Family members, ambulance clinicians and attempting CPR in the community: the ethical and legal imperative to reach collaborative consensus at speed.

Here we present the personal perspectives of two authors on the important and unfortunately frequent scenario of ambulance clinicians facing a deceased individual and family members who do not wish them to attempt cardiopulmonary resuscitation. We examine the professional guidance and the protection provided to clinicians, which is not matched by guidance to protect family members. We look at the legal framework in which these scenarios are taking place, and the ethical issues which are presented. We consider the interaction between ethics, clinical practice and the law, and offer suggested changes to policy and guidance which we believe will protect ambulance clinicians, relatives and the patient.

UK clinical guideline for the prevention and treatment of osteoporosis.

The National Osteoporosis Guideline Group (NOGG) has revised the UK guideline for the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women, and men age 50 years and older. Accredited by NICE, this guideline is relevant for all healthcare professionals involved in osteoporosis management. INTRODUCTION: The UK National Osteoporosis Guideline Group (NOGG) first produced a guideline on the prevention and treatment of osteoporosis in 2008, with updates in 2013 and 2017. This paper presents a major update of the guideline, the scope of which is to review the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women, and men age 50 years and older. METHODS: Where available, systematic reviews, meta-analyses and randomised controlled trials were used to provide the evidence base. Conclusions and recommendations were systematically graded according to the strength of the available evidence. RESULTS: Review of the evidence and recommendations are provided for the diagnosis of osteoporosis, fracture-risk assessment and intervention thresholds, management of vertebral fractures, non-pharmacological and pharmacological treatments, including duration and monitoring of anti-resorptive therapy, glucocorticoid-induced osteoporosis, and models of care for fracture prevention. Recommendations are made for training; service leads and commissioners of healthcare; and for review criteria for audit and quality improvement. CONCLUSION: The guideline, which has received accreditation from the National Institute of Health and Care Excellence (NICE), provides a comprehensive overview of the assessment and management of osteoporosis for all healthcare professionals involved in its management. This position paper has been endorsed by the International Osteoporosis Foundation and by the European Society for the Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases.

Lateral back pain identifies prevalent vertebral fractures in post-menopausal women: cross-sectional analysis of a primary care-based cohort.

OBJECTIVE: Vertebral fractures (VFs) are frequently under-recognized, reflecting their lack of diagnostic clinical features. For example, although VFs are associated with back pain, this is also common in the general population. To establish whether back pain can be used to recognize patients with VF, we investigated the site of pain in people with and without VFs using a simple tool. METHODS: A cohort of 504 post-menopausal women was recruited from primary care in South West UK. Back pain was assessed by self-completion of the Margolis pain diagram, and analysis was modified to assess whether pain was mid-line or lateral. VFs were diagnosed by the algorithm-based qualitative method on radiographs. A cross-sectional analysis was carried out to assess the association between back pain and VFs. RESULTS: Three hundred and twenty-two women (64.1%) reported back pain over the last 12 months. Thirty seven (7.3%) had one or more VFs. In women with back pain, the presence of lateral waist area pain was associated with a 4.5-fold increased risk of VFs [odds ratio (OR) 4.48; 95% CI 2.02, 9.94; P < 0.001]. CONCLUSIONS: In post-menopausal women with back pain, the presence of lateral waist pain, as shown on the Margolis pain diagram, may identify women at higher risk of prevalent VF.

Self-Performed Lung Ultrasound for Home Monitoring of a Patient Positive for Coronavirus Disease 2019.

A subset of patients with coronavirus disease 2019 (COVID-19) and lung involvement pose a disposition challenge, particularly when hospital resources are constrained. Those not in respiratory failure are sent home, often with phone monitoring and/or respiratory rate and oxygen saturation monitoring. Hypoxemia may be a late presentation and is often preceded by abnormal lung findings on ultrasound. Early identification of pulmonary progression may preempt emergency hospitalization for respiratory decompensation and facilitate more timely admission. With the goal of safely isolating infected patients while providing advanced monitoring, we present a first report of patient self-performed lung ultrasound in the home with a hand-held device under the guidance of a physician using a novel teleguidance platform.

Educating nursing home staff on fracture prevention: a cluster randomised trial.

OBJECTIVE: to assess whether specialist osteoporosis nurses delivering training to care home staff can reduce fractures and improve the prescription of treatments to reduce fractures versus usual care. DESIGN: pragmatic cluster randomised controlled trial (RCT) with randomisation at the Primary Care Organisation (PCO) level. SETTING: care homes (residential, nursing and EMI) across England and Wales within PCOs. PARTICIPANTS: all 300 PCOs in England and Wales were invited to take part. Of these, 58 agreed to participate and gained ethical approval in time to start the study: 29 clusters were randomised to the intervention group and 29 to the control. INTERVENTION: specialist osteoporosis nurses undertaking short training sessions with care home staff emphase the importance of fracture and fall prevention and train staff on how to identify those residents at high risk of fracture. Residents' risk of fracture and falls was reported to general practitioners (GPs) of patients along with treatment recommendations. OUTCOME MEASURES: primary outcome measures were total fractures over the past 12 months and total hip fractures over past the 12 months. Secondary outcome measures were total home falls, number of residents sustaining a fall, number of residents prescribed bisphosphonates, number of residents prescribed calcium and vitamin D and number of residents wearing hip protectors. All outcomes were measured at the care home level. RESULTS: of the 230 care homes randomised data were collected from 209 of these containing 5,637 residents. There were no differences between the groups in the incidence rate ratios (IRRs) for total fractures (IRR = 0.94 [0.71, 1.26] P = 0.70) or total hip fractures (IRR = 0.86 [0.63, 1.18] P = 0.36). No differences were found between groups for home falls or hip protector use. A significant increase in bisphosphonate prescription was seen in the intervention group over the control group (IRR = 1.50 [1.00, 2.24] P = 0.05). Calcium and vitamin D prescription was significantly increased in the intervention group over the control group (IRR = 1.64 [1.23, 2.18] P<0.01). CONCLUSION: the intervention significantly increased the prescription of bisphosphonates and calcium/vitamin D, but was not associated with a significant effect on the rate of falls or fractures.

Ten Strategies for Optimizing Ultrasound Instruction for Group Learning.

Ultrasound use is rapidly increasing in clinical care and as an educational modality. While there is widespread interest in training health-care professionals to incorporate ultrasound into their daily practice, there are few resources available to guide instructors in the design of impactful and efficient training sessions. We present 10 practical strategies to optimize the educational value of ultrasound workshops for any audience.

Mutations in Known Monogenic High Bone Mass Loci Only Explain a Small Proportion of High Bone Mass Cases.

High bone mass (HBM) can be an incidental clinical finding; however, monogenic HBM disorders (eg, LRP5 or SOST mutations) are rare. We aimed to determine to what extent HBM is explained by mutations in known HBM genes. A total of 258 unrelated HBM cases were identified from a review of 335,115 DXA scans from 13 UK centers. Cases were assessed clinically and underwent sequencing of known anabolic HBM loci: LRP5 (exons 2, 3, 4), LRP4 (exons 25, 26), SOST (exons 1, 2, and the van Buchem's disease [VBD] 52-kb intronic deletion 3'). Family members were assessed for HBM segregation with identified variants. Three-dimensional protein models were constructed for identified variants. Two novel missense LRP5 HBM mutations ([c.518C>T; p.Thr173Met], [c.796C>T; p.Arg266Cys]) were identified, plus three previously reported missense LRP5 mutations ([c.593A>G; p.Asn198Ser], [c.724G>A; p.Ala242Thr], [c.266A>G; p.Gln89Arg]), associated with HBM in 11 adults from seven families. Individuals with LRP5 HBM (∼prevalence 5/100,000) displayed a variable phenotype of skeletal dysplasia with increased trabecular BMD and cortical thickness on HRpQCT, and gynoid fat mass accumulation on DXA, compared with both non-LRP5 HBM and controls. One mostly asymptomatic woman carried a novel heterozygous nonsense SOST mutation (c.530C>A; p.Ser177X) predicted to prematurely truncate sclerostin. Protein modeling suggests the severity of the LRP5-HBM phenotype corresponds to the degree of protein disruption and the consequent effect on SOST-LRP5 binding. We predict p.Asn198Ser and p.Ala242Thr directly disrupt SOST binding; both correspond to severe HBM phenotypes (BMD Z-scores +3.1 to +12.2, inability to float). Less disruptive structural alterations predicted from p.Arg266Cys, p.Thr173Met, and p.Gln89Arg were associated with less severe phenotypes (Z-scores +2.4 to +6.2, ability to float). In conclusion, although mutations in known HBM loci may be asymptomatic, they only account for a very small proportion (∼3%) of HBM individuals, suggesting the great majority are explained by either unknown monogenic causes or polygenic inheritance.

Once-weekly treatment for osteoporosis.

Daily oral bisphosphonates are a well-established treatment option for osteoporosis. However, many patients find the daily dosing regimen inconvenient. Once-weekly alendronate offers greater convenience to patients while providing equal efficacy.

Serum from postmenopausal women directs differentiation of human clonal osteoprogenitor cells from an osteoblastic toward an adipocytic phenotype.

A consistent observation in osteoporosis is bone volume reduction accompanied by increased marrow adipose tissue. No single cause linking the two phenomena has yet been identified. In a human progenitor cell clone (hOP 7) derived from bone marrow, however, we have demonstrated that rabbit serum can direct differentiation away from an osteoblast lineage to one of adipocytes. We now report on whether human serum has a similar effect. Serum was collected from 10 pre- and 10 postmenopausal women and from the 10 postmenopausal women before and following 6-week hormone replacement therapy (HRT). hOP 7 cells were cultured with the various sera, and after 7-14 days adipocytogenesis was determined by oil red O staining and lipoprotein lipase (LPL) and glycerol 3-phosphate dehydrogenase (G3PDH) expression. Incubation with 10% premenopausal serum led to labeling of 10.9% of cells (P < 0.05) with oil red O, whereas application of 10% postmenopausal serum led to a much larger effect, 43.5% labeling (P < 0.001 with respect to premenopausal serum). Oil red O positivity was accompanied by loss of type I collagen expression and increased LPL and G3PDH expression. HRT did not reverse the adipocytogenic effect of postmenopausal serum. In conclusion, serum from postmenopausal women contains factors that steer hOP 7 bone progenitor cells toward an adipocytic phenotype, irrespective of HRT. The study suggests a role for serum factors in the development of fatty marrow in postmenopausal osteoporosis.

Ecotourism and community development: case studies from Hainan, China.

The connections between people, parks, and tourism have received significant attention in recent years, recognizing the potential for mutually beneficial relationships. Ecotourism has been promoted and widely adopted as a strategy for funding conservation initiatives, while at the same time contributing to the socioeconomic development of host communities and providing for quality tourism experiences. Parks are among the most common ecotourism destinations. Employing interviews, observations and secondary sources, this study assesses the current status of ecotourism at two protected areas in Hainan, China, where it is being promoted as a strategy for balancing regional economic growth and conservation objectives. Through an evaluation of the existing tourism-park-community relationships, opportunities and constraints are identified. Ecotourism development was found to be at an early stage at both study sites. Socioeconomic benefits for the local communities have been limited and tourism activity has not contributed revenues towards conservation to date. Community residents, nevertheless, generally support conservation and are optimistic that tourism growth will yield benefits. In light of the study findings and the salient literature, planning direction is offered with the intention of enhancing the capacity of ecotourism to generate benefits for both communities and the parks, and thus contribute to the sustainable development of the region more generally. Lessons derived have broad applicability for ecotourism destinations elsewhere.

Preparticipation examination (screening): practical issues as determined by sport: a United Kingdom perspective.

