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Background Care givers of Palliated patients are at risk of adverse physical, psychosocial and emotional sequelae in varied nature. Efficient and valid assessment tools facilitate early detection to take corrective measures. The Modified Caregiver Strain Index (MCSI), composed of domains associated with caregiver strain is a simple and brief tool that can be used in both clinical and field settings. This study aimed to adapt and validate this in order to cater effective palliative care services in Sri Lanka. Methods After cross-cultural adaptation, 200 primary caregivers in 3 teaching hospitals were recruited. The internal consistency, item-total correlations, of the 13-item S-MCSI were performed. The criterion validity was assessed by Pearson correlation between the total scores of S-MCSI, the Karnofky Performance Scale and the Barthel index. Construct validity was determined by the principal component analysis keeping the Varimax with Keiser normalization as the rotation method. The Kaiser-Meyer-Olkin test (KMO) and Bartlett’s test of sphericity statistics were also performed to determine the adequacy of the sample and correlations between items, respectively. The number of factors was determined by the Scree plot, percentage of variance explained by each component and number of Eigen values over 01 (Kaiser-Guttman rule). Results The total MCSI score ranged 0 to 26. The overall Cronbach’s alpha of the 13-item questionnaire was 0.80 while item-total corrections ranged 0.34 to 0.62, exception of one item (0.11). Inverse correlations were demonstrated in total scores of MCSI and Karnofky Performance Scale (r =- 0.32, p < 0.001) and Barthel index (r =-0.34, P < 0.001). A Kaiser-Meyer-Olkin value of 0.79 (p < 0.001) for Bartlett’s test indicated adequate sampling and nonlinearity of factors. The Scree plot showed a three-factor structure explaining 57% of the variation. Items regarding personal wellbeing of caregiver loaded together while the effects on the family loaded separately. Adjustment of personal concerns and family issues along with time alteration grouped as the third factor. Conclusions The study showed that the Sinhala version of MCSI has adequate psychometric properties and reliability to be used as a validated tool to estimate the caregiver burden within a short time period for any health care workers.

Summary This paper provides a framework for the development of national guidelines for the management of glucocorticoid-induced osteoporosis in men and women aged 18 years and over in whom oral glucocorticoid therapy is considered for 3 months or longer. Introduction The need for updated guidelines for Europe and other parts of the world was recognised by the International Osteoporosis Foundation and the European Calcified Tissue Society, which set up a joint Guideline Working Group at the end of 2010. Methods and results The epidemiology of GIO is reviewed. Assessment of risk used a fracture probability-based approach, and intervention thresholds were based on 10-year probabilities using FRAX. The efficacy of intervention was assessed by a systematic review. Conclusions Guidance for glucocorticoid-induced osteoporosis is updated in the light of new treatments and methods of assessment. National guidelines derived from this resource need to be tailored within the national healthcare framework of each country.

SummaryGuidelines for doctors managing osteoporosis in the Asia-Pacific region vary widely. We compared 18 guidelines for similarities and differences in five key areas. We then used a structured consensus process to develop clinical standards of care for the diagnosis and management of osteoporosis and for improving the quality of care.PurposeMinimum clinical standards for assessment and management of osteoporosis are needed in the Asia-Pacific (AP) region to inform clinical practice guidelines (CPGs) and to improve osteoporosis care. We present the framework of these clinical standards and describe its development.MethodsWe conducted a structured comparative analysis of existing CPGs in the AP region using a “5IQ” model (identification, investigation, information, intervention, integration, and quality). One-hundred data elements were extracted from each guideline. We then employed a four-round Delphi consensus process to structure the framework, identify key components of guidance, and develop clinical care standards.ResultsEighteen guidelines were included. The 5IQ analysis demonstrated marked heterogeneity, notably in guidance on risk factors, the use of biochemical markers, self-care information for patients, indications for osteoporosis treatment, use of fracture risk assessment tools, and protocols for monitoring treatment. There was minimal guidance on long-term management plans or on strategies and systems for clinical quality improvement. Twenty-nine APCO members participated in the Delphi process, resulting in consensus on 16 clinical standards, with levels of attainment defined for those on identification and investigation of fragility fractures, vertebral fracture assessment, and inclusion of quality metrics in guidelines.ConclusionThe 5IQ analysis confirmed previous anecdotal observations of marked heterogeneity of osteoporosis clinical guidelines in the AP region. The Framework provides practical, clear, and feasible recommendations for osteoporosis care and can be adapted for use in other such vastly diverse regions. Implementation of the standards is expected to significantly lessen the global burden of osteoporosis.

