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Osteoporotic fractures are a common and serious health problem for older adults living in nursing homes (NHs). Risk of fracture increases with age and dementia status, yet gaps in evidence result in controversies around when to start and stop treatment for osteoporosis in NH residents, particularly those who have high fracture risk but have limited life expectancy. In this article, we discuss these areas of controversy. We provide an overview of current guidelines that explicitly address osteoporosis treatment strategies for NH residents, review the evidence for osteoporosis medications in NH residents, and use these sources to suggest practical recommendations for clinical practice and for research. Three published guidelines (from the United States, Canada, and Australia) and several studies provide the current basis for clinical decisions about osteoporosis treatment for NH residents. Practical approaches may include broad use of vitamin D and selective use of osteoporosis medication based on risks, benefits, and goals of care. Clinicians still lack strong evidence to guide treatment of NH residents with advanced dementia, multimorbidity, or severe mobility impairment. Future priorities for research include identifying optimal approaches to risk stratification and prevention strategies for NH residents and evaluating the risk-benefit profile of pharmacologic treatments for osteoporosis NH residents across key clinical strata. In the absence of such evidence, decisions for initiating and continuing treatment should reflect a patient-centered approach that incorporates life expectancy, goals of care, and the potential burden of treatment.

Summary Background Self-reported symptoms during the COVID-19 pandemic have been used to train artificial intelligence models to identify possible infection foci. To date, these models have only considered the culmination or peak of symptoms, which is not suitable for the early detection of infection. We aimed to estimate the probability of an individual being infected with SARS-CoV-2 on the basis of early self-reported symptoms to enable timely self-isolation and urgent testing. Methods In this large-scale, prospective, epidemiological surveillance study, we used prospective, observational, longitudinal, self-reported data from participants in the UK on 19 symptoms over 3 days after symptoms onset and COVID-19 PCR test results extracted from the COVID-19 Symptom Study mobile phone app. We divided the study population into a training set (those who reported symptoms between April 29, 2020, and Oct 15, 2020) and a test set (those who reported symptoms between Oct 16, 2020, and Nov 30, 2020), and used three models to analyse the self-reported symptoms: the UK's National Health Service (NHS) algorithm, logistic regression, and the hierarchical Gaussian process model we designed to account for several important variables (eg, specific COVID-19 symptoms, comorbidities, and clinical information). Model performance to predict COVID-19 positivity was compared in terms of sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) in the test set. For the hierarchical Gaussian process model, we also evaluated the relevance of symptoms in the early detection of COVID-19 in population subgroups stratified according to occupation, sex, age, and body-mass index. Findings The training set comprised 182 991 participants and the test set comprised 15 049 participants. When trained on 3 days of self-reported symptoms, the hierarchical Gaussian process model had a higher prediction AUC (0·80 [95% CI 0·80–0·81]) than did the logistic regression model (0·74 [0·74–0·75]) and the NHS algorithm (0·67 [0·67–0·67]). AUCs for all models increased with the number of days of self-reported symptoms, but were still high for the hierarchical Gaussian process model at day 1 (0·73 [95% CI 0·73–0·74]) and day 2 (0·79 [0·78–0·79]). At day 3, the hierarchical Gaussian process model also had a significantly higher sensitivity, but a non-statistically lower specificity, than did the two other models. The hierarchical Gaussian process model also identified different sets of relevant features to detect COVID-19 between younger and older subgroups, and between health-care workers and non-health-care workers. When used during different pandemic periods, the model was robust to changes in populations. Interpretation Early detection of SARS-CoV-2 infection is feasible with our model. Such early detection is crucial to contain the spread of COVID-19 and efficiently allocate medical resources. Funding ZOE, the UK Government Department of Health and Social Care, the Wellcome Trust, the UK Engineering and Physical Sciences Research Council, the UK National Institute for Health Research, the UK Medical Research Council, the British Heart Foundation, the Alzheimer's Society, the Chronic Disease Research Foundation, and the Massachusetts Consortium on Pathogen Readiness.

Objectives To compare the standardized incidence rates (IRs) of hip fracture for Native Americans versus other racial groups in U.S. nursing homes (NHs). Methods We studied Medicare fee-for-service NH residents aged ≥65 years who became long-stay (index date) between 1/1/2008 and 12/31/2009 (n = 1,136,544). Residents were followed from the index date until occurrence of hip fracture, death, Medicare disenrollment, or study end (12/31/2013). We calculated hip fracture IRs by race and used inverse probability weighting to standardize the rates for baseline demographic and clinical characteristics collected from the Minimum Data Set and Medicare claims data. We compared characteristics of NHs used by residents of different races using Online Survey, Certification and Reporting (OSCAR) data. Results Among long-stay U.S. NH residents, the standardized IR of hip fracture per 100 person-years was highest in Native Americans [2.16; 95% confidence interval (CI) 1.91–2.44] and white residents (2.05; 2.03–2.06), and lowest in black residents (0.82; 0.79–0.85). NHs caring for Native American residents were more likely to be rurally located as compared to other racial group. Conclusions In U.S. NHs, Native Americans and whites have the highest standardized IR of hip fracture and should receive particular attention in fracture prevention efforts.

