The prevention of fractures in adults

Background General practitioners (GPs) encounter patients who have suffered a fracture or are at an increased risk. Fragility fractures cost Europe 32 billion Euros per year. Recognizing this challenge and understanding its management allows GPs to engage in primary and secondary prevention of fragility fractures. Aim To illustrate lifestyle and pharmacological management options offered by a general practitioner to an adult at increased risk of fractures or low bone mineral density (BMD). The National Osteoporosis Guideline Group (NOGG, 2016), World Health Organisation (WHO), International Osteoporosis Foundation (IOF, 2012), Kidney Disease Improving Global Outcomes (KDIGO, 2009), Scottish Intercollegiate Guidelines Network (SIGN) and National Institute for Health and Care Excellence (NICE) management guidelines are discussed in this regard. Objectives • To provide key definitions in the management of osteoporosis. • To identify groups at risk of developing low BMD, vitamin D deficiency and fragility fractures. • To illustrate the current management options for an adult at increased risk of fractures or low bone mass by a general practitioner. • To discuss current methods of investigation and measurement of low BMD, fracture risk assessment and vitamin D deficiency. • To address dietary requirements of calcium and vitamin D and local formulations available. Method A literature search was conducted using Pubmed and Google search engines. Keywords included: osteoporosis; low bone mineral density; vitamin D; fragility fracture; postmenopausal. The NOGG (2016), WHO, IOF (2012), KDIGO (2009), SIGN and NICE management guidelines were included directly. Treatments ranging from fall prevention, dietary modification, anti-resorptive therapy and tailoring in subgroups were reviewed. Conclusion Guidelines can close the gap between physicians in primary and secondary care, institutions and private practice providing a multifaceted approach for the proper identification, prevention and management of fragility fractures.peer-reviewe

An evaluation of referral tickets for acute psychiatric admissions

Background Tickets of referral assist in clerking and the enforcement of the Mental Health Act. Initial reviewers of the patient who may be more aware of his/her background may provide this information when transferring a patient to Mount Carmel Hospital, Malta’s psychiatric hospital. Objectives The aims of this study were to assess whether key information on referral tickets was lacking as well as to justify the importance of such information when referring a new case and raise awareness on appropriate referral. Methods Permission to review the tickets of referral for new admissions from the community to Mount Carmel Hospital during the month of June 2015 was obtained from the Chairman of Psychiatry. The files of new admissions were assessed to see if the following were present: official referral ticket; drug history; next of kin details; handover to staff at Mount Carmel Hospital. The place of initial assessment was also noted. All data was anonymised and data input was done using a prepared proforma. Patients referred from the civil prison and by the caring consultant’s firm were not included. Results Seventy admissions were assessed. Eighty-nine per cent (n=62) of these admissions included an official ticket of referral. Most referrals came from health centres: 31% (n=22). Seventy-four per cent (n=51) had a drug history present. Seventy-six per cent (n=53) were lacking next of kin details. Forty per cent (n=28) of the cases had documentation of a handover to a senior on call. Conclusions Poor quality referral tickets with missing information are often present which makes it difficult for the on-call staff at Mount Carmel Hospital to clerk the patient and come up with a provisional treatment plan.peer-reviewe

Fetal MRI : an essential step in interpreting complex ultrasound findings

Background: Fetal magnetic resonance imaging (MRI) allows for the interpretation of complex fetal anomalies detected on ultrasound (US). Locally it has been available since 2013 but has remained underused. Method: In this paper we report the US and MRI findings of all cases of fetal MRI that were taken to date locally and how MRI can contribute to the clarification of malformations, management, counseling, evaluation of prognosis and ruling out of other possible malformations. Results: The cases reported were: two cases of hydroureter; gastroschisis; ventriculomegaly; intracranial haemorrhage; splenic cyst; Arnold Chiari II malformation. In all seven cases MRI was able to add to or change the diagnosis. Conclusion: Fetal MRI acts as an adjunct to US in interpreting abnormal fetal development. It is a safe non-invasive method of imaging that allows the clinician to take more informed decisions and better parental counselling.peer-reviewe

