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

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

New trends in the cyber and street market of recreational drugs? The case of 2C-T-7 ('Blue Mystic')

2C-T-7 (‘Blue Mystic’), an illicit compound which shows similarities with MDMA and other designer drugs, has been only occasionally identified in the EU, but discussion on the Internet between experimenters has recently grown significantly. We aimed at collecting together in a review the available information on 2C-T-7, both at the cyber and at the street market level. 2C-T-7 was first synthesized in 1986; its desired effects include both a sense of empathy and of well-being. Hallucinations, nausea, anxiety, panic attacks and paranoid ideation are anecdotally reported. According to the different European sources here approached, the availability of 2C-T-7 at street level seems to be currently very low, although one death related to a mono-intoxication with 2C-T-7 has been documented in the USA. With respect to information on 2C-T-7 available online, due to both redundancy and relevance issues the initial identified sample of 360 was reduced to 118 websites. In 14 (11.9%) websites, the detailed description of the 2C-T-7 synthesis was given. Harm Reduction websites appeared significantly earlier in the search engines results’ list than Anti drugs (p 0.006) websites. Five (4.2%) websites apparently offered 2C-T-7 for sale. The large body of knowledge available online seems to contrast with small numbers of seizures at street level; an exhaustive web mapping of drug-related issues may be of interest for the clinician. Projects aimed at designing more ‘attractive’ prevention websites should be planned and future studies should better assess the characteristics of those consumers who take advantage of the online information of hallucinogenic compounds

Drugs on the web; the Psychonaut 2002 EU project

Abstract Purpose: Only a few formal assessments of websites with drug-related contents have been carried out. We aimed here at fostering collection and analysis of data from web pages related to information on consumption, manufacture and sales of psychoactive substances. General methods: An 8-language, two-engine, assessment of the information available in a purposeful sample of 1633 unique websites was carried out. Findings: A pro-drug and a harm reduction approach were evident, respectively, in 18% and 10% of websites accessed. About 1 in 10 websites offered either psychoactive compounds for sale or detailed data on drugs' synthesis/extraction procedures. Information on a number of psychoactive substances and on unusual drugs' combinations not found in the Medline was elicited. Abbreviations: 2C-E, 2,5-dimethoxy-4-ethylphenethylamine; 2C-I, 2,5-dimethoxy-4-iodophenethylamine; 2C-P, 4-( n )-propyl-2,5-DMPEA; 2C-T-2, 2,5-dimethoxy-4-ethylthiophenethylamine; 2C-T-7, 2,5-dimethoxy-4-(n)-propylthiophenethylamine; 4 OH-DET (''CZ-74''), N,N-diethyl-4-hydroxytryptamine; 4 OH-DIPT, 4-hydroxy-N,N-diisopropyltryptamine; 4-acetoxy-DET, 4-acetoxy-hydroxytryptamine; 4-acetoxy-DIPT, 4-acethoxydiisopropyltryptamine; 5-MeO-AMT, 5-methoxyalpha-methyltryptamine; 5-MeO-DALT, 5-methoxy-diallyltryptamine; 5-MeO-DMT, 5-methoxydimethyltryptamine; ANOVA, analysis of variance; BZP, 1-benzylpiperazine; DMT, dimethyltryptamine; DPT, N,N-dipropyltryptamine; GHB, gamma-hydroxy-butyrate; HSD, Honestly Significant Difference; mCPP, mchlorophenylpiperazine; MDMA, 3,4-methylenedioxymethamphetamine; TFMPP, 3-trifluoromethylphenylpiperazine monohydrochloride; i, trade mark; URL, Uniform Resource Locator. Conclusions: This represents the first review which is both comprehensive and multilingual of the online available information on psychoactive compounds. Health professionals may need to be aware of the web being a new drug resource for information and possibly purchase.

New trends in the cyber and street market of recreational drugs? : The case of 2C-T-7 ('Blue Mystic')

2C-T-7 ('Blue Mystic'), an illicit compound which shows similarities with MDMA and other designer drugs, has been only occasionally identified in the EU, but discussion on the Internet between experimenters has recently grown significantly. We aimed at collecting together in a review the available information on 2C-T-7, both at the cyber and at the street market level. 2C-T-7 was first synthesized in 1986; its desired effects include both a sense of empathy and of well-being. Hallucinations, nausea, anxiety, panic attacks and paranoid ideation are anecdotally reported. According to the different European sources here approached, the availability of 2C-T-7 at street level seems to be currently very low, although one death related to a mono-intoxication with 2C-T-7 has been documented in the USA. With respect to information on 2C-T-7 available online, due to both redundancy and relevance issues the initial identified sample of 360 was reduced to 118 websites. In 14 (11.9%) websites, the detailed description of the 2C-T-7 synthesis was given. Harm Reduction websites appeared significantly earlier in the search engines results' list than Anti drugs (p = 0.006) websites. Five (4.2%) websites apparently offered 2C-T-7 for sale. The large body of knowledge available online seems to contrast with small numbers of seizures at street level; an exhaustive web mapping of drug-related issues may be of interest for the clinician. Projects aimed at designing more 'attractive' prevention websites should be planned and future studies should better assess the characteristics of those consumers who take advantage of the online information of hallucinogenic compounds. © 2005 British Association for Psychopharmacology.Peer reviewe

Establishing core outcome domains in pediatric kidney disease: report of the Standardized Outcomes in Nephrology—Children and Adolescents (SONG-KIDS) consensus workshops

Trials in children with chronic kidney disease do not consistently report outcomes that are critically important to patients and caregivers. This can diminish the relevance and reliability of evidence for decision making, limiting the implementation of results into practice and policy. As part of the Standardized Outcomes in Nephrology—Children and Adolescents (SONG-Kids) initiative, we convened 2 consensus workshops in San Diego, California (7 patients, 24 caregivers, 43 health professionals) and Melbourne, Australia (7 patients, 23 caregivers, 49 health professionals). This report summarizes the discussions on the identification and implementation of the SONG-Kids core outcomes set. Four themes were identified; survival and life participation are common high priority goals, capturing the whole child and family, ensuring broad relevance across the patient journey, and requiring feasible and valid measures. Stakeholders supported the inclusion of mortality, infection, life participation, and kidney function as the core outcomes domains for children with chronic kidney disease

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially