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Purpose: Worldwide, many people who would benefit from osteoporosis drugs are not offered or receiving them, resulting in an osteoporosis care gap. Adherence with bisphosphonates is particularly low. This study aimed to identify stakeholder research priorities relating to bisphosphonate treatment regimens for prevention of osteoporotic fractures. Methods: A three-step approach based on the James Lind Alliance methodology for identification and prioritisation of research questions was used. Research uncertainties were gathered from a large programme of related research studies about bisphosphonate regimens and from recent published international clinical guidelines. Clinical and public stakeholders refined the list of uncertainties into research questions. The third step prioritised the questions using a modified nominal group technique. Results: In total, 34 draft uncertainties were finalised into 33 research questions by stakeholders. The top 10 includes questions relating to which people should be offered intravenous bisphosphonates first line (1); optimal duration of treatment (2); the role of bone turnover markers in treatment breaks (3); support patient need for medicine optimisation (4); support primary care practitioner need regarding bisphosphonates (5); comparing zoledronate given in community vs hospital settings (6); ensuring quality standards are met (7); the long-term model of care (8); best bisphosphonate for people aged under 50 (9); and supporting patient decision-making about bisphosphonates (10). Conclusion: This study reports, for the first time, topics of importance to stakeholders in the research of bisphosphonate osteoporosis treatment regimens. These findings have implications for research into implementation to address the care gap and education of healthcare professionals. Summary: Using James Lind Alliance methodology, this study reports prioritised topics of importance to stakeholders in the research of bisphosphonate treatment in osteoporosis. The priorities address how to better implement guidelines to address the care gap, understanding patient factors influencing treatment selection and effectiveness, and how to optimise long-term care. [ABSTRACT FROM AUTHOR]

Currently in the UK and Ireland, after a hip fracture most patients do not receive bone protection medication to reduce the risk of refracture. Yet randomised controlled trial data specifically examining patients with hip fracture have shown that intravenous zoledronate reduces refracture risk by a third. Despite this evidence, use of intravenous zoledronate is highly variable following a hip fracture; many hospitals are providing this treatment, whilst most are currently not. A range of clinical uncertainties, doubts over the evidence base and practical concerns are cited as reasons. This paper discusses these concerns and provides guidance from expert consensus, aiming to assist orthogeriatricians, pharmacists and health services managers establish local protocols to deliver this highly clinically and cost-effective treatment to patients before they leave hospital, in order to reduce costly re-fractures in this frail population. [ABSTRACT FROM AUTHOR]

Introduction Acute vertebral fragility fracture requiring hospital admission is common, painful and disabling. No comprehensive clinical guideline for their care exists. To support the development of such a guideline, we sought the views of experts in the field. Methods A modified Delphi study was used. A total of 70 statements were presented, using an online platform, over three consensus-seeking rounds, to participants with experience in the hospital care of patients with acute vertebral fragility fractures from UK-based specialist societies. Participants rated the level of their agreement with each statement on a 5-point Likert scale. Consensus was defined at 70% of respondents choosing either agree/strongly agree or disagree/strong disagree. Over the first two rounds, statements not reaching consensus were modified in subsequent rounds, and new statements proposed by participants and agreed by the research team could be added. Results There were 71 participants in the first round, 37 in the second round and 28 (most of whom were geriatricians) in the third round. Consensus was reached in 52 statements covering fracture diagnosis, second-line imaging, organisation of hospital care, pain management and falls and bone health assessment. Consensus was not achieved for whether vertebral fragility fractures should be managed in a specific clinical area. Discussion These findings provide the basis for the development of clinical guidelines and quality improvement initiatives. They also help to justify research into the merits of managing acute vertebral fragility fracture patients in a specific clinical area. [ABSTRACT FROM AUTHOR]