Introduction/objectivesPsoriatic arthritis (PsA) occurs in one-third of patients with psoriasis and mostly remains undetected leading to debilitating deforming arthritis, eventually. The Psoriasis Epidemiology Screening Tool (PEST) is a quick and valid tool, widely used to detect PsA in clinical practice, and it has been validated to many languages. In this study, we intended to validate a Sinhala version of the PEST and assess its psychometric properties.MethodsThe Sinhala version of the questionnaire was tested on 199 patients with psoriasis attending the dermatology clinic at a tertiary care National Hospital in Sri Lanka. Patients who were detected to have PsA previously (n = 5) and those with other rheumatologic conditions (n = 12) were excluded. All patients were examined by a dermatologist, and demographic and disease characteristics were obtained. All patients were assessed by two rheumatologists who were blinded to the answers provided in the questionnaire. The diagnosis of PsA was made based on the CASPAR criteria.ResultsWe observed the total PEST score of 3 or more to be the best cutoff value to screen for PsA. This cutoff value showed the highest Youden index (sensitivity = 0.89, specificity = 0.95). In the ROC analysis, the area under the curve of the PEST_sv was 0.95 (SE 0.02, p < 0.001). PEST_sv total score showed a significant correlation with body surface area involved but not with Dermatology Life Quality Index or Psoriasis area and severity index score.ConclusionThe Sinhala version of PEST demonstrated satisfactory performance as a screening tool for PsA.Key Points• Psoriatic arthritis (PsA) is the most debilitating complication of psoriasis and lack of quick, valid screening tool is a limiting factor for early identification in Sri Lankan context.• Sinhala version of the Psoriasis Epidemiology Screening Tool (PEST_sv) was tested on 199 patients with psoriasis and examined for the diagnosis of PsA according to Classification of Psoriatic Arthritis (CASPAR) criteria.• PEST_sv score of 3 or more was observed to be the best cutoff value to screen for PsA with sensitivity and specificity of 0.89 and 0.95 respectively.• PEST_sv demonstrated satisfactory performance as a screening tool for PsA.

Background: Despite different management strategies, progression of proteinuria occurs in a sizable category of patients with diabetic nephropathy (DN). Increase in serum renin levels induced by the renin-angiotensin system (RAS) may contribute to this. Vitamin D therapy is found to have an inhibitory effect on the RAS. We aimed to study the effects of Vitamin D therapy on renal functions of patients with DN. Methods: This was a double-blind, randomized, placebo-controlled study. Patients with DN (urinary albumin [UA] >30 mg/g of creatinine) whose estimated glomerular filtration rate (eGFR) was more than 30 mL/min were selected and their plasma renin, parathyroid hormone, serum Vitamin D, serum calcium, serum creatinine, fasting blood sugar were done as baseline measurements. Subjects were randomized into two groups and treatment group was given Vitamin D, 50000 IU (0.25 ml) intramuscularly (IM) monthly for 6 months; control group received distilled water IM. Investigations were repeated after 6 months of therapy. Results: Of 155 patients invited, 85 were randomly assigned to two groups. After 6 months, mean reduction of UA to creatinine ratio in the treatment and control group was 51.8 mg/g (95% confidence interval [CI]; 66.1-−37.5, P ≤ 0.001); 22.4 mg/g (95% CI; −45.7-0.8, P = 0.06), respectively (between group difference P = 0.001). Significant increase in the eGFR observed in the treatment group while eGFR remained unchanged in the control group (P = 0.03 for the between-group difference). Mean reduction in plasma renin in treatment group and control group was 5.85 pg/mL (95% CI; −6.7-−4.6) (P < 0.001) and 0.95 pg/mL (95% CI; −1.4-−0.14, P = 0.02), respectively. Conclusions: Vitamin D 50000 IU given IM monthly for 6 months reduces urine albumin, serum creatinine, and renin levels in patients with DN.

