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Sahota O, Narayanasamy M, Bastounis A, Paskins Z, Bishop S, Langley T, Gittoes N, Davis S, Baily A, Holmes M, Leonardi-Bee J. Bisphosphonate alternative regimens for the prevention of osteoporotic fragility fractures: BLAST-OFF, a mixed-methods study. Health Technol Assess 2024; 28:1-169. [PMID: 38634483 PMCID: PMC11056815 DOI: 10.3310/wypf0472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024] Open
Abstract
Background Bisphosphonates are a class of medication commonly used to treat osteoporosis. Alendronate is recommended as the first-line treatment; however, long-term adherence (both treatment compliance and persistence) is poor. Alternative bisphosphonates are available, which can be given intravenously and have been shown to improve long-term adherence. However, the most clinically effective and cost-effective alternative bisphosphonate regimen remains unclear. What is the most cost-effective bisphosphonate in clinical trials may not be the most cost-effective or acceptable to patients in everyday clinical practice. Objectives 1. Explore patient, clinician and stakeholder views, experiences and preferences of alendronate compared to alternative bisphosphonates. 2. Update and refine the 2016 systematic review and cost-effectiveness analysis of bisphosphonates, and estimate the value of further research into their benefits. 3. Undertake stakeholder/consensus engagement to identify important research questions and further rank research priorities. Methods The study was conducted in two stages, stages 1A and 1B in parallel, followed by stage 2: • Stage 1A - we elicited patient and healthcare experiences to understand their preferences of bisphosphonates for the treatment of osteoporosis. This was undertaken by performing a systematic review and framework synthesis of qualitative studies, followed by semistructured qualitative interviews with participants. • Stage 1B - we updated and expanded the existing Health Technology Assessment systematic review and clinical and cost-effectiveness model, incorporating a more comprehensive review of treatment efficacy, safety, side effects, compliance and long-term persistence. • Stage 2 - we identified and ranked further research questions that need to be answered about the effectiveness and acceptability of bisphosphonates. Results Patients and healthcare professionals identified a number of challenges in adhering to bisphosphonate medication, balancing the potential for long-term risk reduction against the work involved in adhering to oral alendronate. Intravenous zoledronate treatment was generally more acceptable, with such regimens perceived to be more straightforward to engage in, although a portion of patients taking alendronate were satisfied with their current treatment. Intravenous zoledronate was found to be the most effective, with higher adherence rates compared to the other bisphosphonates, for reducing the risk of fragility fracture. However, oral bisphosphonates are more cost-effective than intravenous zoledronate due to the high cost of zoledronate administration in hospital. The importance of including patients and healthcare professionals when setting research priorities is recognised. Important areas for research were related to patient factors influencing treatment selection and effectiveness, how to optimise long-term care and the cost-effectiveness of delivering zoledronate in an alternative, non-hospital setting. Conclusions Intravenous zoledronate treatment was generally more acceptable to patients and found to be the most effective bisphosphonate and with greater adherence; however, the cost-effectiveness relative to oral alendronate is limited by its higher zoledronate hospital administration costs. Future work Further research is needed to support people to make decisions influencing treatment selection, effectiveness and optimal long-term care, together with the clinical and cost-effectiveness of intravenous zoledronate administered in a non-hospital (community) setting. Limitations Lack of clarity and limitations in the many studies included in the systematic review may have under-interpreted some of the findings relating to effects of bisphosphonates. Trial registration This trial is registered as ISRCTN10491361. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR127550) and is published in full in Health Technology Assessment; Vol. 28, No. 21. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Opinder Sahota
- Department of Health Care for Older People, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | | | - Zoe Paskins
- School of Medicine, Keele University and Haywood Academic Rheumatology Centre, Stoke-on-Trent, UK
| | - Simon Bishop
- Business School, University of Nottingham, Nottingham, UK
| | - Tessa Langley
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Neil Gittoes
- Centre for Endocrinology Diabetes and Metabolism, University of Birmingham, Birmingham, UK
| | - Sarah Davis
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Ann Baily
- Lay Member, Nottingham Osteoporosis Society Patient Support group, Nottingham, UK
| | - Moira Holmes
- Lay Member, Nottingham Osteoporosis Society Patient Support group, Nottingham, UK
| | - Jo Leonardi-Bee
- School of Medicine, University of Nottingham, Nottingham, UK
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Baig A, Foss A, Sahota O, Sehat K, Ash I. Vision Screening in Older Adults Admitted with a Fragility Hip Fracture: A Healthcare Quality Improvement Report. Br Ir Orthopt J 2023; 19:96-107. [PMID: 38027394 PMCID: PMC10668886 DOI: 10.22599/bioj.331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 10/27/2023] [Indexed: 12/01/2023] Open
Abstract
Background This healthcare quality improvement report focussed on the effectiveness of an orthoptic-led inpatient vision screening service at Nottingham University Hospitals for older adults admitted with a fragility hip fracture. The service was developed in response to national guidance, which recommended a multifactorial assessment, including a vision assessment for older adults presenting following a fall. Method Vision screening was carried out by orthoptists on eligible patients ≥65 years of age admitted to the trauma and orthopaedic wards with a hip fracture. Retrospective data for patients screened between 2015-2019 were analysed, including: patient demographics; screening eligibility and outcome; ophthalmology referrals made; ophthalmology appointment attendance; and outcome. Results Of the 3321 patients admitted with a hip fracture between 2015-2019, 2033 (61%) were eligible for vision screening and 1532 (75%) of these were screened. Furthermore, 784 (51%) of the patients screened had an ocular abnormality requiring an ophthalmology referral, or a sight test at an optician. Only 144 of the 383 (38%) who required an ophthalmology referral via the GP were successfully referred, and only 107 of the 186 (58%) patients who were given appointments attended them. Additionally, 98 of 107 had pathology, with cataracts the most common finding (51%), and 61 of 98 (62%) patients had treatable vision impairment. Conclusions We found a large proportion of fragility hip fracture patients with impaired vision, much of which was treatable and could be detected effectively with orthoptic-led bedside screening. The most common eye problem in those referred to ophthalmology was cataracts. An internal referral pathway to ophthalmology is proposed. There is a need to investigate reasons for disengagement with eye care services in this population.
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Affiliation(s)
- Aishah Baig
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Alexander Foss
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Opinder Sahota
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Khosrow Sehat
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Isabel Ash
- Nottingham University Hospitals NHS Trust, Nottingham, UK
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Tan CW, Arlachov Y, Czernicki M, Bishop S, Pasku D, Drummond A, Podlasek A, Sahota O. Spinal medial branch nerve root block (MBNB) intervention compared to standard care-vertebroplasty (VP) for the treatment of painful osteoporotic vertebral fractures in frail, older hospitalised patients: a feasibility study. Arch Osteoporos 2023; 18:126. [PMID: 37831315 DOI: 10.1007/s11657-023-01336-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/03/2023] [Indexed: 10/14/2023]
Abstract
Our study aimed to assess the feasibility outcomes comparing spinal medial branch nerve root block intervention to standard care vertebroplasty for the treatment of painful osteoporotic vertebral fractures in frail, hospitalised older patients. We found the study to be feasible and now propose a clinical effectiveness, cost effectiveness and safety evaluation. INTRODUCTION Vertebroplasty (VP) is a key-hole procedure involving injection of bone cement into a fractured vertebral body, to reduce pain and increase vertebral body stability, although it is associated with a small risk of complications, particularly in frail, older hospitalised patients. Medial branch spinal nerve block (MBNB) may be an alternative treatment to alleviate pain symptoms, with less complications; however, no study has prospectively compared the clinical effectiveness, cost-effectiveness and safety of MBNB to VP, in frail, older hospitalised patients. The aim of our study was to conduct a 1st stage feasibility study, exploring recruitment, retention and several outcomes measures (means and SDs), together with qualitative interviews to assess participant and clinician views, to inform a definitive larger study. METHODS We conducted a two-arm feasibility randomised controlled trial with participants allocated to continue with routine surgical care-VP or MBNB treatment, with an embedded qualitative study. Data was collected at baseline, week 1, 4, and week 8. RESULTS Out of 40 eligible patients, 30 (75%) consented to take part in the study. The overall median time from randomisation to intervention was 3 days, IQR 1-7 days, 5 (1-7) days for VP and 2 (1-3) days for MBNB. Median (IQR) length of hospital stay for the VP group was 20 (8) days and for the MBNB 15(22) days. The proportion of completeness of outcome data collection at weeks 1, 4 and 8 was at least 77%: 14 (100%), 12 (85.7%) and 11(78.9%) for VP and 13 (100%), 12 (92.3%) and 10 (76.8%) for MBNB, respectively. There were no significant difference in the clinical outcomes or adverse events between the two groups. DISCUSSION Our study was feasible in achieving is target recruitment, participants adhered to the randomisation and at least 77% completeness of data at the 8 week end-point (target 75%). We now plan to conduct a definitive clinical effectiveness, cost effectiveness and safety outcome study, comparing VP to MBNB in frail, older patients hospitalised with an acute vertebral osteoporotic fracture.
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Affiliation(s)
- Chia Wei Tan
- Healthcare of the Older People, QMC, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Yuriy Arlachov
- Department of Radiology, QMC, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Michal Czernicki
- Department of Anaesthesia, QMC, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Simon Bishop
- Nottingham University Business School, Jubilee Campus, Nottingham, NG8 1BB, UK
| | - Dritan Pasku
- Centre for Spinal Studies and Surgery, QMC, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Avril Drummond
- School of Health Sciences, B236, Medical School, QMC, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Anna Podlasek
- Healthcare of the Older People, QMC, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Opinder Sahota
- Healthcare of the Older People, QMC, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK.
- Centre for Spinal Studies and Surgery, QMC, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK.
- National Institute for Health Research (NIHR) Nottingham, Biomedical Research Centre (BRC), Nottingham, UK.
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Paskins Z, Moult A, Corp N, Bastounis A, Davis S, Narayanasamy MJ, Griffin J, Gittoes N, Leonardi-Bee J, Langley T, Bishop S, Sahota O. Research priorities regarding the use of bisphosphonates for osteoporosis: a UK priority setting exercise. Osteoporos Int 2023; 34:1711-1718. [PMID: 37294333 DOI: 10.1007/s00198-023-06806-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 05/23/2023] [Indexed: 06/10/2023]
Abstract
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. 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.
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Affiliation(s)
- Zoe Paskins
- School of Medicine, Keele University, David Weatherall Building, Newcastle-Under-Lyme, ST5 5BG, UK.
- Haywood Academic Rheumatology Centre, Haywood Hospital, High Lane, Burslem, Stoke-On-Trent, ST6 7AG, UK.
| | - Alice Moult
- School of Medicine, Keele University, David Weatherall Building, Newcastle-Under-Lyme, ST5 5BG, UK
| | - Nadia Corp
- School of Medicine, Keele University, David Weatherall Building, Newcastle-Under-Lyme, ST5 5BG, UK
| | - Anastasios Bastounis
- Faculty of Medicine & Health Sciences, University of Nottingham, City Hospital, Nottingham, NG5 1PB, UK
| | - Sarah Davis
- School of Health and Related Research (ScHARR), University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | | | - Jill Griffin
- Royal Osteoporosis Society (ROS), St James House, The Square, Lower Bristol Road, BA2 3BH, UK
| | - Neil Gittoes
- Centre for Endocrinology, Diabetes and Metabolism, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Jo Leonardi-Bee
- Centre for Evidence Based Healthcare, Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, NG5 1PB, UK
| | - Tessa Langley
- Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, NG5 1PB, UK
| | - Simon Bishop
- Nottingham University Business School, University of Nottingham, Nottingham, NG8 1BB, UK
| | - Opinder Sahota
- Department of Healthcare of Older People, Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB, UK
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Bishop S, Narayanasamy MJ, Paskins Z, Corp N, Bastounis A, Griffin J, Gittoes N, Leonardi-Bee J, Langley T, Sahota O. Clinicians' views of prescribing oral and intravenous bisphosphonates for osteoporosis: a qualitative study. BMC Musculoskelet Disord 2023; 24:770. [PMID: 37770860 PMCID: PMC10540377 DOI: 10.1186/s12891-023-06865-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 09/08/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND Bisphosphonate medications, including alendronate, ibandronate and risedronate administered orally and zoledronate, administered intravenously, are commonly prescribed for the treatment of osteoporosis based on evidence that, correctly taken, bisphosphonates can improve bone strength and lead to a reduction in the risk of fragility fractures. However, it is currently unclear how decisions to select between bisphosphonate regimens, including intravenous regimen, are made in practice and how clinicians support patients with different treatments. METHODS This was an interpretivist qualitative study. 23 semi-structured telephone interviews were conducted with a sample of general practitioners (GPs), secondary care clinicians, specialist experts as well as those providing and leading novel treatments including participants from a community intravenous (IV) zoledronate service. Data analysis was undertaken through a process of iterative categorisation. RESULTS The results report clinicians varying experiences of making treatment choices, as well as wider aspects of osteoporosis care. Secondary care and specialist clinicians conveyed some confidence in making treatment choices including on selecting IV treatment. This was aided by access to diagnostic testing and medication expertise. In contrast GPs reported a number of challenges in prescribing bisphosphonate medications for osteoporosis and uncertainty about treatment choice. Results also highlight how administering IV zoledronate was seen as an opportunity to engage in broader care practices. CONCLUSION Approaches to making treatment decisions and supporting patients when prescribing bisphosphonates for osteoporosis vary in practice. This study points to the need to co-ordinate osteoporosis treatment and care across different care providers.