The cost of blood in paediatric oncology patients

Introduction: Consumption of blood products is significant aiming to treat low cell counts and improve quality of life however 9% to 44% of the total consumption in centres abroad are unjustified. We reviewed thresholds at which blood products were administered and costs incurred by administering blood products at the local paediatric oncology ward at Mater Dei hospital and assessed whether they were inkeeping with local guidelines. Methods: Patient files were analyzed retrospectively for demographics, disease, type and amount of blood products used from January to May 2013. The costs involved were obtained from the Blood Bank at Mater Dei Hospital. The standards used were the protocol by HBB regarding administration on KURA and ‘Supportive care protocols’ in paediatric oncology and haematology. Results: Nine children were given blood products. Red cell products (RCP) use ranged from 0-10 units. and platelets derived products ranged 0- 12 units per patient. haemoglobin levels and platelet counts before transfusions ranged from 3.1 to 8.6g/dL and 9 to 60x109/L respectively. The total cost for the department was €17,950 while the total amount spent for tests done prior to ordering products was €3,276 out of 22 RCP requests for transfusion only once were RCPs transfused above the standard 7g/dL. Platelets were requested 26 times. Documentation regarding the reason for administration was lacking in patient files. Conclusion: The use of blood products is dependent on patient needs and is not influenced by prices. Thresholds at which platelets and RCP are administered vary according to the clinical scenario. Rising costs and shrinking donor pools require blood products to be used judiciously.peer-reviewe

Updates in the prevention of fractures

BACKGROUND: The prevention of fractures is multifaceted and relies on reorienting lifestyles and targeting persons with increased fracture risk. Following an earlier review in 2017, the International Osteoporosis Foundation (IOF) has provided several updates for fracture prevention.OBJECTIVES: This bibliographic review will provide family doctors with the IOF’s updates published on its website, noting changes to treatments and guidelines, addressing the prevention of fractures and discussing the new recommendations in the context of the Maltese healthcare system.METHOD: The IOF website (https://www.osteoporosis. foundation/) was reviewed for guidance on preventing fractures from the 19th to the 27th of February 2023. The Scottish Intercollegiate Guidelines Network SIGN 2021 guidelines on managing osteoporosis and the UK Steady, Strong, Straight consensus statement were included. Updates in fracture prevention management were noted, and domestic practices and services available in the community were discussed.RESULTS: The IOF promotes bone health through educational means, lobbying, and developing strategies, such as the Scorecard for Osteoporosis in Europe (SCOPE), which compares EU countries based on expenditure outcomes and accessibility to fracture prevention and management services. The review also emphasises using fracture risk calculators and densitometry to determine treatment and measure responses.CONCLUSION: Strategies can reduce the risk of fractures by giving specific, measurable, and doable objectives to different stakeholders. For family doctors, this could involve community services in assessing the domestic milieu and improving access to social benefits and interventions. Home improvement measures improve both the risk and rate of falls while intervening on a personal level by improving physical and mental attributes to improve the rates of falls.peer-reviewe

National analyses on survival in Maltese adult patients on renal replacement therapy started during 2009–2012

Chronic kidney disease patients on maintenance dialysis (CKD 5D) experience major morbidity and mortality. No data on survival in Maltese dialysis patients exist; therefore, the aim of this study was to rigorously examine survival statistics in a complete cohort of Maltese CKD 5D patients. The study population was comprised of all incident chronic patients (N=328) starting dialysis at the renal unit, Mater Dei hospital, Msida, Malta, for 4 consecutive years (2009–2012). Each yearly cohort was analysed in detail up to 31st December 2017, providing up to 8 years follow-up. Demographics (male 65%; female 35%), aetiology of renal failure (diabetic kidney disease: n=191; 58.2%), comorbidities, transplant status, and death were documented. Data collection and follow up were completed and statistical analysis was performed on the aggregated cohorts with SPSS version 23 with censoring up to 31st December 2017. The cumulative adjusted 5-year overall survival in Maltese CKD 5D patients was 0.36 and 0.25 at 8 years. No statistical difference was observed according to the year of starting dialysis. Cox regression analysis showed that age and transplant status influenced survival. The unadjusted hazard of death increased by 3% for every 1-year increase in age and was increased by 7% if the patient did not receive a transplant, and overall 22% (n=72) of the entire cohort eventually received transplants. This study reports an approximate 65% mortality at 5 years in Maltese haemodialysis patients, a poor prognosis that, despite optimal medical management, is consistent with worldwide reports.peer-reviewe

Preparing an interdisciplinary guidance for the management of generalised paediatric status epilepticus

BACKGROUND: A guidance was created to assist family doctors in managing generalized paediatric status epilepticus (GPSE) at Primary HealthCare (PHC) clinics.AIM: The article aims to discuss the process by which the GPSE guidance was prepared.OBJECTIVES: The authors intend to provide information on how the literature review was carried out, what clinical threshold was decided as appropriate for the administration of rescue medication, and what treatments may be used in PHC.METHOD: An initial search and guidance draft was forwarded to a Joint Working Group (JWG) composed of professionals working at PHC and Mater Dei Hospital (MDH). The names of benzodiazepines and their formulations available at PHC clinics were forwarded to the JWG by the clinical Chairperson of Primary HealthCare. A Pubmed search was carried out for the terms “status epilepticus,” “children”, and “prehospital”, filtering for free full text publications, humans, English language, and dating from 1999 to 2019, yielding seventeen results in the English language. Eight were relevant. A second Pubmed search for “diazepam use in paediatric seizures” and “midazolam use in paediatric seizures” yielded fifty-five results, filtering for English and dating from 2010-2019. Two were relevant. Several guidelines and literature were directly referenced. The literature review process and results were summarised and modified into a flowchart.RESULTS: An interdisciplinary approach was used to decide how GPSE should be treated. Consensus was agreed that if a seizure lasts more than five minutes, benzodiazepines midazolam and diazepam available at PHC clinics, may be used. Intramuscular, intranasal, buccal, or rectal routes are preferred per the child’s weight; and time the duration of seizure activity.CONCLUSION: GPSE may terminate during the first five minutes of ictal activity. Midazolam and diazepam may be administered by different methods if seizures persist, depending on the clinical scenario.peer-reviewe