BACKGROUND: Nursing home (NH) residents have borne a disproportionate share of SARS-CoV-2 morbidity and mortality. Vaccines have limited hospitalisation and death from earlier variants in this vulnerable population. With the rise of Omicron and future variants, it is vital to sustain and broaden vaccine-induced protection. We examined the effect of boosting with BNT162b2 mRNA vaccine on humoral immunity and Omicron-specific neutralising activity among NH residents and healthcare workers (HCWs). METHODS: We longitudinally enrolled 85 NH residents (median age 77) and 48 HCWs (median age 51), and sampled them after the initial vaccination series; and just before and 2 weeks after booster vaccination. Anti-spike, anti-receptor binding domain (RBD) and neutralisation titres to the original Wuhan strain and neutralisation to the Omicron strain were obtained. FINDINGS: Booster vaccination significantly increased vaccine-specific anti-spike, anti-RBD, and neutralisation levels above the pre-booster levels in NH residents and HCWs, both in those with and without prior SARS-CoV-2 infection. Omicron-specific neutralisation activity was low after the initial 2 dose series with only 28% of NH residents’ and 28% HCWs’ titres above the assay's lower limit of detection. Omicron neutralising activity following the booster lifted 86% of NH residents and 93% of HCWs to the detectable range. INTERPRETATION: With boosting, the vast majority of HCWs and NH residents developed detectable Omicron-specific neutralising activity. These data provide immunologic evidence that strongly supports booster vaccination to broaden neutralising activity and counter waning immunity in the hope it will better protect this vulnerable, high-risk population against the Omicron variant.

Background Demand for measurement of 25-hydroxyvitamin D (25OHD) is growing and dried blood spot (DBS) sampling is attractive as samples are easier to collect, transport and store. Methods A 2D LC-MS/MS assay without derivatization was developed. DBS punches (3.2 mm) were ultrasonicated with d6-25OHD3 in 70% methanol followed by hexane extraction, dry-down and reconstitution. The assay was validated and applied to two studies comparing whole blood adult DBS with serum samples (n = 40) and neonatal whole blood DBS with cord serum samples (n = 80). Results The assay was validated in whole blood DBS over the range 13–106 nmol/L 25OHD3 and 11–91 nmol/L 25OHD2 with a limit of detection of 3 nmol/L. Intra- and inter-day imprecision was Conclusions Direct quantitation of 25OHD in DBS by 2D LC-MS/MS without derivatization was found to be an alternative to serum quantitation applicable to clinical research studies on adult DBS samples.

In developed countries, exposure to wood or coal smoke occurs predominantly from neighbourhood emissions arising from household heating. The effect of this exposure on child health is not well characterized. Within a birth cohort study in New Zealand we assessed healthcare events associated with exposure to neighbourhood smoke from household heating. Our outcome measure was non-accidental presentations to hospital emergency departments (ED) before age three years. We matched small area-level census information with the geocoded home locations to measure the density of household heating with wood or coal in the neighbourhood and applied a time-weighted average exposure method to account for residential mobility. We then used hierarchical multiple logistic regression to assess the independence of associations of this exposure with ED presentations adjusted for gender, ethnicity, birth weight, breastfeeding, immunizations, number of co-habiting smokers, wood or coal heating at home, bedroom mold, household- and area-level deprivation and rurality. The adjusted odds ratio of having a non-accidental ED visit was 1.07 [95%CI: 1.03–1.12] per wood or coal heating household per hectare. We found a linear dose-response relationship (p-value for trend = 0.024) between the quartiles of exposure (1st as reference) and the same outcome (odds ratio in 2nd to 4th quartiles: 1.14 [0.95–1.37], 1.28 [1.06–1.54], 1.32 [1.09–1.60]). Exposure to neighbourhoods with higher density of wood or coal smoke-producing households is associated with an increased odds of ED visits during early childhood. Policies that reduce smoke pollution from domestic heating by as little as one household per hectare using solid fuel burners could improve child health.

Objectives: To determine whether specific demographic characteristics are associated with the presence or absence of household safety strategies. Methods: This study was conducted within Growing Up in New Zealand, a contemporary longitudinal study of New Zealand (NZ) children. Multivariable analyses were used to examine the maternal (self-prioritised ethnicity, education, age, self-reported health) and household (area-level deprivation, tenure, crowding, residential mobility, dwelling type) determinants of household safety strategies being present in the homes of young children. Results: In comparison to family-owned homes, privately owned rental homes were less likely (OR=0.78; 95%CI 0.65–0.92), and government-owned rental homes were more likely (OR=1.74, 95%CI 1.25–2.41) to have eight or more household safety strategies present. Conclusions: Living in a privately owned rental home in NZ exposes children to an environment where there are fewer household safety strategies in place. Implications for public health: Housing tenure provides a clear target focus for improving the household safety environment for NZ children.