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Affiliation(s)
- Simon Bishop
- Nottingham University Business School, University of Nottingham, Nottingham, NG5 1PB, UK.
| | | | - Zoe Paskins
- School of Medicine, Keele University, David Weatherall Building, Newcastle-Under-Lyme, UK
- ST5 5BG and Haywood Academic Rheumatology Centre, Haywood Hospital, High Lane, Burslem, Stoke-On-Trent, ST6 7AG, UK
| | - Nadia Corp
- School of Primary, Community and Social Care, Keele University, Newcastle-Under-Lyme, ST5 5BG, UK
| | - Anastasios Bastounis
- Division of Epidemiology & Public Health, School of Medicine, University of Nottingham, City Hospital, Nottingham, NG5 1PB, UK
| | - Jill Griffin
- Royal Osteoporosis Society (ROS), St James House, The Square, Lower Bristol Road, Bath, BA2 3BH, UK
| | - Neil Gittoes
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Jo Leonardi-Bee
- Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, NG5 1PB, UK
| | - Tessa Langley
- Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, NG5 1PB, UK
| | - Opinder Sahota
- Department of Healthcare of Older People, Nottingham University Hospitals NHS Trust, Nottingham, NG72UH, UK
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Marsh K, Avery A, Taylor R, Cameron M, Sahota O. Comparison of the taste and acceptability of a new high protein ice cream (Nottingham-Ice cream) with standard hospital milkshake oral nutritional supplement in older people with fragility fractures: a short report. BMJ Open Qual 2023; 12:e002297. [PMID: 37783514 PMCID: PMC10565127 DOI: 10.1136/bmjoq-2023-002297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 07/12/2023] [Indexed: 10/04/2023] Open
Abstract
INTRODUCTION Oral nutritional supplement (ONS) prescription iscommonly recommended for older patients with hip fractures. However, ONS compliance is often low. Ice cream may be a promising nutritional intervention. Using a Plan-Do-Study Act methodology we describe the second cycle of a project using an ice cream based nutritional supplement called Nottingham-Ice cream (N-ICE CREAM) to address malnutrition in older adults. The project aimed to identify whether N-ICE CREAM is a suitable option/alternative to standard ONS. METHODS Fifty older (≥ 65 years) inpatients with hip or spine fractures were recruited. Both groups received two days each of N-ICE CREAMand milkshake ONS. We measured compliance, acceptability (rating 0"dislike a lot" to 7 "like a lot"), attitudes towards prescription length (rating 0 "very unconfident" to 4 "very confident") and preference. RESULTS Mean (standard deviation, SD) patient age was 80.6 (7.7) years. The majority (n = 21, 67.7%) preferred N-ICE CREAM. Mean compliance to N-ICE CREAM was greater in both groups (group A (n = 22) 69.9 (30.0)% and group B (n = 26) 56.3 (39.3)%) compared to milkshake ONS (group A (n = 22) 43.4 (4.7)% and group B (n = 26) 53.6 ± (40.2)%). Mean acceptability ratings were higher for N-ICE CREAM, thus the overall impression score was greater. Confidence score for both products decreased with increasing time. CONCLUSIONS N-ICE CREAM is more accepted by older patients with hip or spine fractures compared to milkshake ONS. Further research should explore long-term compliance and clinical outcomes.
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Affiliation(s)
- Kirandeep Marsh
- Department of Dietetics, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Amanda Avery
- Nutrition and Dietetics, University of Nottingham Faculty of Sciences, Nottingham, UK
| | - Rachael Taylor
- Department for Health Care of Older People, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Maribel Cameron
- Department for Health Care of Older People, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Opinder Sahota
- Department for Health Care of Older People, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Centre for Spinal Studies and Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Nottingham Biomedical Research Centre, National Institute for Health Research, Nottingham, UK
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Johansen A, Sahota O, Dockery F, Black AJ, MacLullich AMJ, Javaid MK, Ahern E, Gregson CL. Call to action: a five nations consensus on the use of intravenous zoledronate after hip fracture. Age Ageing 2023; 52:afad172. [PMID: 37776543 PMCID: PMC10542103 DOI: 10.1093/ageing/afad172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Indexed: 10/02/2023] Open
Abstract
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.
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Affiliation(s)
- Antony Johansen
- University Hospital of Wales and College of Medicine, Cardiff University, Cardiff CF14 4XW, UK
- Falls and Fragility Fracture Audit Programme, Royal College of Physicians, London NW1 4LE, UK
| | - Opinder Sahota
- Department of Health Care of Older People, Nottingham University Hospital, Nottingham NG7 2UH, UK
| | | | - Alison J Black
- NHS Grampian, Aberdeen Royal Infirmary, Aberdeen, AB25 2ZN, UK
| | - Alasdair M J MacLullich
- Ageing and Health Research Group, University of Edinburgh, Edinburgh EH9 3EG, UK
- Scottish Hip Fracture Audit (SHFA), Edinburgh, UK
| | - M Kassim Javaid
- Falls and Fragility Fracture Audit Programme, Royal College of Physicians, London NW1 4LE, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), University of Oxford, Oxford OX3 7HE, UK
| | - Emer Ahern
- Cork University Hospital and University College Cork, Cork, Ireland
- Health Service Executive, Dublin 8D08 W2A8, Ireland
- Irish Hip Fracture Database (IHFD), National Office of Clinical Audit, Dublin 2, D02 VN51, Ireland
| | - Celia L Gregson
- Musculoskeletal Research Unit, Bristol Medical School, University of Bristol, Bristol BS10 5NB, UK
- Older Persons Unit, Royal United Hospital NHS Trust, Combe Park, Bath BA1 3NG, UK
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Sahota A, Marsh K, Avery A, Sahota O. Are we achieving the standards of good nutritional care for older people in hospital with fragility fractures? BMJ Open Qual 2023; 12:e002288. [PMID: 37783519 PMCID: PMC10565263 DOI: 10.1136/bmjoq-2023-002288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 06/11/2023] [Indexed: 10/04/2023] Open
Abstract
Malnutrition is common in older people with fragility fractures and is associated with poor clinical outcomes and increased risk of complications. The UK National Health Service has published national standards for food and drink for patients, staff and visitors, in hospitals. These standards describe the methods to ensure quality and sustainability.We assessed these standards and report the nutritional status of older (70 years of age) patients admitted to hospital with fragility fracture, and weighed food trolley and plate waste after lunch and supper for five days.There were 19 older patients with fragility fractures on the trauma and orthopaedic ward. The mean intake for 'nutritionally well' was 1592 kcal/day and 65.7 g/day protein; the mean intake for 'nutritionally vulnerable' was 643 kcal/day and 24.8 g/day protein.Although all key characteristics of good nutrition and hydration care for patients in hospital were achieved, energy and protein intake was poor in the nutritionally vulnerable group. Further interventions are necessary to improve dietary intake in hospital, particularly in those who are nutritionally vulnerable.
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Affiliation(s)
- Amunpreet Sahota
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Kirandeep Marsh
- Department of Dietetics, Nottingham University Hospitals NHS Trust Queen's Medical Centre Campus, Nottingham, UK
| | - Amanda Avery
- Nutrition and Dietetics, University of Nottingham Faculty of Sciences, Nottingham, UK
| | - Opinder Sahota
- Healthcare of Older People, Nottingham University Hospitals NHS Trust Queen's Medical Centre Campus, Nottingham, UK
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Tan CW, Sahota O. A 3-year retrospective analysis of patients admitted with clinical vertebral fragility fractures across hospitals in England, UK. Osteoporos Int 2023; 34:607-611. [PMID: 36607407 PMCID: PMC9908666 DOI: 10.1007/s00198-022-06647-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 12/13/2022] [Indexed: 01/07/2023]
Abstract
UNLABELLED Our database aimed to assess the impact of vertebral fragility fractures (VFFs) on hospitalisation in England. The results showed that admissions secondary to VFF are increasing annually, more significantly in patients aged 75 years and over. Vertebral augmentation has been showed to reduce length of stay in hospital. INTRODUCTION Vertebral fragility fractures (VFFs) are the most common osteoporotic fracture. VFF can result in significant pain requiring hospitalisation. However, there are little data on patient numbers, hospital bed days, and costs, contributed to by these patients. METHODOLOGY We report a retrospective analysis of patients aged 55 years and over admitted to hospitals across England from 2017 to 2019. ICD-10 classifications for VFF and OPCS codes were used to identify admissions and patients who had undergone vertebral augmentation (VA). RESULTS There were 99,370 patients (61% female) admitted during this period, with 64,370 (65%) patients aged over 75 years. There was a 14.3% average increase in admissions annually. Patients aged over 75 years accounted for 1.5 million bed days, costing £465 million (median length of stay (MLOS) 14.4 days). In comparison, those aged 55-74 years, accounted for 659,000 bed days, costing £239 million (MLOS 10.7 days). The majority of patients (84%) were admitted under a non-surgical speciality and were primarily older (median age 76.8 vs 67.6 years, MLOS 8.2 vs 6.0 days), compared to those admitted to surgical wards 1755 patients underwent vertebral augmentation (VA) (1.8% of the total cohort). The median age of patients undergoing VA was 73.3 years, with 775 (44.2%) of these were aged 75 years and over. In comparison, the median age of patients managed conservatively (non-surgically) was 75.7 years, with 63,595 patients (65.1%) aged 75 years and over. The MLOS and cost per patient admission were lower in the VA group compared to those managed non-surgically. CONCLUSION Hospitalised VFF patients represented a significant number, cost, and use of bed days. Those undergoing VA had a significantly shorter length of stay. Further studies are necessary to define those who may benefit from early VA.
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Affiliation(s)
- Chia Wei Tan
- Healthcare of the Older People, QMC, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK.
| | - Opinder Sahota
- Healthcare of the Older People, QMC, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
- Centre for Spinal Studies and Surgery, QMC, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Nottingham, UK
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham, UK
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Marsh K, Avery A, Sahota O. 1179 4.5 TONNES OF FOOD WASTED ACROSS A HOSPITAL WARD: A SERVICE EVALUATION OF DIETARY INTAKE AND FOOD WASTE. Age Ageing 2023. [DOI: 10.1093/ageing/afac322.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Abstract
Introduction
Malnutrition is a debilitating condition in hospitalised older people. There has been limited studies exploring dietary intake and oral nutritional supplement (ONS) compliance in these people. The purpose of this service evaluation was to observe daily energy and protein intake, plate waste and ONS compliance and to report food waste at ward level.
Methods
Three-day dietary (food-only) intake and plate waste of 19 older (≥ 65 years) people on a hospital trauma and orthopaedic (T&O) ward were assessed. Patients were categorised as ‘nutritionally well’ or ‘nutritionally vulnerable’ as per British Dietetics Association’s (BDA) Nutrition and Hydration Digest criteria. Dietary intake was calculated by a Dietitian and compared with adjusted BDA standards to exclude energy and protein from drinks. Ward plate and food trolley waste were weighed after lunch and supper for five days. Thirty-three ONS from 11 patients were collected before disposal and weighed.
Results
Mean age of the patients were 84 ± 9 years (9 female, and 10 male) with the most common injury hip fracture (68.4%). Mean (standard deviation, SD) intake for ‘nutritionally well’ was 1592 (257) kcal/day and 65.7(8.5) g/day protein and ‘nutritionally vulnerable’ (n= 15) 643 (354) kcal/day and 24.8 (14.0) g/day protein. Plate waste for ‘nutritionally well’ was 4.1 (5.8)% at main meals and 1.7 (3.4)% at pudding and for ‘nutritionally vulnerable’ 53.1 (26.6)% at main meals and 38.6 (32.2)% at pudding. Compliance to ONS was 28.3 (38.8)%. The combined mealtime plate waste weighed 6.2 (1.2) kg/day and food-trolley waste 6.2 (0.9) kg/day. This equates to approximately 4526kg/year (4.5T).
Conclusions
Energy and protein intake and compliance to ONS in older T&O patients is sub-optimal. Food waste is high and urgently needs addressing. Further, interventions are warranted to improve dietary intake in hospital and to explore the acceptability of alternative ONS food/drink styles.
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Affiliation(s)
- K Marsh
- Nottingham University School of Biosciences,
- Nottingham University Hospitals NHS Trust Department of Health Care of Older People,
| | - A Avery
- Nottingham University School of Biosciences,
| | - O Sahota
- Nottingham University Hospitals NHS Trust Department of Health Care of Older People,
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11
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Dwivedi R, Mishra L, Ghobrial H, Abbas H, Ali A, Khalid M, Sahota O. Prevalent vertebral fractures in patients admitted with acute hip fracture. Osteoporos Int 2023; 34:207-208. [PMID: 36342538 DOI: 10.1007/s00198-022-06564-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 09/14/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Rajesh Dwivedi
- Department of Health Care for Older People, Nottingham University Hospital, Derby Road, Nottingham, NG7 2UH, UK.
| | - Lalit Mishra
- Department of Health Care for Older People, Nottingham University Hospital, Derby Road, Nottingham, NG7 2UH, UK
| | - Hedra Ghobrial
- Department of Health Care for Older People, Nottingham University Hospital, Derby Road, Nottingham, NG7 2UH, UK
| | - Hashim Abbas
- Department of Health Care for Older People, Nottingham University Hospital, Derby Road, Nottingham, NG7 2UH, UK
| | - Asad Ali
- Department of Health Care for Older People, Nottingham University Hospital, Derby Road, Nottingham, NG7 2UH, UK
| | - Mohammed Khalid
- Department of Health Care for Older People, Nottingham University Hospital, Derby Road, Nottingham, NG7 2UH, UK
| | - Opinder Sahota
- Department of Health Care for Older People, Nottingham University Hospital, Derby Road, Nottingham, NG7 2UH, UK
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12
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Narayanasamy M, Bishop S, Sahota O, Paskins Z, Gittoes N, Langley T. Acceptability and engagement amongst patients on oral and intravenous bisphosphonates for the treatment of osteoporosis in older adults. Age Ageing 2022; 51:6834153. [PMID: 36413592 DOI: 10.1093/ageing/afac255] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 09/05/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Osteoporosis is common in older adults leading to fragility fractures at enormous individual and economic cost. Improving long-term adherence with bisphosphonate treatments reduces fracture risk, but adherence rates for first-line oral bisphosphonate alendronate remains low. Although alternative treatment regimens, including annual intravenous infusions are available, patient acceptability remains unclear. Therefore, understanding patients' acceptability and engagement in different bisphosphonate regimens is important to ensure optimal treatment benefits. METHODS Semi-structured interviews were conducted with 78 patients with a mean age of 69.9 years, who had taken or received bisphosphonates for osteoporosis within the last 24 months. Data analysis included iterative categorisation and used the theoretical framework of acceptability (TFA) to compare the acceptability of treatments regimens. RESULTS Treatment acceptability and engagement were influenced by the extent to which patients understood the prescribed treatment, and evidence of the treatment working. Acceptability and engagement were compromised when treatment was perceived as burdensome, personal costs were incurred, and patients' values were incompatible with the regimen. The balancing of these factors contributed to patients' ability to cope with the treatment and their emotional responses. Intravenous treatment was generally perceived as easier to understand, more effective, less burdensome with fewer opportunity costs, and a preferable regimen compared with oral bisphosphonates. CONCLUSIONS Annual intravenous zoledronate bisphosphonate treatment was generally more acceptable to patients, perceived as more straightforward to engage in, although a small portion of patients on oral bisphosphonates were satisfied with treatment. Further research is needed to identify how acceptability and engagement can be optimised.
