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AimStress fracture aetiology is often multifactorial and laboratory blood tests (LBT) can unmask underlying metabolic bone risk factors and disorders. Coeliac disease (CD) is associated with low bone mineral density and an increased risk of fractures.1 In addition, there are rare reports of occult CD presenting with stress fractures.2 Anti-tissue transglutaminase antibody (TTG) testing has a high sensitivity and specificity for CD and is used as a screening test.3 This report examines the incidence of undiagnosed CD in patients presenting with stress fractures to a Sport and Exercise Medicine (SEM) clinic.MethodsA retrospective analysis of 100 consecutive patients with radiologically proven stress fractures presenting to a single tertiary NHS SEM clinic was performed. Age, gender, fracture site, co-morbidities, TTG result and subsequent investigations were examined. Records were reviewed to confirm LBT, including TTG, had been performed at the time of diagnosis.ResultsSeventy patients (70%) were female and mean age was 37 years (range 18–69). Metatarsal (35%) and tibial (21%) fractures were most common. TTG was performed in 85 patients. Two patients were excluded due to pre-existing CD. Five patients (5/83 (6%), mean age 38 years (28–57), 80% female) had a positive TTG; three of whom had CD confirmed by endoscopic biopsy and two are awaiting investigation. Four patients with a positive TTG underwent dual energy X-ray absorptiometry, with osteopenia (T-Score between −1.0 and −2.5) found in 75% of cases, although only one had a Z-score less than -2.0.ConclusionIn this cohort, the incidence of undiagnosed CD was between 3.6% to 6%, with a prevalence between 5% to 7%, approximately 5-fold higher than UK population estimates. We recommend that TTG screening should be performed in all patients presenting with stress fractures to identify underlying CD. Further work is required to confirm this association and elucidate potential underlying mechanisms.ReferencesHeikkilä K, Pearce J, Mäki M, et al. Celiac disease and bone fractures: a systematic review and meta-analysis. J Clin Endocrinol Metab 2015;100(1):25–34.Gilbody J, Trevett M. Coeliac disease presenting with bilateral fibular stress fractures. Foot Ankle Surg 2009;15:96–100.3. Downey L, Houten R, Murch S, Longson D, Group GD. Recognition, assessment, and management of coeliac disease: summary of updated NICE guidance. BMJ 2015;351:h4513.

Aims Economic evaluations provide a useful comparative approach for considering costs and consequences on patient outcomes, thus providing a foundation for effective policy and decision making.1 2 This descriptive review aims to better understand how economic evaluations of cardiac rehabilitation (CR) services are conducted to inform future research addressing the impact of a physical exercise component on cost-effectiveness. Methods Electronic databases were searched for economic evaluations of exercise-based CR programs published in English between 2000 and 2014. The methodological quality of included economic evaluations was reviewed using criteria taken from the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement.3 Results Fifteen economic studies met the eligibility criteria but exhibited wide variability in study perspective, time horizon, setting, comparators and included costs, with significant heterogeneity for exercise dose between interventions. Ten evaluations were based on randomised controlled trials (RCTs) with time horizons between 6–24 months, but which largely produced weak or inconclusive results. Excluding two modelling studies, only three studies utilised longer time horizons (3.5–5 years), and findings suggest exercise-based CR leads to lowered costs, reduced rehospitalisation9s and longer cumulative lifetime in the long-term. Conclusions Variability in CR program delivery and exercise dose along with weak consistency between study perspective and included costs makes it difficult to compare cost and health outcomes between studies and accumulate evidence in support of a particular exercise regime. The dominance of RCTs with their extensive patient selectivity process and exclusion of comorbid patients questions whether cost-effectiveness findings would translate to a real-world setting. The use of longer time horizons would be more compatible with a chronic condition and allow the long-term effects of exercise-based CR to be evaluated.