Geographical and temporal distribution of SARS-CoV-2 clades in the WHO European Region, January to June 2020

We show the distribution of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) genetic clades over time and between countries and outline potential genomic surveillance objectives. We applied three genomic nomenclature systems to all sequence data from the World Health Organization European Region available until 10 July 2020. We highlight the importance of real-time sequencing and data dissemination in a pandemic situation, compare the nomenclatures and lay a foundation for future European genomic surveillance of SARS-CoV-2

SMS SOS: A randomized controlled trial to reduce self-harm and suicide attempts using SMS text messaging

Background: Hospital-treated deliberate self-harm (DSH) is common, costly and has high repetition rates. Since brief contact interventions (BCIs) may reduce the risk of DSH repetition, we aim to evaluate whether a SMS (Short Message Service) text message Intervention plus Treatment As Usual (TAU) compared to TAU alone will reduce hospital DSH re-presentation rates in Western Sydney public hospitals in Australia. Methods/design: Our study is a 24-month randomized controlled trial (RCT). Adult patients who present with DSH to hospital emergency, psychiatric, and mental health triage and assessment departments will be randomly assigned to an Intervention condition plus TAU receiving nine SMS text messages at 1, 2, 3, 4, 5, 6, 8, 10 and 12-months post-discharge. Each message will contain telephone numbers for two mental health crises support tele-services. Primary outcomes will be the difference in the number of DSH re-presentations, and the time to first re-presentation, within 12-months of discharge. Discussion: This study protocol describes the design and implementation of an RCT using SMS text messages, which aim to reduce hospital re-presentation rates for DSH. Positive study findings would support the translation of an SMS-aftercare protocol into mental health services at minimal expense. Trial registration and ethics approval: This trial has been registered with the Australian and New Zealand Clinical Trials Registry (Trial registration: ACTRN12617000607370. Registered 28 April 2017) and has been approved by two Local Health Districts (LHDs). Western Sydney LHD Human Research Ethics Committee approved the study for Westmead Hospital and Blacktown Hospital (Protocol: HREC/16/WMEAD/336). Nepean Blue Mountains LHD Research Governance Office approved the study for Nepean Hospital (SSA/16/Nepean/170)

SMS SOS: a randomized controlled trial to reduce self-harm and suicide attempts using SMS text messaging

Abstract Background Hospital-treated deliberate self-harm (DSH) is common, costly and has high repetition rates. Since brief contact interventions (BCIs) may reduce the risk of DSH repetition, we aim to evaluate whether a SMS (Short Message Service) text message Intervention plus Treatment As Usual (TAU) compared to TAU alone will reduce hospital DSH re-presentation rates in Western Sydney public hospitals in Australia. Methods/design Our study is a 24-month randomized controlled trial (RCT). Adult patients who present with DSH to hospital emergency, psychiatric, and mental health triage and assessment departments will be randomly assigned to an Intervention condition plus TAU receiving nine SMS text messages at 1, 2, 3, 4, 5, 6, 8, 10 and 12-months post-discharge. Each message will contain telephone numbers for two mental health crises support tele-services. Primary outcomes will be the difference in the number of DSH re-presentations, and the time to first re-presentation, within 12-months of discharge. Discussion This study protocol describes the design and implementation of an RCT using SMS text messages, which aim to reduce hospital re-presentation rates for DSH. Positive study findings would support the translation of an SMS-aftercare protocol into mental health services at minimal expense. Trial registration and ethics approval This trial has been registered with the Australian and New Zealand Clinical Trials Registry (Trial registration: ACTRN12617000607370. Registered 28 April 2017) and has been approved by two Local Health Districts (LHDs). Western Sydney LHD Human Research Ethics Committee approved the study for Westmead Hospital and Blacktown Hospital (Protocol: HREC/16/WMEAD/336). Nepean Blue Mountains LHD Research Governance Office approved the study for Nepean Hospital (SSA/16/Nepean/170)