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Affiliation(s)
- Melanie Narayanasamy
- Centre for Rehabilitation & Ageing Research, School of Medicine, University of Nottingham, Nottingham, UK
| | - Simon Bishop
- Organisational Behaviour and Human Resource Management, Nottingham University Business School, University of Nottingham, Nottingham, UK
| | - Opinder Sahota
- Geriatric Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Zoe Paskins
- Primary Care and Health Sciences, School of Medicine, Keele University, Staffordshire, UK
| | - Neil Gittoes
- Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Tessa Langley
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
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13
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Sahota A, Barbary R, Cameron M, Stewart AM, Sahota O. Safety of zoledronate in older patients at high risk of fracture with reduced renal function. Osteoporos Int 2022; 33:1823-1824. [PMID: 35599255 DOI: 10.1007/s00198-022-06427-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 05/04/2022] [Indexed: 10/18/2022]
Affiliation(s)
- A Sahota
- Medical School, George Davies Centre, University of Leicester, Lancaster Rd, Leicester, UK
| | - R Barbary
- East Bridgford Medical Centre, Nottinghamshire Healthcare, Nottingham, UK
| | - M Cameron
- Depart HCOP, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - A-M Stewart
- East Bridgford Medical Centre, Nottinghamshire Healthcare, Nottingham, UK
| | - O Sahota
- Depart HCOP, Nottingham University Hospitals NHS Trust, Nottingham, UK.
- The Centre for Spinal Studies and Surgery, Nottingham University Hospital NHS Trust, Nottingham, UK.
- Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Nottingham, UK.
- National Institute for Health Research (NIHR), Nottingham Biomedical Research Centre (BRC), University of Nottingham, Nottingham, UK.
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14
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Sahota A, Desai H, Hershkovica O, Sahota O. Poor Attendance for bone densitometry in patients at high risk of subsequent fragility fractures. J Clin Densitom 2022; 25:380-383. [PMID: 34973896 DOI: 10.1016/j.jocd.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/11/2021] [Accepted: 11/08/2021] [Indexed: 11/25/2022]
Abstract
Fracture Liaison Services (FLS) are considered the most effective model for the prevention of subsequent fractures however, the uptake of these services has shown to be suboptimal. 6,528 patients were identified and referred on for bone densitometry assessment over a 6 yr period, however, 21% of these patients did not attend, with a trend towards a higher re-fracture rate in those that did not attend compared to those that did. The presence of a fragility fracture increases the risk of further fractures. Fracture Liaison Services (FLS) are considered the most effective model for the prevention of subsequent fractures, although the uptake amongst patients invited for bone densitometry assessment has shown to be suboptimal. The UK has one of the most comprehensive numbers of FLS, however the proportion and characteristics of patients identified through the FLS that do not respond to bone densitometry invitation, in the UK, remains unclear. We report the 6 yr. findings from the Nottingham FLS. The Nottingham Fracture Liaison Service (N-FLS) systematically identifies those adults aged 50 yr. and older with fragility fractures presenting to the fracture clinic and where appropriate, arranges referral for bone densitometry assessment. Routine clinical data is collected onto the N-FLS database. Patient characteristics, between January 2012 and December 2017, were examined of those referred for bone densitometry examination, comparing those that attended to those that did not attend (DNA). Deprivation scores for each patient were calculated using the English indices of deprivation 2015 (1-Most deprived; 5- Least deprived). Follow up data was available for those attending from 2016 onwards, which allowed an assessment of re-fracture. Over the 6 yr period, 6,528 patients as identified by the N-FLS were referred on for bone densitometry assessment. 1,386 patients (21%) did not attend (DNA) for bone densitometry assessment. The proportion was similar for each of the years. High prevalence of non-attendance was in females [1032 patients (74%)] and the most deprived individuals [398 patients (29%), which were significant when compared to those that did attend, p=0.042]. 826 patients were referred in 2016. Median follow-up time was 2.46 yr. (IQR 0.16-3.00 yr.). 52 (7%) patients, in this group, sustained a subsequent fracture (35 patients in the group that did not attend for bone density assessment and 17 in those that attend, p=0.092). Nottingham FLS have identified patients with fragility fractures that are at high-risk of further fractures. Despite a dedicated FLS, 21% of those invited for bone densitometry assessment, did not attend for their appointment, over the 6 yr. period, similar proportion each year. There was a significantly higher proportion of those identified as 'most deprived' not attending for a bone densitometry, compared to those who attended. Sub-analysis in those aged 75 yr. and over, showed a high non-attendance in this group. Further qualitative studies are necessary to explore this patient group in detail, who remain at high risk of re-fracture.
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Affiliation(s)
- Arunpreet Sahota
- Medical School, University of Leicester, Leicester, UK; Department of Ophthalmology, Queens Medical Centre, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Henal Desai
- Department for Healthcare of Older People, Queens Medical Centre, Nottingham University Hospital NHS Trust, Nottingham, UK; Department of Ophthalmology, Queens Medical Centre, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Orly Hershkovica
- Department for Healthcare of Older People, Queens Medical Centre, Nottingham University Hospital NHS Trust, Nottingham, UK; Department of Ophthalmology, Queens Medical Centre, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Opinder Sahota
- Department for Healthcare of Older People, Queens Medical Centre, Nottingham University Hospital NHS Trust, Nottingham, UK; Department of Ophthalmology, Queens Medical Centre, Nottingham University Hospital NHS Trust, Nottingham, UK; Division of Injury, Inflammation and Recovery Sciences, University of Nottingham, Nottingham, UK; Nottingham Biomedical Research Centre (BRC), National Institute for Health Research (NIHR) , Nottingham, UK.
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15
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Tan CW, Cameron M, Arlachov Y, Bastounis A, Bishop S, Czernicki M, Drummond A, Fakis A, Pasku D, Sahota O. The Acute VertEbRal AugmentaTion (AVERT) study: protocol for a randomised controlled, feasibility trial of spinal medial branch nerve block in hospitalised older patients with vertebral fragility fractures. BMJ Open 2022; 12:e059194. [PMID: 35697440 PMCID: PMC9196181 DOI: 10.1136/bmjopen-2021-059194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Vertebral fragility fractures (VFFs) are the most common type of osteoporotic fracture found in older people, resulting in increasing morbidity and excess mortality. These fractures can cause significant pain, requiring admission to hospital. Vertebroplasty (VP) is effective in reducing pain and allowing early mobilisation in hospitalised patients. However, it may be associated with complications such as cement leakage, infection, bleeding at the injection site and fracture of adjacent vertebrae. It is also costly and not readily accessible in many UK hospitals.A recent retrospective study reported that spinal medial branch nerve block (MBNB), typically used to treat facet arthropathy, had similar efficacy in terms of pain relief compared with VP for the treatment of painful VFF. However, to date, no study has prospectively compared MBNB to VP. We therefore propose a prospective feasibility randomised controlled trial (RCT) to compare the role of MBNB to VP, in hospitalised older patients. METHOD A parallel, two-arm RCT with participants allocated on a 1:1 ratio to either standard care-VP or MBNB in hospitalised patients aged over 70 with acute osteoporotic vertebral fractures. Follow-up will be at weeks 1, 4 and 8 post intervention. The primary objective is to determine the feasibility and design of a future trial, including specific outcomes of recruitment, adherence to randomisation and safety. Embedded within the trial will be a health economic evaluation to understand resource utilisation and implications of the intervention and a qualitative study of the experiences and insights of trial participants and clinicians. Secondary outcomes will include pain scores, analgesia requirements, resource use and quality of life data. ETHICS AND DISSEMINATION Ethical approval was granted by the Yorkshire & the Humber Research Ethics Committee (reference 21/YH/0065). AVERT (Acute VertEbRal AugmentaTion) has received approval by the Health Research Authority (reference IRAS 293210) and is sponsored by Nottingham University Hospitals NHS Trust (reference 21HC001). Recruitment is ongoing. Results will be presented at relevant conferences and submitted to appropriate journals for publication on completion. TRIAL REGISTRATION NUMBER ISRCTN18334053.
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Affiliation(s)
- Chia Wei Tan
- Health Care of the Older People, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Maribel Cameron
- Health Care of the Older People, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Yuriy Arlachov
- Department of Radiology, Nottingham University Hospitals NHS Trust, Nottingham, Nottingham, UK
| | - Anastasios Bastounis
- Division of Epidemiology & Public Health, University of Nottingham, Nottingham, UK
| | - Simon Bishop
- Nottingham University Business School, Nottingham University, Nottingham, UK
| | - Michal Czernicki
- Department of Anaesthesia, Nottingham University Hospitals NHS Trust, Nottingham, Nottingham, UK
| | - Avril Drummond
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Apostolos Fakis
- Derby Clinical Trials Support Unit, Royal Derby Hospital, Derby, UK
| | - Dritan Pasku
- Centre for Spinal Studies and Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Opinder Sahota
- Health Care of the Older People, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Centre for Spinal Studies and Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
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16
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Bastounis A, Langley T, Davis S, Paskins Z, Gittoes N, Leonardi-Bee J, Sahota O. Comparing medication adherence in patients receiving bisphosphonates for preventing fragility fractures: a comprehensive systematic review and network meta-analysis. Osteoporos Int 2022; 33:1223-1233. [PMID: 35188591 PMCID: PMC9106630 DOI: 10.1007/s00198-022-06350-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 02/14/2022] [Indexed: 10/24/2022]
Abstract
BACKGROUND Bisphosphonates are effective in preventing fragility fractures; however, high rates of adherence are needed to preserve clinical benefits. OBJECTIVE To investigate persistence and compliance to oral and intravenous bisphosphonates (alendronate, ibandronate, risedronate, and zoledronate). METHODS Searches of 12 databases, unpublished sources, and trial registries were conducted, covering the period from 2000 to April 2021. Screening, data extraction, and risk of bias assessment (Cochrane Collaboration risk-of-bias tool 1.0 & ROBINS-I) were independently undertaken by two study authors. Randomised controlled trials (RCTs) and observational studies that used prescription claim databases or hospital medical records to examine patients' adherence were included. Network meta-analyses (NMA) embedded within a Bayesian framework were conducted, investigating users' likelihood in discontinuing bisphosphonate treatment. Where meta-analysis was not possible, data were synthesised using the vote-counting synthesis method. RESULTS Fifty-nine RCTs and 43 observational studies were identified, resulting in a total population of 2,656,659 participants. Data from 59 RCTs and 24 observational studies were used to populate NMAs. Zoledronate users were the least likely to discontinue their treatment HR = 0.73 (95%CrI: 0.61, 0.88). Higher rates of compliance were observed in those receiving intravenous treatments. The paucity of data and the heterogeneity in the reported medication possession ratio thresholds precluded a NMA of compliance data. CONCLUSIONS Users of intravenously administered bisphosphonates were found to be the most adherent to treatment among bisphosphonates' users. Patterns of adherence will permit the more precise estimation of clinical and cost-effectiveness of bisphosphonates. TRIAL REGISTRATION PROSPERO 2020 CRD42020177166.
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Affiliation(s)
- A. Bastounis
- grid.412920.c0000 0000 9962 2336Division of Epidemiology & Public Health, School of Medicine, University of Nottingham, City Hospital, Nottingham, NG5 1PB UK
| | - T. Langley
- grid.412920.c0000 0000 9962 2336Division of Epidemiology & Public Health, School of Medicine, University of Nottingham, City Hospital, Nottingham, NG5 1PB UK
| | - S. Davis
- grid.11835.3e0000 0004 1936 9262School of Health and Related Research, Regent Court (ScHARR), University of Sheffield, Sheffield, S1 4DA UK
| | - Z. Paskins
- grid.9757.c0000 0004 0415 6205School of Medicine, Keele University, Keele, ST5 5BG UK
- grid.500956.fHaywood Academic Rheumatology Centre, Midlands Partnership NHS Foundation Trust, Stoke-on-Trent , Staffordshire UK
| | - N. Gittoes
- grid.6572.60000 0004 1936 7486Centre for Endocrinology, Diabetes and Metabolism (CEDAM), University of Birmingham, Birmingham, UK
- grid.412563.70000 0004 0376 6589Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH UK
| | - J. Leonardi-Bee
- grid.412920.c0000 0000 9962 2336Division of Epidemiology & Public Health, School of Medicine, University of Nottingham, City Hospital, Nottingham, NG5 1PB UK
| | - O. Sahota
- grid.240404.60000 0001 0440 1889Queens Medical Centre (QMC), University of Nottingham, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH UK
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17
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Ong T, Suazo Di Paola A, Brookes C, Drummond A, Hendrick P, Leighton P, Jones M, Salem K, Quraishi N, Sahota O. ASSERT (Acute Sacral inSufficiEncy fractuRe augmenTation): randomised controlled, feasibility trial in older people. BMJ Open 2022; 12:e050535. [PMID: 35504639 PMCID: PMC9066477 DOI: 10.1136/bmjopen-2021-050535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/21/2022] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To determine the feasibility of designing and conducting a definitive trial to evaluate the effectiveness of sacral fracture fixation compared with non-surgical management among older people admitted with a lateral compression pelvic fragility fracture (PFF). DESIGN Single-site, parallel, two-arm randomised controlled feasibility trial. SETTING A UK tertiary centre hospital. PARTICIPANTS Patients aged ≥70 years who were ambulating pre-injury requiring hospital admission (within 28 days of injury) with a type 1 lateral compression PFF. INTERVENTIONS The intervention group received sacral fracture fixation (cement augmentation±screw fixation) within 7 days of randomisation. Routine preoperative and postoperative care followed each surgical intervention. The control group received usual care consisting of analgesia, and regular input from the medical and therapy team. PRIMARY AND SECONDARY OUTCOME MEASURES The feasibility outcomes were the number of eligible patients, willingness to be randomised, adherence to allocated treatment, retention, data on the completeness and variability of the proposed definitive trial outcome measures, and reported adverse events. RESULTS 241 patients were screened. 13 (5.4%) were deemed eligible to participate. Among the eligible participants, nine (69.2%) were willing to participate. Five participants were randomised to the intervention group and four to the control group. The clinicians involved were willing to allow their patients to be randomised and adhere to the allocated treatment. One participant in the intervention group and two participants in the control group received their allocated treatment. All participants were followed up until 12 weeks post-randomisation, and had an additional safety follow-up assessment at 12 months. Overall, the proportion of completeness of outcome measures was at least 75%. No adverse events were directly related to the trial. CONCLUSIONS There were significant challenges in recruiting sufficient participants which will need to be addressed prior to a definitive trial. TRIAL REGISTRATION NUMBER ISRCTN16719542.
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Affiliation(s)
- Terence Ong
- Department of Healthcare for Older People, Nottingham University Hospitals NHS Trust, Nottingham, UK
- Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | | | - Cassandra Brookes
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Avril Drummond
- Division of Rehabilitation and Ageing, School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Paul Hendrick
- School of Health Sciences, Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, UK
| | - Paul Leighton
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Matthew Jones
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Khalid Salem
- Centre for Spinal Studies and Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Nasir Quraishi
- Centre for Spinal Studies and Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Opinder Sahota
- Department of Healthcare for Older People, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Paskins Z, Bullock L, Manning F, Bishop S, Campbell P, Cottrell E, Jinks C, Narayanasamy M, Scott I, Sahota O, Ryan S. P059 Acceptability of remote consulting during COVID-19 among patients with two common long-term musculoskeletal conditions: findings from three qualitative studies and recommendations for practice. Rheumatology (Oxford) 2022. [DOI: 10.1093/rheumatology/keac133.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background/Aims
The COVID-19 pandemic led to the widespread adoption of remote consultations. Whilst remote consultations offer many potential advantages to patients and healthcare services, they are unlikely to be suitable for all. Guidance encourages clinicians to consider patient preferences when choosing face-to-face vs remote consultations. However, little is known about acceptability of, and preferences for remote consultations, particularly amongst patients with musculoskeletal conditions. This study aimed to explore the acceptability of, and preferences for, remote consultations among patients with osteoporosis and rheumatoid arthritis.