Background: chair-based pedal exercises potentially offer a simple method of improving physical activity in older people admitted to hospital. Objective: to assess the feasibility of using chair-based pedal exercisers on acute medical wards for older people. To study if there is any effect on muscle strength, mobility and time spent physically active. Subjects: fifty participants ≥65 years who were able to pedal admitted to acute medical wards for older people in a UK hospital. Methods: participants were randomised to either pedal for 5 min three times a day with minimal supervision; or standard care. Outcome data (compliance with exercise and change in lower limb muscle strength, mobility and level of physical activity) were collected on day 7 or on discharge, whichever came 1st. Results: there were no significant differences in baseline characteristics between the intervention and standard care group. Participants remained in the study for an average of 5 days. None in the intervention group adhered to the prescribed exercise duration. The intervention group completed a median of 152 revolutions, or a median total pedal time of 5 min during the entire study period. There were no differences in change in lower limb muscle strength, mobility score or the percentage of time spent active between the two groups. Conclusion: pedal exercises with minimal supervision are not feasible as a single intervention to improve physical activity in older people admitted to hospital. There may be a role for it as part of a multifaceted strategy to improve physical activity in hospital. [ABSTRACT FROM AUTHOR]

Objective: to compare the clinical and cost-effectiveness of a Community In-reach Rehabilitation and Care Transition (CIRACT) service with the traditional hospital-based rehabilitation (THB-Rehab) service. Design: pragmatic randomised controlled trial with an integral health economic study. Settings: large UK teaching hospital, with community follow-up. Subjects: frail older people aged 70 years and older admitted to hospital as an acute medical emergency. Measurements: Primary outcome: hospital length of stay; secondary outcomes: readmission, day 91-super spell bed days, functional ability, co-morbidity and health-related quality of life; cost-effectiveness analysis. Results: a total of 250 participants were randomised. There was no significant difference in length of stay between the CIRACT and THB-Rehab service (median 8 versus 9 days; geometric mean 7.8 versus 8.7 days, mean ratio 0.90, 95% confidence interval (CI) 0.74-1.10). Of the participants who were discharged from hospital, 17% and 13% were readmitted within 28 days from the CIRACT and THB-Rehab services, respectively (risk difference 3.8%, 95% CI -5.8% to 13.4%). There were no other significant differences in any of the other secondary outcomes between the two groups. The mean costs (including NHS and personal social service) of the CIRACT and THB-Rehab service were £3,744 and £3,603, respectively (mean cost difference £144; 95% CI -1,645 to 1,934). Conclusion: the CIRACT service does not reduce major hospital length of stay nor reduce short-term readmission rates, compared to the standard THB-Rehab service; however, a modest (<2.3 days) effect cannot be excluded. Further studies are necessary powered with larger sample sizes and cluster randomisation. Trial registration: ISRCTN 94393315, 25th April 2013 [ABSTRACT FROM AUTHOR]

The care of the older person with hip fracture is complicated by their comorbid condition, limited physiological reserve, cognitive impairment and frailty. Two aspects of hip fracture management that have received considerable attention are how best to manage the pain associated with it and the ideal mode of anaesthesia. Existing literature has reported on the suboptimal treatment of pain in this orthogeriatric cohort. With recent advancements in medical care, a number of options have emerged as alternatives to conservative systemic analgesia. Systemic analgesia, such as opioids, can lead to untoward side effects, especially in this particular group of patients. Hence, peripheral nerve blocks, epidural analgesia and regional anaesthesia have emerged as options in the delivery of adequate pain relief in hip fractures. Besides that, there is ongoing debate regarding the appropriate anaesthesia technique for surgical repair of the fractured hip. The benefits and risks related to either spinal anaesthesia or general anaesthesia have been subject to studies determining which method is associated with better short- and long-term outcomes. In this review, we aim to examine the evidence behind the different analgesia options available, compare spinal and general anaesthesia, and discuss the importance of the multidisciplinary orthogeriatric model of care in hip fracture and its potential role in other fragility fractures. [ABSTRACT FROM AUTHOR]