Summary This pilot audit explored how bone health is assessed patients with diabetes in diverse centres across Asia. Only 343 of 1092 (31%) audited patients had a bone health assessment, 27% of whom were diagnosed with osteoporosis. Quality improvement strategies are needed to address gaps in patient care in this area. Purpose The Asia Pacific Consortium on Osteoporosis (APCO) Framework outlines clinical standards for assessing and managing osteoporosis. A pilot audit evaluated adherence to clinical standard 4, which states that bone health should be assessed in patients with conditions associated with bone loss and/or increased fracture risk; this report summarises the audit findings in patients with diabetes. A secondary aim was to assess the practicality and real-world use of the APCO bone health audit tool kit. Methods Eight centres across Asia participated in the pilot audit, selecting diabetes as the target group. Participants reviewed their practice records for at least 20 consecutively treated patients with the target condition. Questions covered routine investigations, bone health assessment, osteoporosis diagnosis, and patient referral pathways. Data were summarised descriptively. Results The participants represented public hospitals, university medical centres, and private clinics from India, Malaysia, Pakistan, Singapore, Taiwan, and Vietnam that see an estimated total of 95,000 patients with diabetes per year. Overall, only 343 of 1092 audited patients (31%) had a bone health assessment. Osteoporosis was subsequently diagnosed in 92 of 343 (27%) patients. Conclusion Bone health was not assessed in most patients with diabetes. The results provide insight into current practices across diverse Asian centres and demonstrate the practical value of the audit tool kit. Participant feedback has been used to improve the tool kit. Results of this pilot audit are being used in the respective centres to inform quality improvement projects needed to overcome the gap in patient care.

Introduction. This study examined the validity of the 5-item Barthel index for use as a rapid screening tool in a busy clinical setting to detect elderly patients with physical dependence. Method. A consecutive series of 68 men and 34 women aged >65 years who presented with a non-acute medical illness were included. The 5-item Barthel index was administered by intern medical officers. After 48 hours, patients were reassessed using the 10-item Barthel index as the reference by a blinded assessor. The validity of the 2 assessments was analysed using the Pearson correlation. The positive likelihood ratio for different cut-off values of the 5-item Barthel index was examined. Results. The 5-item and 10-item Brathel index scales were highly correlated (r=0.9, p<0.001). In the receiver operating characteristic analysis, the 5-item scale predicted self-reported dependence (<80 in the 10-item scale) with an area under ROC curve of 0.94 and a standard error of 0.024. Conclusion. The 5-item Barthel index can be used as a rapid screening tool to detect elderly patients with physical dependence. It can be easily administered during recording of medical history.

Studies on body composition and its determinants among SLE patients are limited. Estimation of body composition, analysis of determinants and associations of different body compartments are important in planning long-term care of these patients. The aim of the study was to identify the changes in body composition among SLE patients and assess the effect of corticosteroid use, patient and disease-related variables on body composition. We compared lean mass, fat mass, bone mineral density (BMD), and bone mineral content (BMC) determined by dual-energy x-ray absorptiometry technology, in a group of premenopausal women with SLE (n = 27) and an age-matched healthy group of women (n = 27). The median (IQR) duration of SLE was 3 (2-5) years while median (IQR) duration and dose of prednisolone therapy were 108 (88 − 172) weeks and 9730 (6160−15360) mg, respectively. No significant difference was observed in body mass index (BMI) or total fat mass between the two groups. SLE patients, however, had significantly lower lean mass (p < 0.001), BMD (p < 0.001) and BMC (p < 0.005) than healthy controls. Among cases, compared with lean mass, total body fat content showed stronger associations with total body BMD (r = 0.49, p < 0.01) and total body BMC (r = 0.63, p < 0.01). When a stepwise regression model was fitted, lean mass among controls and total fat mass among cases emerged as the best predictors of BMC/BMD. No significant correlations were found between the disease duration or cumulative glucocorticosteroid dose and total body BMD, total body BMC, lean mass or total fat content in SLE patients.

The association between respiratory function and bone mineral density (BMD) among women living in the community has been reported previously. We examined the association between forced expiratory volume in 1 s (FEV(1)) and BMD measured at hip using dual-energy X-ray absorptiometry in a group of 947 men (aged 65 to 76 years) recruited from general practice age-sex registers in Cambridge between 1991 and 1995. A positive and significant correlation was seen between FEV(1) and BMD measured at total hip, femoral neck, and trochanter. A unit change (1 l) in FEV(1) was associated with a change of BMD by 0.019, 0.017, and 0.026 g/cm(2) in the total hip, femoral neck, and tochanteric region, respectively. These associations were independent of possible confounding factors such as age, height, weight, smoking habit, major disease prevalence, and medications, which might affect bone metabolism. In categorical analyses, the highest BMD was seen in the highest FEV(1) quartile, while the lowest BMD was seen in the lowest FEV(1) quartile. This pattern was seen in all three skeletal sites and was independent of covariates listed above. Compared with the bottom FEV(1) quartile, mean hip BMDs in the top quartile were 2-3.5% higher. The exact mechanism of this association is not clear to us. One plausible explanation is that respiratory function and bone health both reflect common but as yet unknown determinants.