Methods
Data for this study derived from three UK qualitative studies: iFraP (improving fracture prevention study), Blast Off (BO; Bisphosphonate aLternAtive regimenS for the prevenTion of Osteoporotic Fragility Fractures), and ERA (Exploring people with Rheumatoid Arthritis’ experience of the pandemic). Each study explored patient experiences of accessing and receiving healthcare during the pandemic year. Transcripts from each data set relating to remote consulting were extracted. A minimum of two study team members worked independently, following a consistent approach, to conduct a rapid deductive analysis using the Theoretical Framework of Acceptability (TFA). The TFA consists of 7 constructs to understand acceptability of, in this context, remote consultations, including: affective attitudes; intervention coherence; perceived effectiveness; burden; self-efficacy; opportunity-costs; and ethicality. Following coding, the findings of all three studies were pooled. Analysis was facilitated by group meetings to discuss interpretations.
Results
Findings from 1 focus group and 64 interviews with 35 people, who had mostly experienced telephone consultations, were included the analysis. Participants’ emotional attitudes to remote consultations, views on fairness (ethicality) and sense making (intervention coherence) varied according to their specific needs for the consultation and values, relative to the pandemic context; participants perceived remote consultations as making more sense and being ‘fairer’ earlier in the pandemic. Some participants valued the reduced burden associated with remote consultations, while others highly valued, and did not want to give up, non-verbal communication or physical examination associated with face-to-face consults (opportunity costs); although perceived need for physical examination in participants with RA was associated with strong preference for face-to-face consultations, asymptomatic participants with RA and osteoporosis also expressed similar strong preferences. Some participants described low confidence (self-efficacy) in being able to communicate in remote consultations and others perceived remote consultations as ineffective, in part due to suboptimal communication.
Conclusion
Acceptability of, and preferences for remote consultation appear to be influenced by a range of societal, healthcare provider and personal factors and in this study, were not fixed, or condition-dependent. Remote care by default has the potential to exacerbate health inequalities and needs nuanced implementation. The findings have supported the development of patient-centred recommendations for practice that should be considered alongside clinician-focused recommendations when deciding whether remote consultations are appropriate.
Disclosure
Z. Paskins: Grants/research support; NIHR, Clinician Scientist Award (CS-2018-18-ST2-010)/NIHR Academy. L. Bullock: None. F. Manning: Grants/research support; part funded NIHR Clinical Research Network Scholar Programme. S. Bishop: None. P. Campbell: None. E. Cottrell: None. C. Jinks: Grants/research support; part funded by the NIHR Applied Research Collaboration (ARC) West Midlands. M. Narayanasamy: None. I. Scott: Grants/research support; funded by an NIHR Advanced Research Fellowship Award (NIHR300826). O. Sahota: None. S. Ryan: None.
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Affiliation(s)
- Zoe Paskins
- School of Medicine, Keele University, Newcastle-under-Lyme, UNITED KINGDOM
- Haywood Academic Rheumatology Centre, Midlands Partnership NHS Foundation Trust, Stoke on Trent, UNITED KINGDOM
| | - Laurna Bullock
- School of Medicine, Keele University, Newcastle-under-Lyme, UNITED KINGDOM
| | - Fay Manning
- School of Medicine, Keele University, Newcastle-under-Lyme, UNITED KINGDOM
- University of Exeter Medical School, University of Exeter, Exeter, UNITED KINGDOM
| | - Simon Bishop
- Centre for Health Innovation, Leadership and Learning, University of Nottingham, Nottingham, UNITED KINGDOM
| | - Paul Campbell
- Haywood Academic Rheumatology Centre, Midlands Partnership NHS Foundation Trust, Stoke on Trent, UNITED KINGDOM
| | - Elizabeth Cottrell
- School of Medicine, Keele University, Newcastle-under-Lyme, UNITED KINGDOM
| | - Clare Jinks
- School of Medicine, Keele University, Newcastle-under-Lyme, UNITED KINGDOM
| | - Melanie Narayanasamy
- Nottingham University Business School, University of Nottingham, Nottingham, UNITED KINGDOM
| | - Ian Scott
- School of Medicine, Keele University, Newcastle-under-Lyme, UNITED KINGDOM
- Haywood Academic Rheumatology Centre, Midlands Partnership NHS Foundation Trust, Stoke on Trent, UNITED KINGDOM
| | - Opinder Sahota
- Department of Health Care of Older People, Nottingham University Hospitals NHS Trust, Nottingham, UNITED KINGDOM
| | - Sarah Ryan
- School of Nursing, Keele University, Newcastle-under-Lyme, UNITED KINGDOM
- Haywood Academic Rheumatology Centre, Midlands Partnership NHS Foundation Trust, Stoke on Trent, UNITED KINGDOM
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19
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Paskins Z, Bullock L, Manning F, Bishop S, Campbell P, Cottrell E, Partner GP, Jinks C, Narayanasamy M, Scott IC, Sahota O, Ryan S. Acceptability of, and preferences for, remote consulting during COVID-19 among older patients with two common long-term musculoskeletal conditions: findings from three qualitative studies and recommendations for practice. BMC Musculoskelet Disord 2022; 23:312. [PMID: 35366845 PMCID: PMC8976169 DOI: 10.1186/s12891-022-05273-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 03/23/2022] [Indexed: 11/23/2022] Open
Abstract
Background Guidance for choosing face-to-face vs remote consultations (RCs) encourages clinicians to consider patient preferences, however, little is known about acceptability of, and preferences for RCs, particularly amongst patients with musculoskeletal conditions. This study aimed to explore the acceptability of, and preferences for, RC among patients with osteoporosis and rheumatoid arthritis. Methods Three UK qualitative studies, exploring patient experiences of accessing and receiving healthcare, undertaken during the pandemic, with people with osteoporosis and rheumatoid arthritis. Study team members agreed a consistent approach to conduct rapid deductive analysis using the Theoretical Framework of Acceptability (TFA) on transcripts from each data set relating to RC, facilitated by group meetings to discuss interpretations. Findings from the three studies were pooled. Results Findings from 1 focus group and 64 interviews with 35 people were included in the analysis. Participants’ attitudes to RC, views on fairness (ethicality) and sense-making (intervention coherence) varied according to their needs within the consultation and views of the pandemic. Some participants valued the reduced burden associated with RC, while others highly valued non-verbal communication and physical examination associated with face-to-face consults (opportunity costs). Some participants described low confidence (self-efficacy) in being able to communicate in RCs and others perceived RCs as ineffective, in part due to suboptimal communication. Conclusions Acceptability of, and preferences for RC appear to be influenced by societal, healthcare provider and personal factors and in this study, were not condition-dependant. Remote care by default has the potential to exacerbate health inequalities and needs nuanced implementation. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05273-1.
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Bastounis A, Langley T, Davis S, Paskins Z, Gittoes N, Leonardi‐Bee J, Sahota O. Assessing the effectiveness of bisphosphonates for the prevention of fragility fractures: an updated systematic review and network meta‐analyses. JBMR Plus 2022; 6:e10620. [PMID: 35509636 PMCID: PMC9059468 DOI: 10.1002/jbm4.10620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 02/10/2022] [Accepted: 02/25/2022] [Indexed: 11/11/2022] Open
Abstract
Bisphosphonates have been found to be effective in preventing fragility fractures. However, their comparative effectiveness in populations at risk has yet to be defined. In light of recent clinical trials, we aimed to compare four bisphosphonates (alendronate, ibandronate, risedronate, and zoledronate) and to identify which are the most effective for the prevention of fragility fractures. This is an update of a systematic review previously published as part of a NICE HTA report. We conducted a systematic review and network meta‐analysis, updating the estimates regarding the comparative effectiveness of the aforementioned bisphosphonates. Studies identified from published and unpublished sources between 2014 and 2021 were added to the studies identified in the previous review. Screening, data extraction and risk of bias assessment were independently undertaken by two reviewers. Outcomes were fractures, femoral neck bone mineral density (BMD), mortality, and adverse events. We identified 25 additional trials, resulting in a total population of 47,007 participants. All treatments had beneficial effects on fractures versus placebo with zoledronate being the most effective treatment in preventing vertebral fractures (hazard ratio [HR] 0.38; 95% credibility interval [CrI], 0.28–0.49). Zoledronate (HR 0.71; 95% CrI, 0.61–0.81) and risedronate (HR 0.70; 95% CrI, 0.53–0.84) were found to be the most effective treatments in preventing nonvertebral fractures. All treatments were associated with increases in femoral neck BMD versus placebo with zoledronate being the most effective treatment mean difference (MD 4.02; 95% CrI, 3.2–4.84). There was a paucity of data regarding hip and wrist fractures. Depending on its cost‐effectiveness, zoledronate could be considered a first‐line option for people at increased risk of fragility fractures. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Anastasios Bastounis
- Division of Epidemiology & Public Health School of Medicine, University of Nottingham, City Hospital Nottingham UK
| | - Tessa Langley
- Division of Epidemiology & Public Health School of Medicine, University of Nottingham, City Hospital Nottingham UK
| | - Sarah Davis
- School of Health and Related Research, Regent Court (ScHARR) University of Sheffield, Sheffield, S1 4DA UK
| | - Zoe Paskins
- School of Medicine Keele University Keele UK
- Haywood Academic Rheumatology Centre, Midlands Partnership NHS Foundation Trust Stoke‐on‐Trent Staffordshire UK
| | - Neil Gittoes
- Centre for Endocrinology, Diabetes and Metabolism (CEDAM) University of Birmingham Birmingham UK
- Queen Elizabeth Hospital University Hospitals Birmingham NHS Foundation Trust Birmingham UK
| | - Jo Leonardi‐Bee
- Division of Epidemiology & Public Health School of Medicine, University of Nottingham, City Hospital Nottingham UK
| | - Opinder Sahota
- Queens Medical Centre (QMC), University of Nottingham Nottingham University Hospitals NHS Trust Nottingham UK
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21
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Cross JL, Hammond SP, Shepstone L, Poland F, Henderson C, Backhouse T, Penhale B, Donell S, Knapp M, Lewins D, MacLullich A, Patel M, Sahota O, Smith TO, Waring J, Howard R, Ballard C, Fox C. PERFECTED enhanced recovery pathway (PERFECT-ER) versus standard acute hospital care for people after hip fracture surgery who have cognitive impairment: a feasibility cluster randomised controlled trial. BMJ Open 2022; 12:e055267. [PMID: 35228288 PMCID: PMC8886407 DOI: 10.1136/bmjopen-2021-055267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 01/21/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES Assess feasibility of a cluster randomised controlled trial (RCT) to measure clinical and cost-effectiveness of an enhanced recovery pathway for people with hip fracture and cognitive impairment (CI). DESIGN Feasibility trial undertaken between 2016 and 2018. SETTING Eleven acute hospitals from three UK regions. PARTICIPANTS 284 participants (208 female:69 male). INCLUSION CRITERIA aged >60 years, confirmed proximal hip fracture requiring surgical fixation and CI; preoperative AMTS ≤8 in England or a 4AT score ≥1 in Scotland; minimum of 5 days on study ward; a 'suitable informant' able to provide proxy measures, recruited within 7 days of hip fracture surgery. EXCLUSION CRITERIA no hip surgery; not expected to survive beyond 4 weeks; already enrolled in a clinical trial. INTERVENTION PERFECT-ER, an enhanced recovery pathway with 15 quality targets supported by a checklist and manual, a service improvement lead a process lead and implemented using a plan-do-study-act model. PRIMARY AND SECONDARY OUTCOME MEASURES Feasibility outcomes: recruitment and attrition, intervention acceptability, completion of participant reported outcome measures, preliminary estimates of potential effectiveness using mortality, EQ-5D-5L, economic and clinical outcome scores. RESULTS 282 participants were consented and recruited (132, intervention) from a target of 400. Mean recruitment rates were the same in intervention and control sites, (range: 1.2 and 2.7 participants/month). Retention was 230 (86%) at 1 month and 54%(144) at 6 months. At 3 months a relatively small effect (one quarter of an SD) was observed on health-related quality of life of the patient measured with EQ-5D-5L proxy in the intervention group. CONCLUSION This trial design was feasible with modifications to recruitment. Mechanisms for delivering consistency in the PERFECT-ER intervention and participant retention need to be addressed. However, an RCT may be a suboptimal research design to evaluate this intervention due to the complexity of caring for people with CI after hip fracture. TRIAL REGISTRATION NUMBER ISRCTN99336264.
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Affiliation(s)
- Jane L Cross
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Simon P Hammond
- School of Education and Lifelong Learning, University of East Anglia, Norwich, UK
| | - Lee Shepstone
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Fiona Poland
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Catherine Henderson
- Care Policy and Evaluation Centre (CPEC), London School of Economics, London, UK, London, UK
| | - Tamara Backhouse
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Bridget Penhale
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Simon Donell
- Norfolk and Norwich University Hospital, Norwich, UK
| | - Martin Knapp
- Care Policy and Evaluation Centre (CPEC), London School of Economics, London, UK, London, UK
| | - Douglas Lewins
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Alasdair MacLullich
- Geriatric Medicine Unit, University of Edinburgh Western General Hospital, Edinburgh, UK
| | - Martyn Patel
- Norfolk and Norwich University Hospital, Norwich, UK
| | - Opinder Sahota
- HCOP, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Toby O Smith
- School of Health Sciences, University of East Anglia, Norwich, UK
| | | | | | - Clive Ballard
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Chris Fox
- College of Medicine and Health, University of Exeter, Exeter, UK
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22
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Taib A, Ong T, Mulvaney E, Neale C, Strawther N, Peters C, Sahota A, Sahota O. Can an Ice-Cream Based Supplement Help Address Malnutrition in Orthogeriatric Patients? J Nutr Gerontol Geriatr 2021; 40:280-289. [PMID: 34635024 DOI: 10.1080/21551197.2021.1984365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Using a Plan-Do-Study-Act (PDSA) methodology, we describe our first cycle of a project using an ice-cream oral nutritional supplement (ONS ice-cream) to address malnutrition in older patients. A Scandishake-based® (Nutricia) vanilla flavored ice-cream was developed and piloted on a cohort of orthopedic patients over 3 days. All suitable patients were offered 100 g ice-cream portions (240 kcal/per portion). Acceptability and energy intake were our primary outcomes. Over 3 days, the ONS ice-cream was accepted in 77% (n = 27, median age, 75 years, IQR 12.5) of the times offered. Among these patients the average energy intake per day including the ONS ice-cream was 1006 kcal, a 41% increase in energy intake compared to an initial nutritional survey among the older orthopedic patients (714 kcal, p = 0.010). When surveyed 84% (n = 16) of patients stated they would have the ONS ice-cream again. An ONS ice-cream intervention to improve energy intake in older adults is feasible.