Introduction: A proportion of patients sustaining hip fractures present with a concomitant fracture. We aimed to evaluate the relationship between patient characteristics and clinical outcomes, in those with a hip and concomitant fracture compared with those sustaining a hip fracture alone from a clinical service registry.Method: Cross-sectional study using data obtained from a clinical service registry (Nottingham Hip Fracture Database) on patients aged 50 and above who suffered a hip fracture between 1/1/2003 and 31/12/2012. Data was collected on patient demographics, fracture information and healthcare outcomes.Results: 7338 patients of which 75 % were female (mean age 82 (SD 9.4), had a hip fracture with 334 (4.6 %) patients having a concomitant fracture. The majority (58 %) were distal radius or proximal humeral fractures. Only females (p = 0.002), those taking three or fewer medications (p = 0.018) and those on long term steroids (p = 0.048) were more likely to suffer a concomitant fracture. There was no difference in mortality, rates of postoperative complication, intensive care unit or care home admission between both groups. Patients with a concomitant fracture have a 16 % longer average length of stay in hospital (mean difference 1.16; 95 % CI 1.07-1.25, p < 0.001).Conclusions: Patients with concomitant fractures have similar patient characteristics, except gender, polypharmacy and long term steroid use; and outcomes to those presenting with hip fracture alone, except a longer average inpatient stay. [ABSTRACT FROM AUTHOR]

Maintenance of fluid and electrolyte balance is essential to healthy living as dehydration and fluid overload are associated with morbidity and mortality. This review presents the current evidence for the impact of hydration status on health. The Web of Science, MEDLINE, PubMed, and Google Scholar databases were searched using relevant terms. Randomized controlled trials and large cohort studies published during the 20 years preceding February 2014 were selected. Older articles were included if the topic was not covered by more recent work. Studies show an association between hydration status and disease. However, in many cases, there is insufficient or inconsistent evidence to draw firm conclusions. Dehydration has been linked with urological, gastrointestinal, circulatory, and neurological disorders. Fluid overload has been linked with cardiopulmonary disorders, hyponatremia, edema, gastrointestinal dysfunction, and postoperative complications. There is a growing body of evidence that links states of fluid imbalance and disease. However, in some cases, the evidence is largely associative and lacks consistency, and the number of randomized trials is limited. [ABSTRACT FROM AUTHOR]

Background/Aims: Appropriate footwear is regarded as an important component of falls prevention in older people. Scant data exists regarding the types of footwear older patients wear in hospital, which may hinder the development of future interventions in this high-risk fall group. To address this, we conducted a service evaluation to examine and describe the style and quality of footwear worn by older patients in hospital. Methods: The footwear of older patients admitted to an acute NHS trust in England was assessed using the Footwear Assessment Tool. Patients were interviewed about their footwear choices. Results: A total of 730 pairs of footwear from 675 patients were assessed. The most common types of footwear worn were slippers (46%) and gripper socks (37%). Much of the footwear had a good fit, but over 50% lacked adequate structure, stability and support, more than 60% had no cushioning and 60% had no fixation. Approximately 60% of footwear was more than 12 months old, with signs of moderate to excess wear. Patients valued comfort and the familiarity of their own footwear. Conclusions: This service evaluation provides new information on footwear worn by older inpatients in hospital. Many patients are wearing footwear with insufficient structure to promote optimal stability or gait. Providing safe footwear that is suitable for use in hospital is potentially a low-technology and resource-efficient way to promote safety in older patients. [ABSTRACT FROM AUTHOR]

Background: falls in hospitals are a major problem and contribute to substantial healthcare burden. Advances in sensor technology afford innovative approaches to reducing falls in acute hospital care. However, whether these are clinically effective and cost effective in the UK setting has not been evaluated.Methods: pragmatic, parallel-arm, individual randomised controlled trial of bed and bedside chair pressure sensors using radio-pagers (intervention group) compared with standard care (control group) in elderly patients admitted to acute, general medical wards, in a large UK teaching hospital. Primary outcome measure number of in-patient bedside falls per 1,000 bed days.Results: 1,839 participants were randomised (918 to the intervention group and 921 to the control group). There were 85 bedside falls (65 fallers) in the intervention group, falls rate 8.71 per 1,000 bed days compared with 83 bedside falls (64 fallers) in the control group, falls rate 9.84 per 1,000 bed days (adjusted incidence rate ratio, 0.90; 95% confidence interval [CI], 0.66–1.22; P = 0.51). There was no significant difference between the two groups with respect to time to first bedside fall (adjusted hazard ratio (HR), 0.95; 95% CI: 0.67–1.34; P= 0.12). The mean cost per patient in the intervention group was £7199 compared with £6400 in the control group, mean difference in QALYs per patient, 0.0001 (95% CI: −0.0006–0.0004, P= 0.67).Conclusions: bed and bedside chair pressure sensors as a single intervention strategy do not reduce in-patient bedside falls, time to first bedside fall and are not cost-effective in elderly patients in acute, general medical wards in the UK.Trial registration: isrctn.org identifier: ISRCTN44972300. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: This study examines the relationship between high BMI, a diagnosis of osteoporosis and low trauma fractures. Method: This is a cross sectional analysis using data collected from the Nottingham Fracture Liaison Service. A total of 4288 participants with a low trauma fracture from 1 January 2007 to 31 August 2012 were analysed. Logistic regression adjusted for potential confounders was used investigate osteoporosis and BMI. Fracture types were compared between those who were obese and non-obese. Results: A total of 30% (1285) were obese. Prevalence of osteoporosis was 13.4%, 24.9%, and 40.4% in the obese, overweight and normal category respectively. Being obese has an odds ratio of 0.23 (95% CI 0.19–0.28, p <0.01) of having osteoporosis compared to a normal BMI category. When variable BMI cut offs were used (BMI 25, 30 and 35) to calculate the positive predictive value of patients not having osteoporosis, it was 80.5%, 86.3% and 88.3%. Examining fracture types, obese patients when compared with the non-obese category, were more likely to fracture their ankle (OR 1.48, p <0.01) and upper arm (OR 1.48, p <0.001), but were less likely to fracture their wrist (OR 0.65, p <0.001). In the elderly (>70years), obesity no longer influenced ankle or wrist fractures but there is an increased risk of upper arm fractures (OR 1.46, p =0.005). Conclusion: Higher BMD in obesity is not protective against fractures as there are a significant number of fractures in this group which may be due to body habitus, mechanism of injury and the effect of adiposity on bone. A low trauma osteoporotic fracture will need to be redefined in light of these findings. [Copyright &y& Elsevier]

Objective: we estimated the cost-effectiveness of a community falls prevention service compared with usual care from a National Health Service and personal social services perspective over the 12 month trial period.Design: a cost-effectiveness and cost utility analysis alongside a randomised controlled trialSetting: community.Participants: people over 60 years of age living at home or in residential care who had fallen and called an emergency ambulance but were not taken to hospital.Interventions: referral to community fall prevention services or usual health and social care.Measurements: incremental cost per fall prevented and incremental cost per Quality-Adjusted Life Years (QALYs)Results: a total of 157 participants (82 interventions and 75 controls) were used to perform the economic evaluation. The mean difference in NHS and personal social service costs between the groups was £-1,551 per patient over 1 year (95% CI: £-5,932 to £2,829) comparing the intervention and control groups. The intervention patients experienced on average 5.34 fewer falls over 12 months (95% CI: −7.06 to −3.62). The mean difference in QALYs was 0.070 (95% CI: −0.010 to 0.150) in favour of the intervention group.Conclusion: the community falls prevention service was estimated to be cost-effective in this high-risk group. Current Controlled Trials ISRCTN67535605. (controlled-trials.com) [ABSTRACT FROM AUTHOR]

