policy and practice. He provided an excellent overview of what they look for during inspections, and how to prepare for one should one be forthcoming. He also stressed how they welcome active engagement, feedback and discussion to protect patients and promote safe practice.

The next session featured four international panellists answering questions about the process and significance of the Position Development Conference (PDC) of the International Society for Clinical Densitometry (ISCD). The panellists were:

  1. Prof. Andrea Singer, USA, 2023 ISCD PDC Expert Panellist and medical director of the National Bone Health Alliance, USA;
  2. Prof. Bobo Tanner, USA, Past-President ISCD, Writing Committee member for The ISCD Osteoporosis Essentials / Bone Densitometry Course;
  3. Prof. Manju Chandram, Singapore, 2023 ISCD PDC Expert Panellist and board member of the International Osteoporosis Foundation.
  4. Prof. Wing Chan, Taiwan, Chair of the ISCD Scientific Advisory Committee, dual trained as an osteoporosis physician and musculoskeletal radiologist.

These experts reviewed the PDC process from the selection of topics to be considered, the extensive reviews of the literature, the work of each team on their individual sections, the voting system to either accept, reject or reconsider the proposed position and the final day of ‘word-smithing’ to use the most appropriate language to ensure that the positions were useful to a global audience. Prof. Carey chaired the session and pointed out that most Irish people would never attend an ISCD PDC and so thanked the panellists for their insights. He also noted that some Irish people perceive these to be “American” guidelines and wondered whether the expert panel agreed or not. The panel emphasised that the teams were composed of experts from around the world, including; Australia, Brazil, Canada, Ireland, Israel, Lebanon, Singapore and of course the USA. They also noted that the positions are as relevant globally as they are in the USA, despite differences in the availability and quality of services across the globe. Prof. Chandran highlighted that Pakistan, a country which is larger than any European country, has only one DXA centre. The experts agreed that local applicability must be considered for all official positions and that in some cases, where there is limited evidence to support or refute a position, a consensus of experts can be very helpful.

Following a short break, Mr. O’Hora again returned to the stage and gave an overview of national audit guidelines published by HIQA in the past year. While these guidelines are new and at the moment are not mandatory, they will be enforced by the end of the year with HIQA requiring every centre to actively perform audits and engage at all levels of their corporation or institution. Mr. O’Hora pointed out that further details are available on the HIQA website, which also offers an excellent overview of what auditing entails and how it promotes and supports safe practice.

Prof. Gerard Boron from Tallaght University Hospital then delivered a brief but excellent overview of the biochemical basis of bone mineral density. He explained the structure and biochemistry of bone and the factors which affect it. He also presented a number of unusual cases to highlight the clinical and biochemical assessment in addition to some of the other factors involved. His review was welcomed by many engaged in clinical practice for a long time, who might not frequently think about some of the more fundamental biochemical and structural aspects of bone disease.

Prof. Wing Chan gave a fantastic overview of vertebral fractures, their importance and their diagnosis. He pointed out that all diagnostic methods have limitations but highlighted how a combined approach could help close the diagnostic gap. He reviewed methods such as the Genant deformity scale and the Yoshida criteria in addition to some cutting edge artificial intelligence driven solutions which are currently attracting a lot of interest.

Following this, Prof. Bobo Tanner took the audience on a journey through the diagnostic approaches used for diagnosing osteoporosis or assessing bone strength. Prof. Tanner covered everything from pre-DXA non-invasive methods, to bone biopsy, engineering laboratories testing mechanical strength and resistance to indentation to state of the art imaging such as virtual bone biopsy and the use of CT and MRI for opportunistic screening. He discussed some of the strengths and limitations of these methods, providing a comprehensive overview of a very complex field with a brief synopsis of each method. Although DXA remains the primary tool in the Republic of Ireland for osteoporosis diagnosis, it is clear there are other options, some of which may have distinct advantages in specific situations although no one solution or alternative is ideal to date.

The session closed with two brief presentations from Irish researchers. First, Dr. Louise Horrigan from the University of Galway presented her findings on using bioimpedance to assess bone strength, noting that future work is needed to correlate these results with DXA or some other gold standard. Prof. Carey then presented the results of the HRB funded DXA-MAP project demonstrating how a new screening tool has the ability to identity healthy men and women most likely to benefit from a DXA test. This tool has the potential to reduce waste by eliminating unnecessary testing in healthy people less likely to benefit, while also identifying those most likely to have osteoporosis who should be tested.

The afternoon session commenced with an excellent overview of the need for, and principles of modern treatment algorithms by Prof. Andrea Singer. She highlighted a paradigm shift whereby it is now clear that those deemed at very high or imminent risk of fracture are most likely to benefit from osteoanabolic therapy. Importantly, she also pointed out that evidence now shows that such therapy has a greater impact if used before rather than after anti-resorptive therapy. Prof. Singer concluded by stating that all osteoporosis medications are effective, and that individual treatment decisions should be made in consultation with the patient taking into account their concerns, wishes and abilities.

Findings from our most recent 2022 census reveal that almost 1 in 5 residents of Ireland were born abroad. This raises the complexity of understanding medical care and assessment. Professor Manju Chandran reviewed the differences between social constructs such as ‘race’ and ‘ethnicity’ and societal norms and cultural issues. She highlighted their importance for understanding both bone mineral density and fracture risk and gave examples of where she works and resides i.e. “The little Red Dot” Singapore, which has a complex multi-ethnic society. She noted there is an ‘Irish’ community there (a ‘little green dot’) who likely differ in bone content and fracture risk compared to indigenous Asian citizens. Despite some clear scientific data, she pointed out the scientific controversies and complexities that arise, especially when considering people of ‘mixed race’ and those who are immigrants in other countries.

Professor Sansin Tuzun reviewed the principles behind the rehabilitation of osteoporotic patients, both with and without fractures. She highlighted key elements which are often not available for Irish patients, including counselling on nutrition, core strengthening and correct posture maintenance, weightbearing exercises, adequate pain control and when needed, osteoporotic medications. She also discussed the limited evidence supporting the use of certain back braces, noting that while some may be helpful in specific circumstances, many are not and/or are too cumbersome for patients to utilise. She reviewed many of these areas which are covered in detail in a recent paper of the Rehabilitation Working Group of the International Osteoporosis Foundation.

Nurse Catherine Armstrong from Galway University Hospital emphasised the importance of DXA in fracture liaison services for patients and healthcare professionals looking after them. She explained how once patients have sustained a fracture, osteoporosis is the likely, diagnosis and DXA measurement of BMD is crucial for assessing prognosis and monitoring treatment. She pointed out that there was much more to DXA than measuring BMD; it includes vertebral fracture assessment technology which can impact management decisions. Also, it serves as another healthcare visit for patients to receive education and discuss their concerns, often helping to bridge the gap between ’what the doctor said’ and what the patient understands. The final session of the day began with a presentation by Nurse Susan van der Kamp on the importance of the “Least significant change” (LSC) and what it means. She explained that LSC is a measure of consistency, also known as the coefficient of variation with a 95% confidence interval; it is an important scientific step to understanding the consistency of measurements. She emphasised that using the manufacturer’s LSC is not recommended as it is only one of four factors that affect the true value. Random error, patient factors and the scanning health professional factors also affect the measurement, underscoring the need for a scientific approach. She pointed out that repeat DXA scans have no proven value in the absence of a known LSC for that DXA machine in that centre, and ideally for each individual involved in scanning patients.

Ms. Ciera O’Reilly followed with a review of their experience in establishing the LSC for their centre, which is a new DXA facility for their institution. She detailed their protocol and how they used the ISCD calculation tool to generate their values. She reiterated that this metric is essential if patients are to have a follow-up scan.

Dr. Eithne Murphy then reviewed the risk of systemic and periarticular bone loss in rheumatic diseases, in particular rheumatoid arthritis. She highlighted that all rheumatic illnesses are associated with a substantially higher risk of fracture compared to the general population. She also noted that not only are these patients at greater risk of losing bone strength but they are also are at greater risk of losing muscle strength and balance due to their underlying arthritis or concomitant use of some medications such as corticosteroids. Dr. Murphy made some general recommendations to assess the bone health and fall risk of all patients with rheumatic diseases and advised consideration of whether risky treatments like corticosteroids are necessary when assessing them.

Finally, the evening finished on a lighter note when Dr. Attracta Brennan showcased Tik Tok videos created by her university students to explain why Humpty Dumpty had osteoporosis and how it affected him. Given the excellent presentations earlier in the day, which highlighted the need for clear and appropriate communication, the use of Tik Tok videos created by non-medical 20-21 year old undergraduate students was seen as an excellent way to help nonmedical individuals understand the significance of bone health. Although it was difficult to choose a winner from several outstanding videos, conference attendees awarded the top prize to a student who not only provided an excellent story outlining why poor old Humpty Dumpty ‘with bones like that never stood a chance’ accompanied by amazing graphics. Other students unpicked the biases in the nursery rhyme questioning why people thought Humpty Dumpty was an egg when he was in fact, a man with osteoporosis. A number of Tik Tok videos featured fantastic rhyming stories and graphical illustrations comparing the difference between falling with healthy bones (or egg-shells) to falling with osteoporosis.

Day two commenced with a brief review of all the society’s activities and some challenging clinical cases that built on some of the principles discussed on the first day. This session prompted pertinent questions and lively discussions. Dr. Erjiang E, from China, then presented his study on the sensitivity, specificity and accuracy of DXA for diagnosing osteoporosis in Irish adults. His extensive analysis showed that there is a considerable range in these values depending on : age, gender, site of BMD measurement and site of skeletal fracture. These factors must always need to be considered when performing any test. For the first time, we have some robust Irish data from thousands of people both with and without fractures.

Next, Dr. Emerald House, Medical physics, Galway University Hospital provided an excellent pre-recorded review of ‘Diagnostic Related Levels’ (DRLs). This presentation helped attendees understand the various ionizing radiation exposures associated with DXA, how these exposures compare to the general environment and other imaging modalities, and the purpose of DRLs. Dr. House clearly explained how DLRs are calculated, their significance and how, like LSC, they are important for understanding the ALARA principle and best practice when it comes to justification for medical ionizing radiation.

Dr. Nicola Crabtree (a lecturer in the first ISCD paediatric course 16 years ago) then reviewed some of the complexities of scanning paediatric patients. She provided some updates on current ISCD positions and practices and reviewed the complexities with some case examples. She emphasised that DXA in children is complex and should not be undertaken by those unfamiliar with the field. The performance and interpretation of these scans is more challenging than in adults in many situations, but can be extremely helpful when performed and interpreted correctly by the right people for the right reasons. She noted that some complex issues in paediatric DXA remain evolving and, similar to adult cases, have certain limitations.

The conference concluded with several workshops and discussion groups. These focussed on manufacturer specific considerations for GE and Hologic DXA systems – the two most common DXA systems in use in Ireland. Led by Irish experts: Ms. Bridie Rooney and Ms. Catherine Corry for G.E. Lunar and Ms. Susan van der Kamp for Hologic, these sessions featured lively discussions with plenty of questions and answers. They provided DXA users, who often operate in remote or single person locations, a chance to discuss any concerns or ask necessary questions. Following these, workshops run by GP and Hospital units that have already undergone HIQA inspections, helped attendees understand the inspection process, how to organise and present their working practices and standard operating procedures to help them prepare for future inspections.

Note: A booklet was provided to the attendees courtesy of the Irish DXA MAP team highlighting several key statistics related to DXA and Osteoporosis in Ireland: References:

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