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Affiliation(s)
- Adnan Taib
- Specialty Trainee in General Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Terence Ong
- Department of Healthcare for Older People, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Emily Mulvaney
- Department of Trauma and Orthopedics, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Chris Neale
- Department of Catering, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Nicola Strawther
- Dietetics and Nutrition, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Christina Peters
- Foundation Year Doctor 1, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Arun Sahota
- School of Medicine, University of Leicester, Leicester, UK
| | - Opinder Sahota
- Department of Healthcare for Older People, Nottingham University Hospitals NHS Trust, Nottingham, UK
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23
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Ong T, Sahota O. The management of patients admitted to hospital with vertebral fragility fractures: experience from a UK university hospital. Injury 2021; 52:2903-2907. [PMID: 34247765 DOI: 10.1016/j.injury.2021.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 06/26/2021] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Terence Ong
- Department for Healthcare of Older People, Nottingham University Hospital NHS Trust, United Kingdom; Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, United Kingdom; Faculty of Medicine, University of Malaya, Malaysia.
| | - Opinder Sahota
- Faculty of Medicine, University of Malaya, Malaysia; Department for Healthcare of Older People, Nottingham University Hospital NHS Trust, United Kingdom; The Centre for Spinal Studies and Surgery, Nottingham University Hospitals NHS Trust, UK; National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), United Kingdom
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24
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Sahota O, Leighton P, Cameron M, Taylor R, Ong T, Drummond A, Hendrick P, Quraishi N, Salem K. ASSERT (Acute Sacral inSufficiEncy fractuRe augmenTation): Perceptions in the Assessment and Treatment of Pubic Rami and Sacral Fragility Fractures Amongst Healthcare Professionals in Geriatric Medicine and Surgery-A Qualitative Study. Geriatr Orthop Surg Rehabil 2021; 12:21514593211026794. [PMID: 34290898 PMCID: PMC8273401 DOI: 10.1177/21514593211026794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/27/2021] [Indexed: 12/29/2022] Open
Abstract
Background: Pubic rami fragility fractures are common in older people and result in significant morbidity and increased mortality. Co-existing fractures of the sacrum are common, but routinely missed. The aim of the study was to explore the perceptions in the assessment and treatment of pubic rami and sacral fragility fractures amongst healthcare professionals. Methods: We interviewed 14 participants about their experience in the assessment and treatment of patients presenting with pubic rami fragility fractures. Data was analyzed using an inductive thematic approach. Results: The majority of patients presenting with a pubic rami fragility fracture were managed by geriatricians. However, many of the geriatricians were not aware that these fractures have a high association with co-existing sacral fragility fractures. Furthermore, they were not aware of the limitations of standard x-ray imaging, nor of the potential benefits of surgical intervention for sacral fragility fractures. Spinal surgeons recommended that early, more specialist imaging in patients with pubic rami fragility fractures failing to mobilize, would change clinical management, if found to have a coexisting sacral fragility fracture, amenable to surgical intervention. Conclusions: The awareness, assessment and management of sacral fragility fractures in patients presenting with pubic rami fragility fractures is poor amongst healthcare professionals in geriatric medicine. Spinal surgeons in this study advocate early further imaging and surgical intervention in patients confirmed to have a concomitant sacral fragility fracture who are failing to mobilize.
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Affiliation(s)
- Opinder Sahota
- Department of HCOP, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom.,The Centre for Spinal Studies and Surgery, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom.,University of Nottingham, Nottingham, United Kingdom.,National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham, United Kingdom
| | - Paul Leighton
- University of Nottingham, Nottingham, United Kingdom
| | - Maribel Cameron
- Department of HCOP, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Rachael Taylor
- Department of HCOP, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Terence Ong
- Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Paul Hendrick
- University of Nottingham, Nottingham, United Kingdom
| | - Nasir Quraishi
- The Centre for Spinal Studies and Surgery, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Khalid Salem
- The Centre for Spinal Studies and Surgery, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
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25
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Sahota A, Wallman J, Worrall R, Sahota O. 487 NOTTINGHAM (N-ICE) CREAM-A MORE NUTRITIOUS, PALATABLE AND PREFERRED HIGH PROTEIN, VITAMIN D FORTIFIED VANILLA ICE CREAM-A STEP TOO FAR? Age Ageing 2021. [DOI: 10.1093/ageing/afab116.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Oral Nutritional Supplement (ONS) drinks are commonly used to support nutritional intake in older people, however these are poorly consumed and frequently wasted. Fortified ice-cream offers a more acceptable ONS.
Methods
In collaboration with the University of Nottingham, Department of Food Sciences, we developed a high protein, vanilla ice cream (20 g/120 mL serving), fortified with vitamin D (400 IU)-Nottingham Ice (N-ICE) Cream. An anonymised Google consumer survey was untaken amongst older patients from the Nottingham Osteoporosis Patient Support group. We evaluated (on a rating scale of 1–10): Taste (1 unpleasant to 10 tasty), Mouthfeel (1 grainy to 10 smooth), Smell (1 unpleasant to 10 enticing), Appearance (1 off-putting to 10 inviting) and Colour (1 dull to 10 appealing) of the N-ICE Cream. Further comparison was made with an over-the-counter ONS drink Amyes Complete™ (similar in energy and protein content to N-ICE Cream).
Results
32 participants completed the consumer survey. The mean (SD) age of the patients was 79.1 (4.5) yrs. The mean (SD) score out of 10 for Taste was 8.95 (1.02), Mouthfeel 9.14 (0.98), Smell 8.86 (1.06), Appearance 8.95 (1.12) and Colour 9.10 (1.14). Overall acceptability was 8.92 (1.18). 64% of the participants were able to consume all of the 120 mL tub, 22% ¾, 10% ½ and the remaining only ¼ (4%). 30/32 participants preferred the Taste, 29/32 Mouthfeel and 28/32 the Smell of N-ICE Cream, when compared to the ONS drink, and overall if given a choice, 30/32 (94%) of the participants preferred N-ICE Cream over the Amyes Complete™ ONS drink. The retail cost of Amyes Complete was £2.50 and 28/32 of the participants said they would be willing to pay the same amount for N-ICE Cream.
Conclusion
N-ICE Cream is highly acceptable, nutritious and preferred by the consumer group evaluated when compared to an ONS Amyes Complete™ drink.
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Affiliation(s)
- A Sahota
- University of Leicester; University of Nottingham; Nottingham University Hospitals NHS Trust
| | - J Wallman
- University of Leicester; University of Nottingham; Nottingham University Hospitals NHS Trust
| | - R Worrall
- University of Leicester; University of Nottingham; Nottingham University Hospitals NHS Trust
| | - O Sahota
- University of Leicester; University of Nottingham; Nottingham University Hospitals NHS Trust
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26
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Wijayasiri P, Than HP, Munir M, Sahota O. 480 INFORMATION OVERKILL: IF THE WALLS ACROSS HOSPITALS WARDS COULD TALK. Age Ageing 2021. [DOI: 10.1093/ageing/afab116.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The walls across hospital wards are cluttered with posters, which, in some places, are peeling and staining with the years. Hospital management and well intention ward users dictate these displays, however their effectiveness in delivering essential information is rarely measured. We undertook a survey to establish: a) Whether posters are effective, b) What information ward users want, c) How they want information to be delivered.
Methods
100 participants (68 staff and 32 patients’ relatives) were surveyed across three 28 bedded wards for older people. They had to recall as many posters as possible then identify useful posters from a current list. They were asked about unmet information needs, other media that they would utilise and alternative uses for ward walls. Interventions were made on one ward based on initial findings: 1. An ‘Information for Relatives’ board was created, 2. A mural was installed. 20 relatives were asked to complete an anonymous form reviewing the board.
Results
Only 23% of participants were able to recall at least 3 posters. 34% could not find a single useful topic among the current posters. The most popular unmet information needs, among many, were ‘the discharge pathway’, ‘delirium’ and ‘falls’. Most participants said they would engage with alternative information media, suggesting leaflets, email and websites. A quarter felt walls should be for artwork, not posters. The ‘Information for Relatives’ board was well received. In the second survey, new unmet information needs were uncovered and, despite the new mural, 45% called for more paintings still.
Conclusions
Most people do not read the information on the walls on hospital wards. An appetite exists for alternative media. Paintings were earnestly called for at every point; a comforting ward environment should be part of the holistic care we aim to offer, especially for older patients.
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Affiliation(s)
| | | | - M Munir
- Nottingham University Hospitals
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27
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Ogliari G, Ong T, Marshall L, Sahota O. Seasonality of adult fragility fractures and association with weather: 12-year experience of a UK Fracture Liaison Service. Bone 2021; 147:115916. [PMID: 33737194 DOI: 10.1016/j.bone.2021.115916] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 03/02/2021] [Accepted: 03/11/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To investigate the monthly and seasonal variation in adult osteoporotic fragility fractures and the association with weather. METHODS 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. RESULTS 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). CONCLUSION Different types of fragility fractures present different seasonal patterns. Weather may modulate their seasonality and consequent healthcare utilisation.
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Affiliation(s)
- Giulia Ogliari
- Department of Health Care for Older People, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham NG7 2UH, United Kingdom.
| | - Terence Ong
- Department of Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia.
| | - Lindsey Marshall
- Department of Trauma & Orthopaedics, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham NG7 2UH, United Kingdom.
| | - Opinder Sahota
- Department of Health Care for Older People, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham NG7 2UH, United Kingdom; Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Derby Road, Nottingham NG7 2UH, United Kingdom; National Institute for Health Research (NIHR, Nottingham Biomedical Research Centre (BRC), Queen's Medical Centre, Derby Road, Nottingham NG7 2UH, United Kingdom.
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28
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Palliyil N, Dhake R, Olakunle B, Evans E, Salem K, Sahota O. Clinical dilemma in the management of an unstable spinal fracture in a frail older patient with multiple comorbidities-conservative versus non-conservative care. A case report. JGG 2021. [DOI: 10.36150/2499-6564-n342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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van Berkel D, Herschkovich O, Taylor R, Ong T, Sahota O. The truth behind the pubic rami fracture: identification of pelvic fragility fractures at a university teaching hospital. Clin Med (Lond) 2021; 20:s113. [PMID: 32409416 DOI: 10.7861/clinmed.20-2-s113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
| | | | - Rachael Taylor
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Terence Ong
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Opinder Sahota
- Nottingham University Hospitals NHS Trust, Nottingham, UK
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30
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Ong T, Sahota O, Gladman JRF. Management of patients admitted to hospital with acute vertebral fragility fractures: a modified Delphi study. Age Ageing 2021; 50:985-989. [PMID: 33951150 DOI: 10.1093/ageing/afaa225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Terence Ong
- Department for Healthcare of Older People, Queens Medical Centre, Nottingham University Hospital NHS Trust, Nottingham NG7 2UH, UK
- Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Nottingham NG7 2UH, UK
- Department of Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Opinder Sahota
- Department for Healthcare of Older People, Queens Medical Centre, Nottingham University Hospital NHS Trust, Nottingham NG7 2UH, UK
| | - John R F Gladman
- Department for Healthcare of Older People, Queens Medical Centre, Nottingham University Hospital NHS Trust, Nottingham NG7 2UH, UK
- Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Nottingham NG7 2UH, UK
- National Institute for Health Research (NIHR, Nottingham Biomedical Research Centre (BRC), Queens Medical Centre, Nottingham NG7 2UH, UK
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Ong T, Copeland R, Thiam CN, Cerda Mas G, Marshall L, Sahota O. Integration of a vertebral fracture identification service into a fracture liaison service: a quality improvement project. Osteoporos Int 2021; 32:921-926. [PMID: 33170309 DOI: 10.1007/s00198-020-05710-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 10/20/2020] [Indexed: 10/23/2022]
Abstract
Integration of a vertebral fracture identification service into a Fracture Liaison Service is possible. Almost one-fifth of computerised tomography scans performed identified an individual with a fracture. This increase in workload needs to be considered by any FLS that wants to utilise such a service. INTRODUCTION This service improvement project aimed to improve detection of incidental vertebral fractures on routine imaging. It embedded a vertebral fracture identification service (Optasia Medical, OM) on routine computerised tomography (CT) scans performed in this hospital as part of its Fracture Liaison Service (FLS). METHODS The service was integrated into the hospital's CT workstream. Scans of patients aged ≥ 50 years for 3 months were prospectively retrieved, alongside their clinical history and the CT report. Fractures were identified via OM's machine learning algorithm and cross-checked by the OM radiologist. Fractures identified were then added as an addendum to the original CT report and the hospital FLS informed. The FLS made recommendations based on an agreed algorithm. RESULTS In total, 4461 patients with CT scans were retrieved over the 3-month period of which 850 patients had vertebra fractures identified (19.1%). Only 49% had the fractures described on hospital radiology report. On average, 61 patients were identified each week with a median of two fractures. Thirty-six percent were identified by the FLS for further action and recommendations were made to either primary care or the community osteoporosis team within 3 months of fracture detection. Of the 64% not identified for further action, almost half was because the CT was part of cancer assessment or treatment. The remaining were due to a combination of only ≤ 2 mild fractures; already known to a bone health specialist; in the terminal stages of any chronic illness; significant dependency for activities of daily living; or a life expectancy of less than 12 months CONCLUSION: It was feasible to integrate a commercial vertebral fracture identification service into the daily working of a FLS. There was a significant increase in workload which needs to be considered by any future FLS planning to incorporate such a service into their clinical practice.
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Affiliation(s)
- T Ong
- Department for Healthcare of Older People, Queens Medical Centre, Nottingham University Hospital NHS Trust, Nottingham, UK.
- Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.
| | - R Copeland
- Department for Healthcare of Older People, Queens Medical Centre, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - C N Thiam
- Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - G Cerda Mas
- Consorci Sanitari de Terrassa, Terrassa, Spain
| | - L Marshall
- Department for Trauma and Orthopaedics, Queens Medical Centre, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - O Sahota
- Department for Healthcare of Older People, Queens Medical Centre, Nottingham University Hospital NHS Trust, Nottingham, UK
- Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Nottingham, UK
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham, UK
- National Institute for Health Research (NIHR) Collaboration for Applied Health Research and Care (CLAHRC) East Midlands, Nottingham, UK
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Sahota O, van Berkel D, Ong T, Drummond A, Hendrick P, Quraishi N, Salem K. Pelvic fragility fractures-the forgotten osteoporotic fracture! Osteoporos Int 2021; 32:785-786. [PMID: 33491138 PMCID: PMC8026450 DOI: 10.1007/s00198-021-05848-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 01/12/2021] [Indexed: 02/07/2023]
Affiliation(s)
- O Sahota
- Depart HCOP, Nottingham University Hospitals NHS Trust, Nottingham, UK.
- The Centre for Spinal Studies and Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK.
- Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, UK.
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham, UK.
- National Institute for Health Research (NIHR) Collaboration for Applied Health Research and Care (CLAHRC) East Midlands, Nottingham, UK.
| | - D van Berkel
- Depart HCOP, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - T Ong
- Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - A Drummond
- Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, UK
| | - P Hendrick
- Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, UK
| | - N Quraishi
- The Centre for Spinal Studies and Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - K Salem
- The Centre for Spinal Studies and Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Tarawneh AM, Sadanandan N, Salem KMI, Sahota O. 128 Prevalence of Older People Presenting Acutely to A Regional Spine Unit. Age Ageing 2021. [DOI: 10.1093/ageing/afab030.89] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
With ageing demographics, the number of older people is expected to rise exponentially over the next decade. With increasing numbers, the numbers of patients presenting to hospital will also increase. These patients have significant underlying comorbidities and thus further surgical interventions are more challenging.
Objective
To investigate the incidence of all in-patient referrals to the Nottingham Regional Spinal unit for patients aged 70 years and above over a 30-month period.
Methods
A retrospective 30-month review (Jan 2017-Aug 2019) of the clinical records of all in-patients’ referrals to the regional spinal unit (catchment population 4.5 million) for patients aged 70 years and above was undertaken. Patient demographics, co-morbidities, cause of referral, treatment modality (conservative vs. surgical), length of hospital stay, discharge destination (home vs. rehab) and mortality rates were collected and analysed.
Results
A total of 677 (Male: 335, Female: 342) in-patients’ referrals for patients aged 70 years and above were received. The mean age at presentation was 82.3 (±7.48) years. Trauma (low & high energy) was the most common cause of inpatient referrals (n = 448; 66.2%). Low energy trauma (insufficiency) fractures contributed to more than half of the total referrals (n = 256). Spondylodiscitis was the least common cause of referral (n = 34; 5%). Five-hundred forty-five patients were treated conservatively (80.5%). Average length of hospital stay was 16.7 days (range:1–282 days). Eighty-one of the discharged patients (13.5%) were transferred to rehabilitation after discharge, and the over-all 30-day mortality rate was 11.5% (n = 78).
Conclusion
Frail older people represent a significant workload to the regional spine unit. Adapting an ortho-geriatric model of care as with hip fracture care may be the optimal model of service delivery to improve outcomes for this patients group.
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Affiliation(s)
- A M Tarawneh
- Queen's Medical Centre, Nottingham University Hospitals NHS Trust
| | - N Sadanandan
- Queen's Medical Centre, Nottingham University Hospitals NHS Trust
| | - K MI Salem
- Queen's Medical Centre, Nottingham University Hospitals NHS Trust
| | - O Sahota
- Queen's Medical Centre, Nottingham University Hospitals NHS Trust
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Sahota A, Ong T, Kumar A, Simmonds L, Yoon WW, Salem K, Sahota O. Vertebroplasty for vertebral fragility fractures in the 'very elderly': experience from a regional UK spine unit. Osteoporos Int 2021; 32:395-396. [PMID: 33392717 DOI: 10.1007/s00198-020-05770-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 11/30/2020] [Indexed: 11/26/2022]
Affiliation(s)
- A Sahota
- Medical School, University of Leicester, George Davies Centre, Lancaster Rd, Leicester, UK
| | - T Ong
- Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - A Kumar
- Department for Healthcare of Older People, Queens Medical Centre, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - L Simmonds
- Department for Healthcare of Older People, Queens Medical Centre, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - W W Yoon
- The Centre for Spinal Studies and Surgery, Queens Medical Centre, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - K Salem
- The Centre for Spinal Studies and Surgery, Queens Medical Centre, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - O Sahota
- Department for Healthcare of Older People, Queens Medical Centre, Nottingham University Hospital NHS Trust, Nottingham, UK.
- The Centre for Spinal Studies and Surgery, Queens Medical Centre, Nottingham University Hospital NHS Trust, Nottingham, UK.
- Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Nottingham, UK.
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham, UK.
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Ong T, Bin Syed Ali SA, Sahota O. The Presentation of Older People with Vertebral Fragility Fractures to a University Hospital: A Cross-sectional Analysis. Curr Rheumatol Rev 2021; 17:109-112. [PMID: 32867654 DOI: 10.2174/1573397116999200820170559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 06/26/2020] [Accepted: 07/02/2020] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- Terence Ong
- Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Syed Ajmal Bin Syed Ali
- Department for Healthcare of Older People, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham NG7 2UH, United Kingdom
| | - Opinder Sahota
- Department for Healthcare of Older People, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham NG7 2UH, United Kingdom
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Griffiths R, Babu S, Dixon P, Freeman N, Hurford D, Kelleher E, Moppett I, Ray D, Sahota O, Shields M, White S. Guideline for the management of hip fractures 2020: Guideline by the Association of Anaesthetists. Anaesthesia 2020; 76:225-237. [PMID: 33289066 DOI: 10.1111/anae.15291] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2020] [Indexed: 12/26/2022]
Abstract
We convened a multidisciplinary Working Party on behalf of the Association of Anaesthetists to update the 2011 guidance on the peri-operative management of people with hip fracture. Importantly, these guidelines describe the core aims and principles of peri-operative management, recommending greater standardisation of anaesthetic practice as a component of multidisciplinary care. Although much of the 2011 guidance remains applicable to contemporary practice, new evidence and consensus inform the additional recommendations made in this document. Specific changes to the 2011 guidance relate to analgesia, medicolegal practice, risk assessment, bone cement implantation syndrome and regional review networks. Areas of controversy remain, and we discuss these in further detail, relating to the mode of anaesthesia, surgical delay, blood management and transfusion thresholds, echocardiography, anticoagulant and antiplatelet management and postoperative discharge destination. Finally, these guidelines provide links to supplemental online material that can be used at readers' institutions, key references and UK national guidance about the peri-operative care of people with hip and periprosthetic fractures during the COVID-19 pandemic.
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Affiliation(s)
- R Griffiths
- Department of Anaesthesia, Peterborough and Stamford Hospitals NHS Trust Peterborough, UK and Chair, Working Party, Association of Anaesthetists, UK
| | - S Babu
- Department of Anaesthesia, Warrington and Halton Hospitals NHS Trust, Warrington, UK
| | - P Dixon
- Department of Trauma and Orthopaedics, South Tyneside and Sunderland NHS Trust, Sunderland, UK and British Orthopaedic Association, Orthopaedic Trauma Society, UK
| | - N Freeman
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - D Hurford
- Department of Anaesthesia, Cwm Taf Morgannwg University Health Board and Chair, Welsh Frailty Fracture Network, UK, UK
| | - E Kelleher
- Department of Anaesthesia, University of Galway, Galway, Ireland
| | - I Moppett
- Division of Clinical Neuroscience, School of Medicine, University of Nottingham, UK.,Department of Anaesthesia, Nottingham University Hospitals, Nottingham, UK
| | - D Ray
- Department of Anaesthesia, Royal Infirmary Edinburgh and Honorary Clinical Senior Lecturer, University of Edinburgh, Edinburgh, UK
| | - O Sahota
- Department of Healthcare of Older People, Nottingham University Hospitals, Nottingham, UK and British Geriatrics Society, UK
| | - M Shields
- Department of Anaesthesia, Royal Hospitals, Belfast, UK
| | - S White
- Department of Anaesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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Paskins Z, Crawford-Manning F, Cottrell E, Corp N, Wright J, Jinks C, Bishop S, Doyle A, Ong T, Gittoes N, Leonardi-Bee J, Langley T, Horne R, Sahota O. Acceptability of bisphosphonates among patients, clinicians and managers: a systematic review and framework synthesis. BMJ Open 2020; 10:e040634. [PMID: 33148763 PMCID: PMC7640526 DOI: 10.1136/bmjopen-2020-040634] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To explore the acceptability of different bisphosphonate regimens for the treatment of osteoporosis among patients, clinicians and managers, payers and academics. DESIGN A systematic review of primary qualitative studies. Seven databases were searched from inception to July 2019. Screening, data extraction and quality assessment of full-articles selected for inclusion were performed independently by two authors. A framework synthesis was applied to extracted data based on the theoretical framework of acceptability (TFA). The TFA includes seven domains relating to sense-making, emotions, opportunity costs, burden, perceived effectiveness, ethicality and self-efficacy. Confidence in synthesis findings was assessed. SETTING Any developed country healthcare setting. PARTICIPANTS Patients, healthcare professionals, managers, payers and academics. INTERVENTION Experiences and views of oral and intravenous bisphosphonates. RESULTS Twenty-five studies were included, mostly describing perceptions of oral bisphosphonates. We identified, with high confidence, how patients and healthcare professionals make sense (coherence) of bisphosphonates by balancing perceptions of need against concerns, how uncertainty prevails about bisphosphonate perceived effectiveness and a number of individual and service factors that have potential to increase self-efficacy in recommending and adhering to bisphosphonates. We identified, with moderate confidence, that bisphosphonate taking induces concern, but has the potential to engender reassurance, and that both side effects and special instructions for taking oral bisphosphonates can result in treatment burden. Finally, we identified with low confidence that multimorbidity plays a role in people's perception of bisphosphonate acceptability. CONCLUSION By using the lens of acceptability, our findings demonstrate with high confidence that a theoretically informed, whole-system approach is necessary to both understand and improve adherence. Clinicians and patients need supporting to understand the need for bisphosphonates, and clinicians need to clarify to patients what constitutes bisphosphonate treatment success. Further research is needed to explore perspectives of male patients and those with multimorbidity receiving bisphosphonates, and patients receiving intravenous treatment. PROSPERO REGISTRATION NUMBER CRD42019143526.
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Affiliation(s)
- Zoe Paskins
- School of Medicine, Keele University, Keele, UK
- Haywood Academic Rheumatology Centre, Haywood Hospital, Stoke-on-Trent, UK
| | - Fay Crawford-Manning
- School of Medicine, Keele University, Keele, UK
- Haywood Academic Rheumatology Centre, Haywood Hospital, Stoke-on-Trent, UK
| | | | - Nadia Corp
- School of Medicine, Keele University, Keele, UK
| | | | - Clare Jinks
- School of Medicine, Keele University, Keele, UK
| | - Simon Bishop
- Centre for Health Innovation, Leadership and Learning, University of Nottingham, Nottingham, UK
| | - Alison Doyle
- Operations and Clinical Practice, Royal Osteoporosis Society, Bath, UK
| | - Terence Ong
- Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Neil Gittoes
- Centre for Endocrinology Diabetes and Metabolism, University of Birmingham, Birmingham, UK
| | - Jo Leonardi-Bee
- Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, UK
| | - Tessa Langley
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
| | - Robert Horne
- School of Pharmacy, University College London, London, UK
| | - Opinder Sahota
- Department of Geriatric Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Tarawneh A, Taqvi S, Salem K, Sahota O. Cervical spine fragility fractures in older people: 5-year experience at a regional spine centre. Age Ageing 2020; 49:1102-1104. [PMID: 32520992 DOI: 10.1093/ageing/afaa088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 03/27/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND cervical spine fractures are particularly prevalent in older people and commonly occur following a fall from standing height or less. Atlanto-axial complex (AAC) and, particularly, odontoid process (OP) fractures are the most prevalent injuries. OBJECTIVE to investigate the incidence and characteristics of cervical spine fractures in older patients presenting to a regional spine centre. METHODS a retrospective review of the clinical records and imaging of all patients aged 70 years and over presenting to a regional spinal unit with a cervical injury over a 5-year period was performed. Patient demographics, mechanism of injury, level of fracture, stability of the fracture, treatment modality, imaging modality and mortality rates were collected and analysed. RESULTS during the period between 2015 and 2019, a total of 209 patients aged 70 years and over were presented to the regional spine unit. The mean age at presentation was 82.4 (±7.5) years. Low-energy trauma was the commonest mechanism of injury (n = 169; 80.9%). MRI was undertaken in a quarter of the patients. One-hundred and fifty-one patients (72.2%) suffered an AAC Injury with OP fractures forming the majority of this group (n = 119; 78.8%). One-hundred and ninety-nine patients were treated conservatively, and the overall 30-day mortality rate was 8.1%. CONCLUSION cervical spine fractures are not uncommon amongst older people and are mostly the result of low-energy trauma and predominantly affect the axial cervical spine. The majority of these injuries are managed conservatively with an orthosis. The fractures nevertheless are a serious injury, with a high mortality rate at 30 days.
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Affiliation(s)
- Ahmad Tarawneh
- Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Syed Taqvi
- Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Khalid Salem
- Centre for Spinal Studies and Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Opinder Sahota
- Department of Healthcare of Older People, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Ogliari G, Lunt E, Ong T, Marshall L, Sahota O. The impact of lockdown during the COVID-19 pandemic on osteoporotic fragility fractures: an observational study. Arch Osteoporos 2020; 15:156. [PMID: 33026586 PMCID: PMC7539555 DOI: 10.1007/s11657-020-00825-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 09/15/2020] [Indexed: 02/03/2023]
Abstract
We investigated whether osteoporotic fractures declined during lockdown, among adults aged 50 years and older. We showed that fewer outpatients attended the Fracture Clinic, for non-hip fractures, during lockdown; in contrast, no change in admissions for hip fractures was observed. This could be due to fewer outdoors falls, during lockdown. PURPOSE Many countries implemented a lockdown to control the spread of the COVID-19 pandemic. We explored whether outpatient attendances to the Fracture Clinic for non-hip fragility fracture and inpatient admissions for hip fracture declined during lockdown, among adults aged 50 years and older, in a large secondary care hospital. METHODS In our observational study, we analysed the records of 6681 outpatients attending the Fracture Clinic, for non-hip fragility fractures, and those of 1752 inpatients, admitted for hip fracture, during the time frames of interest. These were weeks 1st to 12th in 2020 ("prior to lockdown"), weeks 13th to 19th in 2020 ("lockdown") and corresponding periods over 2015 to 2019. We tested for differences in mean numbers (standard deviation (SD)) of outpatients and inpatients, respectively, per week, during the time frames of interest, across the years. RESULTS Prior to lockdown, in 2020, 63.1 (SD 12.6) outpatients per week attended the Fracture Clinic, similar to previous years (p value 0.338). During lockdown, 26.0 (SD 7.3) outpatients per week attended the Fracture Clinic, fewer than previous years (p value < 0.001); similar findings were observed in both sexes and age groups (all p values < 0.001). During lockdown, 16.1 (SD 5.6) inpatients per week were admitted for hip fracture, similar to previous years (p value 0.776). CONCLUSION During lockdown, fewer outpatients attended the Fracture Clinic, for non-hip fragility fractures, while no change in inpatient admissions for hip fracture was observed. This could reflect fewer non-hip fractures and may inform allocation of resources during pandemic.