Background: hip fracture represents a huge medical, social and financial burden on patients, their carers and the health and social care systems. For survivors, return to their own home may be a key outcome. The Nottingham Hip Fracture Score (NHFS) is a validated score, based on admission characteristics, for predicting 30-day and 1-year mortality that may be of benefit in predicting return-to-home, directly from the acute orthopaedic ward.Objective: to assess the utility of the NHFS as a predictor of return-to-home in patients following hip fracture.Methods: the NHFS was calculated for all patients admitted from their own home and the correlation between the NHFS and eventual return-to-home was calculated, as well as the probability of discharge by within 7, 14 and 21 days.Results: a total of 6,123 patients were available for analysis. Of which, 3,699 (60%) were discharged from acute hospital to their own home. Increasing NHFS was negatively correlated with eventual return-to-home (r2 = 0.949) and with the proportion of patients discharged back to their own home at 7, 14 and 21 postoperative days, respectively (r2 = 0.84, 0.94, 0.96, respectively).Conclusions: the NHFS is a reliable tool for predicting return-to-home. It may be useful for discharge planning, and for the design of future research trials. [ABSTRACT FROM AUTHOR]

To investigate the monthly and seasonal variation in adult osteoporotic fragility fractures and the association with weather. 12-year observational study of a UK Fracture Liaison Service (outpatient secondary care setting). Database analyses of the records of adult outpatients aged 50 years and older with fragility fractures. Weather data were obtained from the UK's national Meteorological Office. In the seasonality analyses, we tested for the association between months and seasons (determinants), respectively, and outpatient attendances, by analysis of variance (ANOVA) and Tukey's test. In the meteorological analyses, the determinants were mean temperature, mean daily maximum and minimum temperature, number of days of rain, total rainfall and number of days of frost, per month, respectively. We explored the association of each meteorological variable with outpatient attendances, by regression models. The Fracture Liaison Service recorded 25,454 fragility fractures. We found significant monthly and seasonal variation in attendances for fractures of the: radius or ulna; humerus; ankle, foot, tibia or fibula (ANOVA, all p-values <0.05). Fractures of the radius or ulna and humerus peaked in December and winter. Fractures of the ankle, foot, tibia or fibula peaked in July, August and summer. U-shaped associations were showed between each temperature parameter and fractures. Days of frost were directly associated with fractures of the radius or ulna (p-value <0.001) and humerus (p-value 0.002). Different types of fragility fractures present different seasonal patterns. Weather may modulate their seasonality and consequent healthcare utilisation. • Fragility fractures of the radius or ulna and humerus peaked in winter. • Fragility fractures of the ankle, foot, tibia or fibula peaked in summer. • Weather was associated with fragility fractures. • We found U-shaped associations between temperature parameters and fractures. • Days of frost were associated with fractures of the radius or ulna and humerus. [ABSTRACT FROM AUTHOR]

Introduction: Patients that require hospital admission for vertebral fragility fractures were older, multimorbid, frail, have cognitive impairment and were in severe pain. This study aimed to describe the hospital treatment received in one UK university hospital with the purpose of proposing what hospital services should look like., Method: This was an observational study of adults aged 50 years and over admitted to hospital over 12 months with an acute vertebral fragility fracture. Information was collected from patients and electronic health records on their presentation and hospital care., Results: 90 patients were recruited into the study. 69% presented to hospital 24 h after the onset of their severe acute back pain. 38% had a concomitant medical diagnosis, such as an ongoing infection. X-ray of the spine was the most common imaging of choice to diagnose a fracture. There was variation in the content of the radiology reports. 46% or patients were managed on geriatric medicine wards, 39% on general medical wards, and followed by 14% on spinal surgical wards. Patients cared for by medical teams were older, frailer, had a higher prevalence of cognitive impairment, more dependent for daily living and less mobile compared to those under the care of the spinal surgical team. Many patients on medical wards had input from spinal surgical team and vice versa. 9% proceeded to have vertebral augmentation. Despite many in severe pain, only a third were prescribed opioids with the median dose of morphine-equivalent was 10-20 mg daily for the first three days of admission. While in hospital, 31% developed a medical complication, with infection being the most common one. On discharge, 76% still required opioids and only 56% had a plan for their bone health., Discussion: Improvements could be made to hospital vertebral fracture care. Many did not receive adequate pain relief and appropriate assessments to reduce their future fall and fracture risk. Most were medically managed. Quality standards and re-organising care in hip fracture has led to improved outcomes. A similar approach in vertebral fragility fractures might also deliver improved outcomes., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflict of interest., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Introduction: There is a lack of robust data on hospitalised acute vertebral fragility fractures. This analysis aimed to report on the number of hospitalised vertebral fragility fractures treated in a large UK teaching hospital. This information would support better design of hospital services and resource allocation to manage this group of patients., Methods: Patients aged 50 years and over hospitalised with a vertebral fragility fracture from 1/2/2016 to 31/1/2017 were identified from radiology and hospital records. Patients sustaining vertebral fractures due to either major trauma or malignancy were excluded. Data was collected on patient demographics, fracture details, hospitalisation details and health outcomes., Results: 208 patients with acute vertebral fragility fractures were hospitalised over a 12 month period. The mean (SD) age was 80.5 (11) years, of which 68% were female. 94% presented to the Emergency Department (ED) as their first point of contact, of which 70% were subsequently hospitalised. Two-thirds presented with a single level vertebral fracture predominantly around the thoracolumbar region. The majority (87%) were non-operatively managed by general physicians, of which most were under Geriatric Medicine. The median length of stay was 12 (IQR 6-20) days and inpatient mortality was 3%. 52% of patients went on to have a bone health assessment., Conclusion: We have reported on the number of patients presenting to hospital with an acute vertebral fragility fracture over 12 months. This helps identify resources needed to design hospital services to manage them adequately., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Introduction: Osteoporosis and bone fractures are common in chronic obstructive pulmonary disease (COPD) and contribute significantly to morbidity and mortality. Current national guidance on COPD management recommends addressing bone health in patients, however, does not detail how. This consensus outlines key elements of a structured approach to managing bone health and fracture risk in patients with COPD., Methods: A systematic approach incorporating multifaceted methodologies included detailed patient and healthcare professional (HCP) surveys followed by a roundtable meeting to reach a consensus on what a pathway would look like., Results: The surveys revealed that fracture risk was not always assessed despite being recognised as an important aspect of COPD management by HCPs. The majority of the patients also stated they would be receptive to discussing treatment options if found to be at risk of osteoporotic fractures. Limited time and resource allocation were identified as barriers to addressing bone health during consultations. The consensus from the roundtable meeting was that a proactive systematic approach to assessing bone health should be adopted. This should involve using fracture risk assessment tools to identify individuals at risk, investigating secondary causes of osteoporosis if a diagnosis is made and reinforcing non-pharmacological and preventative measures such as smoking cessation, keeping active and pharmacological management of osteoporosis and medicines management of corticosteroid use. Practically, prioritising patients with important additional risk factors, such as previous fragility fractures, older age and long-term oral corticosteroid use for an assessment, was felt required., Conclusion: There is a need for integrating fracture risk assessment into the COPD pathway. Developing a systematic and holistic approach to addressing bone health is key to achieving this. In tandem, opportunities to disseminate the information and educational resources are also required., Competing Interests: SH is funded for 1 session per month to work as a clinical commissioner for respiratory in Somerset CCG and works as a general practitioner partner in Somerset (five sessions per week). He is also a member of the NHS England Cardiovascular and Respiratory Programme Strategic Board and has worked as an unpaid advisor for the British Lung Foundation and Royal College of General Practitioners at a national level. KL owns a share in Primary Integrated Community Service (PICS) that employs respiratory nurses in the community and is also the medical director of PICS. JS has no direct conflict of interest with this publication but has received support or honorarium from Astra Zeneca, Nutricia, ARNS, Chiesi, Mundipharma, ROCHE, Boehringer Ingelheim, Teva, PCRS-UK, MIMS, Mark Allen Group, ADMIT, NIP and Mylan. Prof. CEB reports grants from British Lung Foundation, during the conduct of the study. All authors declare they have no other conflicts of interest in relation to this article., (© 2020 Gupta et al.)