OBJECTIVES: Pre-participation examination, screening and health surveillance are part of the job specification for many roles within Sports Medicine. The type and scope of this activity varies enormously, with little consensus as to best evidence-based practice. The purpose of this work was to explore and understand the practical approaches to pre-participation examination, screening and health surveillance in two contrasting sport scenarios. DATA SOURCE: Team physicians for British Triathlon and Manchester United Football Club. DATA SYNTHESIS/METHODS: Information was gathered under the headings: why screen, screening objectives, practical issues and constraints? RESULTS: The systems evolved within these two sports reflect their respective opportunities and constraints. Different systems, each with merit, have evolved with some generalizable concepts across sport. CONCLUSIONS: A perfect system for pre-participation examination, screening and health surveillance across all sport does not exist, however, within specific sport scenarios examples of good practice are demonstrated.

Seasonal variation in the incidence of wrist and forearm fractures, and its consequences.

We have used the All Wales Injury Surveillance System (AWISS) in a population-based study of wrist and forearm fractures. We examined seasonal variation in the incidence of these injuries, and looked at resulting pressures on outpatient and inpatient trauma services. AWISS collected data from eight Accident and Emergency (A&E) departments which between them serve a total of 1.2 million people in South Wales. During a single year, we identified all 5013 people who presented with a wrist or forearm fracture. Seasonal variation in wrist/forearm fracture incidence was apparent, but showed a different pattern in different age groups. Overall incidence figures were dominated by an increase in children's fractures in spring and summer. Children under the age of 15 suffered a total of 360 wrist and forearm fractures during the three winter months; an incidence of 5.9/1000 per year that was only about half that observed during the remainder of the year (10.7/1000 per year). In contrast, older people showed a higher incidence in the winter. During the winter months people aged over 75 sustained a total of 160 wrist/forearm fractures; an incidence of 8.2/1000 per year, significantly higher than the incidence observed in other months (5.8/1000 per year). Seasonality of incidence was not apparent in other age groups. Children presenting during the spring and summer months were significantly more likely to need admission to hospital; 22.8% were admitted compared with just 10.3% of those presenting during the winter months (P<0.001, chi(2)-test). Other age groups showed no significant seasonal variation in the likelihood of hospital admission.

Place of residence and risk of fracture in older people: a population-based study of over 65-year-olds in Cardiff.

Fracture prevention strategies will be most cost-effective if targeted on groups of frail elderly people who are at particularly high risk of falls and fractures. Elderly people living in care homes are one potential target population, but fracture incidence in this setting remains poorly defined in many countries. We used the All Wales Injury Surveillance System (AWISS) in a population-based study of people aged over 65 years living in the city of Cardiff. We linked a postcode-based register of all sheltered accommodation and all residential and nursing homes in the city with injury data from Cardiff's single Accident and Emergency Department. Cardiff has 47,700 residents aged over 65 years with 1918 (4.0%) living in residential or nursing homes and 1868 (3.9%) in sheltered accommodation. In 1999 we identified a total of 1305 fractures including 366 hip fractures, giving a crude fracture incidence of 27.4/1000 per year and 7.7/1000 per year, respectively. Care home residents suffered 213 fractures, 95 of which were of the hip, giving a crude fracture incidence of 111.1/1000 per year and 49.5/1000 per year, respectively. People living in sheltered accommodation suffered 94 fractures, including 28 at the hip, giving a crude fracture incidence of 51.4/1000 per year and 15.3/1000 per year, respectively. People in care homes and sheltered accommodation tend to be older than those living in the community, and we adjusted for this by calculating age- and gender-standardized relative ratios for each setting. Compared with the community dwelling population, care home residents had an overall fracture risk of 2.9 (95% CI 2.5-3.3) and a hip fracture risk of 3.3 (95% CI 2.6-4.2). People in sheltered accommodation had a total fracture risk of 1.7 (95% CI 1.4-2.1), and a hip fracture risk of 1.6 (95% CI 1.1-2.4). Such figures support the potential cost-effectiveness of strategies that seek to prevent fractures in care homes and sheltered accommodation, and are of special interest to those planning intervention studies in these settings.