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Affiliation(s)
- Giulia Ogliari
- Department of Health Care for Older People (HCOP), Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, Nottinghamshire, NG7 2UH, UK.
| | - Eleanor Lunt
- Department of Health Care for Older People (HCOP), Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, Nottinghamshire, NG7 2UH, UK
| | - Terence Ong
- Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Lindsey Marshall
- Department of Trauma & Orthopaedics, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Opinder Sahota
- Department of Health Care for Older People (HCOP), Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, Nottinghamshire, NG7 2UH, UK
- University of Nottingham , Nottingham, UK
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Ong T, Yong BKA, Shouter T, Shahrokhi N, Sahota O. Optimising bone health among older people with hip fractures and co-existing advanced chronic kidney disease. Eur Geriatr Med 2020; 11:635-638. [DOI: 10.1007/s41999-020-00340-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 05/22/2020] [Indexed: 12/01/2022]
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El-Sharkawy AM, Devonald MAJ, Humes DJ, Sahota O, Lobo DN. Hyperosmolar dehydration: A predictor of kidney injury and outcome in hospitalised older adults. Clin Nutr 2020; 39:2593-2599. [PMID: 31801657 PMCID: PMC7403861 DOI: 10.1016/j.clnu.2019.11.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/13/2019] [Accepted: 11/14/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND & AIMS Hospitalised older adults are vulnerable to dehydration. However, the prevalence of hyperosmolar dehydration (HD) and its impact on outcome is unknown. Serum osmolality is not measured routinely but osmolarity, a validated alternative, can be calculated using routinely measured serum biochemistry. This study aimed to use calculated osmolarity to measure the prevalence of HD (serum osmolarity >300 mOsm/l) and assess its impact on acute kidney injury (AKI) and outcome in hospitalised older adults. METHODS This retrospective cohort study used data from a UK teaching hospital retrieved from the electronic database relating to all medical emergency admissions of patients aged ≥ 65 years admitted between 1st May 2011 and 31st October 2013. Using these data, Charlson comorbidity index (CCI), National Early Warning Score (NEWS), length of hospital stay (LOS) and mortality were determined. Osmolarity was calculated using the equation of Krahn and Khajuria. RESULTS A total of 6632 patients were identified; 27% had HD, 39% of whom had AKI. HD was associated with a median (Q1, Q3) LOS of 5 (1, 12) days compared with 3 (1, 9) days in the euhydrated group, P < 0.001. Adjusted Cox-regression analysis demonstrated that patients with HD were four-times more likely to develop AKI 12-24 h after admission [Hazards Ratio (95% Confidence Interval) 4.5 (3.5-5.6), P < 0.001], and had 60% greater 30-day mortality [1.6 (1.4-1.9), P < 0.001], compared with those who were euhydrated. CONCLUSION HD is common in hospitalised older adults and is associated with increased LOS, risk of AKI and mortality. Further work is required to assess the validity of osmolality or osmolarity as an early predictor of AKI and the impact of HD on outcome prospectively.
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Affiliation(s)
- Ahmed M El-Sharkawy
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Mark A J Devonald
- Renal and Transplant Unit, Nottingham University Hospitals NHS Trust, City Campus, Nottingham, NG5 1PB, UK
| | - David J Humes
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK; Division of Epidemiology and Public Health, University of Nottingham, City Campus, Nottingham NG5 1PB, UK
| | - Opinder Sahota
- Department of Elderly Medicine, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, NG7 2UH, UK.
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Gupta A, Jayes LR, Holmes S, Sahota O, Canavan M, Elkin SL, Lim K, Murphy AC, Singh S, Towlson EA, Ward H, Scullion J, McKeever TM, Bolton CE. Management of Fracture Risk in Patients with Chronic Obstructive Pulmonary Disease (COPD): Building a UK Consensus Through Healthcare Professional and Patient Engagement. Int J Chron Obstruct Pulmon Dis 2020; 15:1377-1390. [PMID: 32606647 PMCID: PMC7311204 DOI: 10.2147/copd.s233398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 03/23/2020] [Indexed: 12/21/2022] Open
Abstract
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.
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Affiliation(s)
- Ayushman Gupta
- NIHR Nottingham BRC Respiratory Theme, School of Medicine, University of Nottingham, City Hospital Campus, Nottingham, UK
| | - Leah R Jayes
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, City Hospital Campus, Nottingham, UK
| | - Steve Holmes
- General Practitioner, Park Medical Partnership, Shepton Mallet, UK
| | - Opinder Sahota
- Department of Geriatric Medicine, Nottingham University Hospitals Trust, Nottingham, UK
| | - Melissa Canavan
- Department of Respiratory, Respiratory Care Solutions, Leeds, UK
| | - Sarah L Elkin
- Department of Respiratory Medicine, Imperial College Healthcare Trust, London W2 1NY, UK; Airways Section, National Heart and Lung Institute, Imperial College, London, UK
| | - Kelvin Lim
- Eastwood Primary Care Centre, Eastwood, Nottingham, UK
| | - Anna C Murphy
- Department of Pharmacy, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Sally Singh
- Department of Respiratory Science, University Hospitals of Leicester NHS Trust, Leicester, UK.,Department of Respiratory Science, University of Leicester, Leicester, UK
| | | | - Helen Ward
- Faculty of Medicine, The Royal Wolverhampton NHS Trust, West Midlands, UK
| | - Jane Scullion
- Department of Respiratory Science, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Tricia M McKeever
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, City Hospital Campus, Nottingham, UK
| | - Charlotte E Bolton
- NIHR Nottingham BRC Respiratory Theme, School of Medicine, University of Nottingham, City Hospital Campus, Nottingham, UK
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Smith TO, Gilbert AW, Sreekanta A, Sahota O, Griffin XL, Cross JL, Fox C, Lamb SE. Enhanced rehabilitation and care models for adults with dementia following hip fracture surgery. Cochrane Database Syst Rev 2020; 2:CD010569. [PMID: 32031676 PMCID: PMC7006792 DOI: 10.1002/14651858.cd010569.pub3] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Hip fracture is a major injury that causes significant problems for affected individuals and their family and carers. Over 40% of people with hip fracture have dementia or cognitive impairment. The outcomes of these individuals after surgery are poorer than for those without dementia. It is unclear which care and rehabilitation interventions achieve the best outcomes for these people. This is an update of a Cochrane Review first published in 2013. OBJECTIVES (a) To assess the effectiveness of models of care including enhanced rehabilitation strategies designed specifically for people with dementia following hip fracture surgery compared to usual care. (b) To assess for people with dementia the effectiveness of models of care including enhanced rehabilitation strategies that are designed for all older people, regardless of cognitive status, following hip fracture surgery, compared to usual care. SEARCH METHODS We searched ALOIS (www.medicine.ox.ac.uk/alois), the Cochrane Dementia and Cognitive Improvement Group Specialised Register, MEDLINE (OvidSP), Embase (OvidSP), PsycINFO (OvidSP), CINAHL (EBSCOhost), Web of Science Core Collection (ISI Web of Science), LILACS (BIREME), ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform on 16 October 2019. SELECTION CRITERIA We included randomised and quasi-randomised controlled trials evaluating the effectiveness of any model of enhanced care and rehabilitation for people with dementia after hip fracture surgery compared to usual care. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion and extracted data. We assessed risk of bias of the included trials. We synthesised data only if we considered the trials to be sufficiently homogeneous in terms of participants, interventions, and outcomes. We used the GRADE approach to rate the overall certainty of evidence for each outcome. MAIN RESULTS We included seven trials with a total of 555 participants. Three trials compared models of enhanced care in the inpatient setting with conventional care. Two trials compared an enhanced care model provided in inpatient settings and at home after discharge with conventional care. Two trials compared geriatrician-led care in-hospital to conventional care led by the orthopaedic team. None of the interventions were designed specifically for people with dementia, therefore the data included in the review were from subgroups of people with dementia or cognitive impairment participating in randomised controlled trials investigating models of care for all older people following hip fracture. The end of follow-up in the trials ranged from the point of acute hospital discharge to 24 months after discharge. We considered all trials to be at high risk of bias in more than one domain. As subgroups of larger trials, the analyses lacked power to detect differences between the intervention groups. Furthermore, there were some important differences in baseline characteristics of participants between the experimental and control groups. Using the GRADE approach, we downgraded the certainty of the evidence for all outcomes to low or very low. The effect estimates for almost all comparisons were very imprecise, and the overall certainty for most results was very low. There were no data from any study for our primary outcome of health-related quality of life. There was only very low certainty for our other primary outcome, activities of daily living and functional performance, therefore we were unable to draw any conclusions with confidence. There was low-certainty that enhanced care and rehabilitation in-hospital may reduce rates of postoperative delirium (odds ratio 0.04, 95% confidence interval (CI) 0.01 to 0.22, 2 trials, n = 141) and very low-certainty associating it with lower rates of some other complications. There was also low-certainty that, compared to orthopaedic-led management, geriatrician-led management may lead to shorter hospital stays (mean difference 4.00 days, 95% CI 3.61 to 4.39, 1 trial, n = 162). AUTHORS' CONCLUSIONS We found limited evidence that some of the models of enhanced rehabilitation and care used in the included trials may show benefits over usual care for preventing delirium and reducing length of stay for people with dementia who have been treated for hip fracture. However, the certainty of these results is low. Data were available from only a small number of trials, and the certainty for all other results is very low. Determining the optimal strategies to improve outcomes for this growing population of patients should be a research priority.
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Affiliation(s)
- Toby O Smith
- University of OxfordNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS)Botnar Research Centre, Windmill RoadOxfordOxfordshireUKOX3 7LD
| | - Anthony W Gilbert
- Royal National Orthopaedic HospitalTherapies DepartmentBrockley HillStanmoreUKHA7 4LP
| | - Ashwini Sreekanta
- University of OxfordNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS)Botnar Research Centre, Windmill RoadOxfordOxfordshireUKOX3 7LD
| | - Opinder Sahota
- Nottingham University Hospitals NHS Trust, QMCHealthcare of Older PeopleDerby RoadNottinghamUKNG7 3UH
| | - Xavier L Griffin
- University of OxfordNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS)Botnar Research Centre, Windmill RoadOxfordOxfordshireUKOX3 7LD
| | - Jane L Cross
- University of East AngliaFaculty of Medicine and Health SciencesNorwich Research ParkNorwichUKNR4 7TJ
| | - Chris Fox
- Norwich Medical SchoolUniversity of East AngliaNorwichUK
| | - Sarah E Lamb
- University of OxfordNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS)Botnar Research Centre, Windmill RoadOxfordOxfordshireUKOX3 7LD
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Poynton-Smith E, Colwill E, Sahota O. 79 Do Medical Students Understand the Ward Environment? A Survey of Penultimate Year Medical Students Exploring How Well Healthcare Of Older People Placements Prepare Them for Working on Hospital Wards. Age Ageing 2020. [DOI: 10.1093/ageing/afz191.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Medical students are expected to know how to function on hospital wards; i.e. where to find things, other Health Care Professionals’ (HCPs’) roles, and how to use certain items of equipment (GMC, 2018). This ward-based knowledge indicates that a student is ‘ward smart’.1 Whilst being ‘ward smart’ is key for many aspects of medicine, it is particularly important for students learning geriatric medicine: older patients (who make up around 42% of all inpatients)2 are more likely to have communication difficulties and to require assistance. However, formal teaching in this area seems to be somewhat neglected, with students being left to ‘pick up’ this knowledge as they go along.3,4
In our sample of 41 students in their penultimate year (most of whom were undertaking their Healthcare of Older People placement), 98% did not know how to turn on a hearing aid and only 24% knew what a Waterlow score was. Furthermore, 88% did not know how to read an oxygen flowmeter, and only 59% knew where the CPR lever on the bed was situated.
This is a significant gap in knowledge: Students may not be as prepared to work in a ward environment as expected. Students felt that their understanding would be improved by teaching sessions, more time on wards, formal ward inductions, and shadowing other HCPs: only 41.5% had had a ward induction or introduction, and less than 20% had shadowed a nurse. We propose specific teaching/practical sessions for students during their Healthcare of Older People placement centred around patient communication and understanding the ward environment.
References
1. Walker, Wallace, Mangera, & Gill, The Clinical Teacher, 2017, 14(5), 336–9.
2. NHS Digital, 2018.
3. Prince, Bozhuizen, Van der Vleuten, & Scherpbier, Medical Education 2005; 39(7):704–12.
4. Monrouxe, et al., BMJ Open 2017; 7(1):e013656.
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Affiliation(s)
| | - E Colwill
- The University of Nottingham Medical School
| | - O Sahota
- The University of Nottingham Medical School
- Department of Healthcare of Older People, Queen’s Medical Centre
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Tarawneh AM, Taqvi S, Salem KMI, Sahota O. 20 Cervical Spine Fragility Fractures in Older People: 5-Year Experience At A Regional Spine Centre. Age Ageing 2020. [DOI: 10.1093/ageing/afz183.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Introduction
Cervical spine fractures are particularly prevalent in older people and commonly occur following a fall from standing height or less, in the presence of degenerative spinal disease. Atlanto-axial complex and odontoid process injuries are the most frequent type of fractures and are potentially life threatening. Published in-hospital and 1-year mortality rates in older people are eightfold higher than in younger patients. The aim of this study was to identify the incidence and characteristics of cervical spine fractures in older people presenting to a regional spine centre.
Methods
Clinical records and radiographs were retrospectively reviewed using our institutional registry covering a 5-year period. Data included patient age, gender, mechanism of trauma, level of fracture, stability of the fracture, treatment modality, imaging modality, and mortality rates.
Results
A total of 209 patients above the age of 70 with cervical spine fractures were treated in our centre from 2015-2019. The mean age of the patients at the time of injury was (82.4 ±7.5) years with the majority (n=117; 56%) being females.
One-hundred fifty-one patients (72.2%) experienced fractures in the atlanto-axial complex. Particularly, Dens fractures were the most commonly reported fracture (n=119; 56.9%). Most of the patients encountered stable cervical spine fractures (n=181; 86.6%) and these were managed by external immobilization with hard collar or halo vest.
Mechanism of trauma was divided into two main categories, low energy and high energy. Low energy trauma was the most common cause that lead to cervical spine fractures (n=169; 80.9%), compared to high energy trauma (n=40; 19.1%). CT scan and X-ray were the main imaging modalities utilized to detect cervical spine fractures. Whereas, MRI was only utilized in (n=51; 24.4%).
