Bisphosphonate-related bilateral atypical femoral fractures : be aware and beware

Although bisphosphonates have a well established therapeutic role in the prevention of osteoporosis-related fractures, several reports published over the past 5-6 years suggest a possible causative relationship between long-term use of bisphosphonates and development of ‘atypical’ subtrochanteric and femoral diaphyseal fractures. A high level of clinical suspicion and prompt imaging when these patients present with groin/thigh pain should lead to a timely diagnosis. Appropriate elective management to mitigate against the increased risks of these fractures becoming complete could then be instituted. We present a case of complete bilateral atypical subtrochanteric fractures in a patient on long-term bisphosphonates for osteoporosis. Our objective is to highlight the fracture risk of this patient population; present the current knowledge; and discuss the dilemmas in management of both femora.peer-reviewe

Is there a need for a chest pain observation unit in St. Luke's Hospital and will it be cost effective?

Objectives: Studies from the USA suggest that using an A&E department based chest pain observation unit (CPOU) saves from $567 to$2030 per patient compared with hospital admission. In the UK cost effectiveness figures are lower at around £78 per patient. This study aims to review current practice for patients presenting with chest pain in St.Luke's Hospital (SLH), to determine the proportion of patients suitable for CPOU evaluation and consequently calculate any related cost effectiveness. Methods: 236 patients presenting with a primary complaint of chest pain to the A&E department at SLH between 1 st June and 12 th July 2003 were selected. The case histories of these patients were reviewed to ascertain how many of them would qualify for a CPOU management and specific data was collected. Results: Notes were retrieved for 217 patients. A total of 103 (47.5%) patients were suitable for a CPOU management. Mean length of in-hospital stay of these patients was 67.5 hours. Estimated mean cost saving per patient was LM220 and overall LM 19,800 per month. Conclusion: Potential exists for the setting up of CPOU care to reduce health service costs and improve health utility at St.Luke's Hospital.peer-reviewe

Karen

Karen is a sociable, physically active 16 year old girl in England who has just commenced the last two years of secondary school. She is academically strong and is also a keen volleyball player. Karen has been selected for elite training squads which is very time consuming, and this makes it difficult to maintain her academic work. She also experiences increasing difficulties managing the cost of travel. Karen retains an Olympic dream, but is uncertain how to get achieve it. Experts in skill acquisition, coach-athlete relationships, socialisation and pedagogy offer advice

Living with diabetes in the workplace

Despite the high prevalence of diabetes in the population, little research has been conducted into the experiences in the workplace of people living with the condition. The evidence that does exist suggests that diabetes can have a negative impact on individuals, in terms of managing their condition optimally and on productivity. By interviewing a small cohort of employees, managers and other stakeholders, this study set out to explore the challenges experienced in the workplace by adults living with diabetes, and employers’ knowledge of the condition. Ways that the experience of living with diabetes in the workplace can be improved are explored and suggestions for advancing the diabetes literacy of everyone in the workforce are made.peer-reviewe

Surveillance Data from Salmonellae Isolated from Pigs in Great Britain over a 10 year period (1991 to 2000).

Isolates from a total of 3170 incidents of Salmonella from pigs were serotyped during the period 1991-2000; 4443 isolates were tested against 16 antimicrobial agents to produce resistance profiles. Of these isolates the predominant serovar appears to be S. Typhimurium; S. Derby, S. Go1dcoast and S. Panama constituted the other serovars recorded as significant in incidents. During the study period both S. Typhimurium and S. Derby both show a trend towards an increase in resistance to tetracycline and compound sulphonamides. Also noted was a fall in sensitivity of the non-Typhimurium isolates to a range of commonly used antimicrobial agents, with an overall fall in sensitivity of7% to 31% of strains being sensitive in 2000

The impact of COVID-19 on fitness behaviour amongst a sample of the Maltese population