Objectives To examine the association between use of opioids versus other analgesics with death and functioning after hip fracture in older nursing home (NH) residents. Design Retrospective cohort using national Medicare fee-for-service claims linked to the Minimum Data Set. Setting US NHs. Participants NH residents aged ≥65 years who became a long-stay resident (>100 days in the NH) between January 2008 and December 2009, had a hospitalized hip fracture, and returned to the NH. Exposure New use of opioid versus nonopioid analgesics (acetaminophen or nonsteroidal anti-inflammatory drugs) within 14 days post hip fracture. Measurements Follow-up began on the index date and continued until the first occurrence of death, significant functional decline (3-point increase on MDS Activities of Daily Living scale), or 120 days of follow-up. Odds ratios (ORs) with 95% confidence intervals (CIs) for outcomes were estimated using inverse probability of treatment–weighted multinomial logistic regression models. Results Among the 2755 NH residents with a hip fracture included in our study, 1155 (41.9%) were opioid users, and 1600 (58.1%) were nonopioid analgesic users. The mean age was 86.3 years, 73.8% were female, and 86.0% were white. Opioid use was associated with a significantly lower likelihood of death (OR = 0.47, 95% CI 0.39-0.56) and a nonsignificant decrease in functional decline (OR = 0.77, 95% CI 0.58-1.03). Conclusion A rigorous study that addresses the limitations of this study is critical to validate our preliminary findings and provide evidence about the effect of using opioid versus nonopioid analgesics to optimize acute pain in NH residents with a hip fracture.

BACKGROUND: Up to 75% of hip fracture patients never recover to their pre-fracture functional status. Supervised exercise that includes strength training can improve functional recovery after hip fracture. The role of testosterone replacement for augmenting the effects of exercise in older women after hip fracture is unknown. METHODS: The Starting Testosterone and Exercise after Hip Injury (STEP-HI) Study is a 6-month Phase 3 multicenter randomized placebo-controlled trial designed to compare supervised exercise (EX) plus 1% testosterone topical gel, with EX plus placebo gel, and with enhanced usual care (EUC). Female hip fracture patients age ≥ 65 years are being recruited from clinical centers across the United States. Participants are community dwelling and enrolled within 24 weeks after surgical repair of the fracture. The EX intervention is a center-based program of progressive resistance training. The EUC group receives a home exercise program and health education. Participants receive dietary counseling, calcium and vitamin D. The primary outcome is the Six Minute Walk Distance. Secondary outcomes include physical performance measures, self-reported function and quality of life, and dual energy x-ray absorptiometry measures of body composition and bone mineral density. RESULTS: Enrollment, interventions, and follow-up are ongoing. We describe the impact of the coronavirus disease 2019 pandemic on the trial, including modifications made to allow continuation of the interventions and outcome data collection using remote video and audio technology. CONCLUSIONS: Results from the STEP-HI study are expected to have important clinical and public health implications for management of the growing population of hip fracture patients.

OBJECTIVE: The FDA recommends a reduced dose of non-benzodiazepine hypnotics in women, yet little is known about the age-, sex-, and dose-specific effects of these drugs on risk of hip fracture, especially among nursing home (NH) residents. We estimated the age-, sex-, and dose-specific effects of non-benzodiazepine hypnotics on the rate of hip fracture among NH residents. DESIGN AND SETTING: Case-crossover study in US NHs. PARTICIPANTS: 691 women and 179 men with hip fracture sampled from all U.S. long-stay NH residents. MEASUREMENTS: Measures of patient characteristics were obtained from linked Medicare and the Minimum Data Set (2007–2008). The outcome was hospitalization for hip fracture with surgical repair. We estimated rate ratios (RR) and 95% confidence intervals (CI) from conditional logistic regression models for non-benzodiazepine hypnotics (vs. non-use) comparing 0–29 days before hip fracture (hazard period) with 60–89 and 120–149 days before hip fracture (control periods). We stratified analyses by age, sex, and dose. RESULTS: The average RR of hip fracture was 1.7 (95% CI 1.5 to 1.9) for any use. The RR of hip fracture was higher for residents aged ≥90 years vs.

Despite high rates of hip fracture among United States (US) nursing home (NH) residents, little is known about geographic variation in hip fracture incidence. We used nationally representative data to identify geographic variation in hip fracture among US NH residents.Retrospective cohort study using Part A claims for a 100% of Medicare enrollees in 15,289 NHs linked to NH minimum data set and Online Survey, Certification, and Reporting databases.A total of 891,085 long-stay (continuous residence of ≥100 days) NH residents ≥65 years old.Medicare Part A claims documenting a hip fracture. Mean incidence rates of hip fracture for long-stay NH residents were calculated for each state and US Census Division from 2007 to 2010.The age-, sex-, and race-adjusted incidence rate of hip fracture ranged from 1.49 hip fractures/100 person-years (Hawaii) to 3.60 hip fractures/100 person-years (New Mexico), with a mean of 2.38 (standard deviation 0.43) hip fractures/100 person-years. The mean incidence of hip fracture was 1.7-fold greater in the highest quintile than the lowest.We observed modest US state and regional variation in hip fracture incidence among long-stay NH residents. Future studies should assess whether state policies or NH characteristics explain the variation.