Overall mortality rate was (n=17; 8.1%) at 30 days. Out of which (n=1; 5.9%) was in a patient who was surgically treated while the remaining (n=16; 94.1%) were in those treated conservatively.
Conclusions
Cervical spine injuries in older people are clinically important. Low energy trauma particularly falls, were the main mechanism of cervical spine injury. Upper cervical spine injuries, mainly C2, is the most common cervical spine fracture and were most commonly detected using CT scan. External immobilization was our treatment of choice for most of the cervical spine injuries in the older people. These patients are very similar with respect to mean age, mechanism of injury and 30 days mortality rate as hip fracture patients.
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Affiliation(s)
- A M Tarawneh
- Centre for Spinal Studies and Surgery, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust
| | - S Taqvi
- Centre for Spinal Studies and Surgery, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust
| | - K M I Salem
- Centre for Spinal Studies and Surgery, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust
| | - O Sahota
- Centre for Spinal Studies and Surgery, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust
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van Berkel D, Herschkovich O, Taylor R, Ong T, Sahota O. 88 The Truth Behind the Pubic Rami Fracture: Identification of Pelvic Fragility Fractures at A University Teaching Hospital. Age Ageing 2020. [DOI: 10.1093/ageing/afz193.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Older patients presenting with pelvic fragility fractures (PFF) is an increasing epidemic. The most common pelvic fracture identified by plain radiograph is pubic rami fracture. These fractures are painful and often require admission to hospital. However, despite optimal analgesia, many of these patients struggle to mobilise and may have fractures of the posterior pelvic ring, which are overlooked and not visible on plain radiograph imaging. We aimed to quantify the number of patients progressing to further pelvic imaging in the form of computed tomography (CT) or magnetic resonance imaging (MRI) and the presence of concurrent fractures.
Methods
Prospective screening of pelvic imaging in patients aged over 70 years was undertaken at Nottingham University Hospitals NHS Trust over an 8-month period from October 2018.
Results
103 predominantly female (83%) patients were confirmed to have an acute fragility fracture of the pubic rami on plain radiograph. 19% of patients were discharged direct from the Emergency Department, 45% were admitted to Health Care of Older People (HCOP) teams, 30% to Trauma and Orthopaedic (T&O) teams and 6% to other specialities. 25% of the patients admitted underwent further pelvic imaging, which confirmed fragility fractures of the pubic rami in 88%, with 40% showing acetabular fractures and 68% showing sacral fractures of all types. A further 10 patients were diagnosed with pubic rami insufficiency fractures on further imaging, having had a normal initial radiograph, but had been admitted with poor mobility due to groin pain. In these 10 patients, 20% also had an acetabular fracture and 60% sacral fractures. Overall, 59% of patients with pubic rami fractures had an ipsilateral sacral fracture; a Type 1 Lateral Compression pelvic fracture by AO classification.
Conclusions
Pubic rami fractures are a significant problem in older people and often require admission to hospital. Further imaging confirms these fractures are complex, with co-existing fractures of the acetabulum and sacrum common. However despite this, only a quarter of patients admitted had further imaging. Where pelvic fractures are missed or severity not appreciated, appropriate pain control can be more difficult to achieve. With the potential for minimally invasive surgical options to aid pain management in sacral fractures, it may be prudent for all patients hospitalised with suspected or confirmed pelvic fracture to undergo further imaging.
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Affiliation(s)
- D van Berkel
- Health Care of the Older Persons, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - O Herschkovich
- Health Care of the Older Persons, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - R Taylor
- Health Care of the Older Persons, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - T Ong
- Health Care of the Older Persons, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - O Sahota
- Health Care of the Older Persons, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Desai H, Hershkovich O, Ong T, Marshall L, Sahota O. 89 Poor Attendance for DXA in Older People with A Low Trauma Fragility Fracture: A 6 Year Data Analysis of the Nottingham Fracture Liaison Service. Age Ageing 2020. [DOI: 10.1093/ageing/afz193.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Hip Fractures are common and result in significant patient morbidity and increased mortality. Up to 40% of these patients have sustained a previous low-trauma fracture. The Department of Health advises that patients presenting with fragility fracture should have access to ‘Fracture Liaison Services (FLS)’. These are models of care which systematically identify patients at risk, assess bone health, treat patients (if needed) and follow patients up to support medication adherence.
Methods
Demographics of FLS patients between January 2012 and December 2017 was obtained retrospectively from the Nottingham University Hospitals FLS database. We examined DNA rates and further characteristics of these types of patients. Deprivation scores were deprived using the English indices of deprivation 2015 (1–Most deprived; 5-Least deprived). The 2016 cohort of patients were followed-up till January 2019 to assess for re-fractures.
Results
6528 high-risk patients were identified and referred to DXA. Mean (SD) age was 68±10.5 years [Females=5302 (81%)]. 1386 patients (21%) did not attend. High prevalence of non-attendance was in females [1032 patients (74%)] and the most deprived individuals [398 patients (29%)]. Females from the most deprived areas had the highest DNA rate [287 patients (29%)]. All eligible patients >75 years old were referred (n=1542 (100%), [Females=1284 (83%), non-attendance=473 (31%), non-attendance in females=390 (82%), highly deprived females=96 (25%)]. 826 patients were referred in 2016. Median follow-up time was 2.46 years (IQR 0.16–3.00 years). 52 patients (7%) re-fractured. 17 patients (33%) DNA their previous DXA scan [Females=12 patients (71%)].
Conclusions
Nottingham FLS have identified patients with fragility fractures that are high-risk for further fractures. Despite a dedicated FLS there is a DNA of 21%. Many patients that DNA are generally considered as having a high-risk of further fractures; females, older age and more deprived. Further studies are needed to explore why patients do not attend for bone density scanning.
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Affiliation(s)
- H Desai
- Department for Healthcare of Older People (HCOP), Queens Medical Centre, Nottingham University Hospital NHS Trust
| | - O Hershkovich
- Department for Healthcare of Older People (HCOP), Queens Medical Centre, Nottingham University Hospital NHS Trust
| | - T Ong
- Department for Healthcare of Older People (HCOP), Queens Medical Centre, Nottingham University Hospital NHS Trust
| | - L Marshall
- Department for Healthcare of Older People (HCOP), Queens Medical Centre, Nottingham University Hospital NHS Trust
| | - O Sahota
- Department for Healthcare of Older People (HCOP), Queens Medical Centre, Nottingham University Hospital NHS Trust
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Ong T, Sahota O, Gladman JRF. The Nottingham Spinal Health (NoSH) Study: a cohort study of patients hospitalised with vertebral fragility fractures. Osteoporos Int 2020; 31:363-370. [PMID: 31696271 PMCID: PMC7010649 DOI: 10.1007/s00198-019-05198-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 10/15/2019] [Indexed: 01/14/2023]
Abstract
Patients hospitalised with vertebral fragility fractures were elderly, multimorbid and frail and lead to poor outcomes. Their hospital treatment needs to consider this alongside their acute fracture. A systematic organised model of care, such as an adaptation of orthogeriatric hip fracture care, will offer a more holistic approach potentially improving their outcomes. PURPOSE Patients admitted to hospital with vertebral fragility fractures are elderly and have complex care needs who may benefit from specialist multidisciplinary input. To date, their characteristics and outcomes have not been reported sufficiently. This study aims to justify such a service. METHODS Patients admitted with an acute vertebral fragility fracture over 12 months were prospectively recruited from a university hospital in England. Data were collected soon after their admission, at discharge from hospital and 6 months after their hospital discharge on their characteristics, pain, physical functioning, and clinical outcomes. RESULTS Data from 90 participants were analysed. They were mainly elderly (mean age 79.7 years), multimorbid (69% had ≥ 3 comorbid condition), frail (56% had a Clinical Frailty Scale score ≥ 5), cognitively impaired (54% had a MoCA score of < 23) and at high risk of falls (65% had fallen ≥ 2 in the previous year). Eighteen percent died at 6 months. At 6 months post-hospital discharge, 12% required a new care home admission, 37% still reported their pain to be severe and physical functioning was worse compared with their preadmission state. CONCLUSION Patients hospitalised with vertebral fragility fractures were elderly, multimorbid, frail and are susceptible to persistent pain and disability. Their treatment in hospital needs to consider this alongside their acute fracture. A systematic organised model of care, such as an adaptation of orthogeriatric hip fracture care, will offer a more holistic approach potentially improving their outcomes.
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Affiliation(s)
- T Ong
- Department for Healthcare of Older People, Queens Medical Centre, Nottingham University Hospital NHS Trust, Derby Road, Nottingham, NG7 2UH, UK.
- Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Nottingham, UK.
| | - O Sahota
- Department for Healthcare of Older People, Queens Medical Centre, Nottingham University Hospital NHS Trust, Derby Road, Nottingham, NG7 2UH, UK
| | - J R F Gladman
- Department for Healthcare of Older People, Queens Medical Centre, Nottingham University Hospital NHS Trust, Derby Road, Nottingham, NG7 2UH, UK
- Division of Rehabilitation, Ageing and Wellbeing, University of Nottingham, Nottingham, UK
- National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre (BRC), Nottingham, UK
- National Institute for Health Research (NIHR) Collaboration for Applied Health Research and Care (CLAHRC) East Midlands, Nottingham, UK
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Wainwright TW, Gill M, McDonald DA, Middleton RG, Reed M, Sahota O, Yates P, Ljungqvist O. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS ®) Society recommendations. Acta Orthop 2020; 91:3-19. [PMID: 31663402 PMCID: PMC7006728 DOI: 10.1080/17453674.2019.1683790] [Citation(s) in RCA: 281] [Impact Index Per Article: 70.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background and purpose - There is a large volume of heterogeneous studies across all Enhanced Recovery After Surgery (ERAS®) components within total hip and total knee replacement surgery. This multidisciplinary consensus review summarizes the literature, and proposes recommendations for the perioperative care of patients undergoing total hip replacement and total knee replacement with an ERAS program.Methods - Studies were selected with particular attention being paid to meta-analyses, randomized controlled trials, and large prospective cohort studies that evaluated the efficacy of individual items of the perioperative treatment pathway to expedite the achievement of discharge criteria. A consensus recommendation was reached by the group after critical appraisal of the literature.Results - This consensus statement includes 17 topic areas. Best practice includes optimizing preoperative patient education, anesthetic technique, and transfusion strategy, in combination with an opioid-sparing multimodal analgesic approach and early mobilization. There is insufficient evidence to recommend that one surgical technique (type of approach, use of a minimally invasive technique, prosthesis choice, or use of computer-assisted surgery) over another will independently effect achievement of discharge criteria.Interpretation - Based on the evidence available for each element of perioperative care pathways, the ERAS® Society presents a comprehensive consensus review, for the perioperative care of patients undergoing total hip replacement and total knee replacement surgery within an ERAS® program. This unified protocol should now be further evaluated in order to refine the protocol and verify the strength of these recommendations.
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Affiliation(s)
- Thomas W Wainwright
- Orthopaedic Research Institute, Bournemouth Univesity, Bournemouth, UK
- The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, UK
| | - Mike Gill
- Golden Jubilee National Hospital, Glasgow, Scotland
| | - David A McDonald
- Scottish Government, Glasgow, Scotland
- Nursing, Midwifery and Allied Health Professions Research Unit, Glasgow Caledonian University, Glasgow, Scotland
| | - Robert G Middleton
- Orthopaedic Research Institute, Bournemouth Univesity, Bournemouth, UK
- The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust, Bournemouth, UK
- Poole Hospital NHS Foundation Trust, Poole, UK
| | - Mike Reed
- Northumbria Healthcare NHS Foundational Trust, Northumbria, UK
- Health Sciences, University of York, York, UK
| | - Opinder Sahota
- Nottingham University Hospital, Nottingham, UK
- Nottingham University, Nottingham, UK
| | - Piers Yates
- University of Western Australia, Perth, Australia
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Hoerlyck C, Ong T, Gregersen M, Damsgaard EM, Borris L, Chia JK, Yap YYW, Weerasuriya N, Sahota O. Do anticoagulants affect outcomes of hip fracture surgery? A cross-sectional analysis. Arch Orthop Trauma Surg 2020; 140:171-176. [PMID: 31542809 PMCID: PMC6989641 DOI: 10.1007/s00402-019-03240-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The management of patients with a hip fracture is affected by the use of oral anticoagulants. A cross-sectional analysis was undertaken to investigate health outcome differences in those anticoagulated compared to those not anticoagulated. METHODS Patients aged 50 years and over presenting to a large university hospital with hip fractures were identified from the service registry. Patient characteristics and health outcomes between those not anticoagulated were compared with those anticoagulated (warfarin and direct oral anticoagulants, DOAC). RESULTS 200/2307 (9%) patients were anticoagulated. 84% were on warfarin, and the rest a DOAC. Compared to those anticoagulated, there was a higher prevalence of dementia (25% vs. 18%, p = 0.02) and a lower prevalence of cardiovascular disease (54% vs. 78%, p < 0.01), atrial fibrillation (10% vs. 82%, p < 0.01), and polypharmacy (55% vs. 76%, p < 0.01). Renal function was lower in the anticoagulated group. Time to operation for those not anticoagulated and anticoagulated was a median (IQR) of 25 (15) and 27 (18) hours. There was no difference in blood transfusion and hospital mortality. Postoperative complications were similar except a higher rate of renal failure (14% vs. 19%, p = 0.04) and heart failure (1% vs. 5%, p < 0.01), and a longer length of stay [median (IQR): 14 (10) vs. 16 (12) days] in the anticoagulated group. This was no longer significant after adjustment of confounders. CONCLUSION There was no statistically significant difference in health outcomes between those anticoagulated and those not after adjusting for patient characteristics. It was feasible to avoid significant delay in hip fracture surgery in those anticoagulated.
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Affiliation(s)
| | - Terence Ong
- Department for Healthcare of Older People, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH UK ,Division of Rehabilitation and Ageing, School of Medicine, University of Nottingham, Nottingham, UK
| | - Merete Gregersen
- Department of Clinical Medicine, Geriatric Section, Aarhus University Hospital, Aarhus, Denmark
| | - Else Marie Damsgaard
- Department of Clinical Medicine, Geriatric Section, Aarhus University Hospital, Aarhus, Denmark
| | - Lars Borris
- Department of Clinical Medicine, Orthopaedic Section, Aarhus University Hospital, Aarhus, Denmark
| | - Jac Kie Chia
- Department for Healthcare of Older People, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH UK
| | - Ying Yi Wendy Yap
- Department for Healthcare of Older People, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH UK
| | - Namal Weerasuriya
- Department for Healthcare of Older People, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH UK
| | - Opinder Sahota
- Department for Healthcare of Older People, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, NG7 2UH UK
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