Background. COVID-19 has brought significant changes all over the world, including Malta. These changes might have impacted people's health and lifestyle. Such changes might have limited health and fitness behaviours such as frequency of exercise, intensity of exercise and water intake. Therefore, this study aims to examine and explore how the COVID-19 pandemic has impacted fitness behaviours amongst a sample of the Maltese population.Methods. The sample (n = 995)was selected through convenience sampling. Data was collected through an online 38-item survey which was dispersed on social media during April and May 2020. The questions measured the frequency of health behaviours to provide a comparison between the participant's health behaviours in November 2019 and April 2020, during the COVID-19 pandemic.Results. The data was analysed through Factor Analysis which was conducted for dimension reduction. Factor analysis resulted in 1 factor composed of 3 variables (frequency of exercise, intensity of exercise and water consumption). Further analyses were conducted using a paired samples t-test on SPSS. Following analysis, the results showed that there was an increase in exercise frequency amongst the sample population, whereas there was a decrease in exercise intensity and water consumption. These results confirm that there was a change in health behaviours amongst the study's sample.Conclusion. This study recommends further investigation as to understand this difference in behaviours and its attributes. This can help inform health behaviours should there be further waves of the pandemic or other lockdowns.peer-reviewe

Assessing the aggregated probability of entry of a novel prion disease agent into the United Kingdom

In 2018 prion disease was detected in camels at an abattoir in Algeria for the first time. The emergence of prion disease in this species made it prudent to assess the probability of entry of the pathogen into the United Kingdom (UK) from this region. Potentially contaminated products were identified as evidenced by other prion diseases. The aggregated probability of entry of the pathogen was estimated as very high and high for legal milk and cheese imports respectively and very high, high and high for illegal meat, milk and cheese products respectively. This aggregated probability represents a qualitative assessment of the probability of one or more entry events per year into the UK; it gives no indication of the number of entry events per year. The uncertainty associated with these estimates was high due to the unknown variation in prevalence of infection in camels and an uncertain number and type of illegal products entering the UK. Potential public health implications of this pathogen are unknown although there is currently no evidence of zoonotic transmission of prion diseases other than bovine spongiform encephalopathy to humans

A review of cleaning and disinfection guidelines and recommendations following an outbreak of classical scrapie

[EN] Classical scrapie is a prion disease of small ruminants, the infectious agent of which has been shown to be extremely persistent in the environment. Cleaning and disinfection (C&D) after a scrapie outbreak is currently recommended by many governments' veterinary advisors and implemented in most farms affected. Yet, the effectiveness of these procedures remains unclear. The aim of this study was to review existing literature and guidelines regarding farm C&D protocols following classical scrapie outbreaks and assess their effectiveness and the challenges that translation of policy and legislative requirements present at a practical level. A review of the literature was conducted to identify the on-farm C&D protocols used following outbreaks of scrapie, assess those materials with high risk for persistence of the scrapie agent on farms, and review the existing evidence of the effectiveness of recommended C&D protocols. An expert workshop was also organised in Great Britain (GB) to assess: the decision-making process used when implementing C&D protocols on GB farms, the experts' perceptions on the effectiveness of these protocols and changes needed, and their views on potential recommendations for policy and research. Outputs of the literature review revealed that the current recommended protocol for C&D [1 h treatment with sodium hypochlorite containing 20,000 ppm free chlorine or 2 M sodium hydroxide (NaOH)] is based on labo-ratory experiments. Only four field farm experiments have been conducted, indicating a lack of data on effec-tiveness of C&D protocols on farms by the re-occurrence of scrapie infection post re-stocking. Recommendations related to the control of outdoor environment, which are difficult and expensive to implement, vary between countries. The expert workshop concluded that there are no practical, cost-effective C&D alternatives to be considered at this time, with control therefore based on C&D only in combination with additional time restrictions on re-stocking and replacement with non-susceptible livestock or more genetically resistant types, where available. Participants agreed that C&D should still be completed on scrapie affected farms, as it is considered to be "good disease practice" and likely to reduce the levels of the prion protein. Participants felt that any additional protocols developed should not be "too prescriptive" (should not be written down in specific policies) because of significant variation in farm types, farm equipment and installations. Under this scenario, control of classical scrapie on farms should be designed with a level of C&D in combination with re-stocking temporal ban and replacement with livestock of limited susceptibility.The APHA would like to thank all the expert contributions at the workshop. This study was funded by Defra (UK) under Project SE1960 and the Government of education and science of the Generalitat Valenciana (Spain)Alarcon, P.; Marco-Jiménez, F.; Horigan, V.; Ortiz-Pelaez, A.; Rajanayagam, B.; Dryden, A.; Simmons, H.... (2021). A review of cleaning and disinfection guidelines and recommendations following an outbreak of classical scrapie. Preventive Veterinary Medicine. 193:1-9. https://doi.org/10.1016/j.prevetmed.2021.1053881919

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication