Medical school dermatology education: a scoping review.

Dermatological diseases are widespread and have a significant impact on the quality of life of patients; however, access to appropriate care is often limited. Improved early training during medical school represents a potential upstream solution. This scoping review explores dermatology education during medical school, with a focus on identifying the factors associated with optimizing the preparation of future physicians to provide care for patients with skin disease. A literature search was conducted using online databases (Embase, MEDLINE, CINAHL and Scopus) to identify relevant studies. The Joanna Briggs Institute methodological framework for scoping reviews was used, including quantitative and qualitative data analysis following a grounded theory approach. From 1490 articles identified, 376 articles were included. Most studies were from the USA (46.3%), UK (16.2%), Germany (6.4%) and Canada (5.6%). Only 46.8% were published as original articles, with a relatively large proportion either as letters (29.2%) or abstracts (12.2%). Literature was grouped into three themes: teaching content, delivery and assessment. Core learning objectives were country dependent; however, a common thread was the importance of skin cancer teaching and recognition that diversity and cultural competence need greater fostering. Various methods of delivery and assessment were identified, including computer-aided and online, audiovisual, clinical immersion, didactic, simulation and peer-led approaches. The advantages and disadvantages of each need to be weighed when deciding which is most appropriate for a given learning outcome. The broader teaching-learning ecosystem is influenced by (i) community health needs and medical school resources, and (ii) the student and their ability to learn and perform. Efforts to optimize dermatology education may use this review to further investigate and adapt teaching according to local needs and context.

Treating 'osteoporosis': a near miss in an unusual case of FGF-23-mediated hypophosphataemic osteomalacia.

Summary: We present the case of a 60-year-old female who developed repeated atraumatic stress fractures. She was initially diagnosed with osteoporosis based on her dual-energy X-ray absorptiometry (DXA) scan bone mineral density (BMD) T-scores and started on denosumab therapy. Secondary osteoporosis screen revealed abnormal myeloma screen and low serum phosphate levels. It was thought that the patient had multiple myeloma with associated Fanconi-related tubular dysfunction. However, fibroblast growth factor-23 (FGF-23) levels were grossly elevated, making Fanconi syndrome unlikely. The patient was subsequently diagnosed with two separate conditions, namely cardiac amyloid light-chain (AL) amyloidosis and FGF-23-related hypophosphataemia, likely due to tumour-induced osteomalacia. This case highlights the importance of excluding osteomalacia as a cause of low BMD and checking FGF-23 levels in the workup for hypophosphataemia. Learning Points: Tumour-induced osteomalacia is a difficult diagnosis as the tumour is often small and slow growing. Imaging may fail to identify a tumour, and treatment therefore consists of calcitriol and phosphate replacement. Tumour-induced osteomalacia should be suspected in the adult presenting with new-onset hypophosphataemia, elevated FGF-23 levels and isolated renal phosphate wasting. Serum phosphate is not part of the routine chemistry panels. Routinely checking phosphate levels prior to initiating antiresorptive therapy is warranted. DXA cannot distinguish low bone mineral density due to osteoporosis from osteomalacia. Antiresorptive therapy should be avoided in osteomalacia due to the risk of clinical and radiographic deterioration.

Experience of a systematic approach to care and prevention of fragility fractures in New Zealand.

This narrative review describes efforts to improve the care and prevention of fragility fractures in New Zealand from 2012 to 2022. This includes development of clinical standards and registries to benchmark provision of care, and public awareness campaigns to promote a life-course approach to bone health. PURPOSE: This review describes the development and implementation of a systematic approach to care and prevention for New Zealanders with fragility fractures, and those at high risk of first fracture. Progression of existing initiatives and introduction of new initiatives are proposed for the period 2022 to 2030. METHODS: In 2012, Osteoporosis New Zealand developed and published a strategy with objectives relating to people who sustain hip and other fragility fractures, those at high risk of first fragility fracture or falls and all older people. The strategy also advocated formation of a national fragility fracture alliance to expedite change. RESULTS: In 2017, a previously informal national alliance was formalised under the Live Stronger for Longer programme, which includes stakeholder organisations from relevant sectors, including government, healthcare professionals, charities and the health system. Outputs of this alliance include development of Australian and New Zealand clinical guidelines, clinical standards and quality indicators and a bi-national registry that underpins efforts to improve hip fracture care. All 22 hospitals in New Zealand that operate on hip fracture patients currently submit data to the registry. An analogous approach is ongoing to improve secondary fracture prevention for people who sustain fragility fractures at other sites through nationwide access to Fracture Liaison Services. CONCLUSION: Widespread participation in national registries is enabling benchmarking against clinical standards as a means to improve the care of hip and other fragility fractures in New Zealand. An ongoing quality improvement programme is focused on eliminating unwarranted variation in delivery of secondary fracture prevention.

Prevention of Osteoporotic Fractures in Residential Aged Care: Updated Consensus Recommendations.

Osteoporosis is underdiagnosed and undertreated in people living in Residential Aged Care Facilities (RACFs), even though aged-care residents are at greater risk of experiencing fractures than their community-dwelling counterparts. The first (2009) and second (2016) Consensus Conferences on the Treatment of Osteoporosis in RACFs in Australia addressed the prevention of falls and fractures in RACFs. A third Consensus Conference was held to review advances in the field of osteoporosis for people living in RACFs and to update current guidelines. The Conference was held virtually in October 2020 due to the COVID-19 pandemic. Attendance at the meeting was open to health practitioners (n = 116) (eg, general practitioners, geriatricians, rehabilitation specialists, endocrinologists, pharmacists, and physiotherapists) working in RACFs. Participants chose and/or were assigned to breakout groups to review the evidence and reach a consensus on the topic area assigned to the group, which was then presented to the entire group by a nominated spokesperson. Recommendations developed by breakout groups were discussed and voted on by all attending participants. This article updates the evidence for preventing falls and fractures and managing osteoporosis in older adults living in RACFs based on agreed outcomes from the group. We anticipate these updated recommendations will provide health practitioners with valuable guidance when practicing in RACFs.

Improving osteoporosis treatment rates in inpatients admitted with hip fracture: A healthcare improvement initiative in a tertiary referral hospital.

Objective: This healthcare improvement initiative was designed to increase inpatient osteoporosis treatment after hip fracture. Methods: A new protocol was developed by Geriatric Medicine and Endocrinology departments at a tertiary care hospital in Sydney. Its aim was to standardize assessment and treatment of osteoporosis in patients admitted with hip fracture. Eligible inpatients would receive intravenous zoledronic acid during their admission. A 6-month sample of hip fracture patients admitted after the protocol's implementation was compared to a group admitted before. Data collected included demographics, biochemistry, treatment rates, adverse effects, and admission survival. Results: There was a considerable increase in osteoporosis treatment after introducing the protocol. Before the protocol's introduction, none of 36 eligible patients received treatment. After the intervention 79% (23 out of 29) of eligible patients were treated.All treated patients had renal function and serum calcium levels checked post-infusion with no adverse outcomes. Eight patients developed flu-like symptoms within 24 h of the infusion. There were no instances of arrhythmias, ocular inflammation, or death. The cost per patient treated was AUD $87. Conclusion: Adopting a standardized protocol for osteoporosis treatment in patients admitted for hip fracture was effective in improving treatment rates whilst being relatively safe and inexpensive.

131I Ablation of an Entire Thyroid Gland in Locally Invasive Differentiated Thyroid Cancer Without Surgery.

ABSTRACT: A 79-year-old man with locally metastatic papillary thyroid cancer to left-sided cervical lymph nodes was referred for radioiodine therapy. He was considered unfit for thyroidectomy due to extensive local involvement and severe interstitial lung disease requiring continuous oxygen. The patient was treated with low doses of radioiodine (approximately 30 mCi) every 6 months with corticosteroid cover for 3 years with good effect. Sequential 131I scanning and serum thyroglobulin levels confirmed virtual complete ablation of the thyroid gland. The patient remained well on thyroid hormone replacement.

Identification of Patients with Osteoporotic Vertebral Fractures via Simple Text Search of Routine Radiology Reports.

Secondary fracture prevention programs mostly identify patients with symptomatic non-vertebral fractures, whereas asymptomatic vertebral fractures are usually missed. We here describe the development and validation of a simple method to systematically identify patients with radiographic vertebral fractures using simple text-based searching of free-text radiology reports. The study consisted of two phases. In the development phase (DP), twelve search terms were used to identify vertebral fractures in all X-ray and CT reports issued over a period of 6 months. Positive reports were manually reviewed to confirm whether or not a vertebral fracture had in fact been reported. The three search terms most effective in detecting vertebral fractures during the DP were then applied during the implementation phase (IP) over several weeks to test their ability to identify patients with vertebral fractures. The search terms 'Loss of Height' (LoH), 'Compression Fracture' (CoF) and 'Crush Fracture' (CrF) identified the highest number of imaging reports with a confirmed vertebral fracture. These three search terms identified 581 of 689 (84%) of all true vertebral fractures with a positive predictive value of 76%. Using these three terms in the IP, 126 reports were identified of which 100 (79%) had a vertebral fracture confirmed on manual review. Amongst a sample of 587 reports in week 1 of the IP, 7 (1.2%) were false negatives. Many patients with vertebral fractures can be identified via a simple text-based search of electronic radiology reports. This method may be utilised by secondary fracture prevention programs to narrow the 'care gap' in osteoporosis management.

Long-term iron polymaltose infusions associated with hypophosphataemic osteomalacia: a report of two cases and review of the literature.

Iron-induced hypophosphataemic osteomalacia remains under-recognized as a potential complication of parenteral iron therapy. We here report two cases of symptomatic hypophosphataemic osteomalacia with multiple insufficiency fractures in the context of chronic gastrointestinal blood loss, necessitating monthly iron polymaltose infusions over prolonged periods of time. Respective blood tests revealed severe hypophosphataemia [0.29 and 0.43; normal range (NR) 0.8-1.5 mmol/l] in the presence of normal serum calcium and 25-hydroxy vitamin D levels. Urinary fractional phosphate excretion was elevated (16% and 24%; NR < 5%) and the tubular maximum phosphate reabsorption was reduced, consistent with renal phosphate wasting. Serum fibroblast growth factor 23 (FGF23) obtained in one patient was significantly elevated at 285 pg/ml (NR < 54 pg/ml). Bone mineral density was significantly reduced and whole-body bone scans revealed metabolic bone disease and multiple insufficiency fractures consistent with osteomalacia. Cessation of iron infusions resulted in clinical and biochemical improvement within 2 months in one patient whereas the second patient required phosphate and calcitriol supplementation to improve symptomatically. Iron-induced hypophosphataemic osteomalacia is thought to be due to reduced degradation of FGF23, resulting in phosphaturia and reduced synthesis of 1,25-dihydroxy vitamin D. Monitoring of patients on long-term parenteral iron is recommended to avoid clinically serious adverse effects.

Implementation of Models of Care for secondary osteoporotic fracture prevention and orthogeriatric Models of Care for osteoporotic hip fracture.

As the world's population ages, the prevalence of osteoporosis and its resultant fragility fractures is set to increase dramatically. This chapter focuses on current frameworks and major initiatives related to the implementation of fracture liaison services (FLS) and orthogeriatrics services (OGS), Models of Care designed to reliably implement secondary fracture prevention measures for individuals presenting to health services with fragility fractures. The current evidence base regarding the impact and effectiveness of FLS and OGS is also considered.

Treatment of Osteoporosis in Australian Residential Aged Care Facilities: Update on Consensus Recommendations for Fracture Prevention.

BACKGROUND: Older people living in residential aged care facilities (RACFs) are at a higher risk of suffering fractures than the community-dwelling older population. The first Consensus Conference on Treatment of Osteoporosis in RACFs in Australia, held in Sydney in July 2009, aimed to address some of the issues relating to the treatment of older residents with osteoporosis in RACFs. Considering that the field of osteoporosis diagnosis and management has significantly advanced in the last 5 years and that new evidence has been generated from studies performed within RACFs, a Second Consensus Conference was held in Sydney in November 2014. METHODS: An expert panel met in November 2014 in Penrith, NSW, Australia in an attempt to reach a consensus on diverse issues related to the treatment of osteoporosis at RACFs. Participants were selected by the scientific committee on the basis of their practice in an RACF and/or major published articles. The co-chairs distributed topics randomly to all participants, who then had to propose a statement on each topic for approval by the conference after a short, evidence-based presentation, when possible. RESULTS: This article provides an update on the most relevant evidence on osteoporosis in older people living in RACFs graded according to its level, quality, and relevance. CONCLUSION: As with the first consensus, it is hoped that this statement will constitute an important guide to aid physicians in their decision making while practicing at RACFs.

An unusual presentation of X-linked adrenoleukodystrophy.

UNLABELLED: X-linked adrenoleukodystrophy (X-ALD) is a rare genetic condition caused by mutations in the ABCD1 gene that result in accumulation of very long chain fatty acids (VLCFAs) in various tissues. This leads to demyelination in the CNS and impaired steroidogenesis in the adrenal cortex and testes. A 57-year-old gentleman was referred for the assessment of bilateral gynaecomastia of 6 months duration. He had skin hyperpigmentation since 4 years of age and spastic paraparesis for the past 15 years. Physical examination findings included generalised hyperpigmentation (including skin, buccal mucosa and palmar creases), blood pressure of 90/60 mmHg, non-tender gynaecomastia and bilateral hypoplastic testes. Lower limb findings were those of a profoundly ataxic gait associated with significant paraparesis and sensory loss. Primary adrenal insufficiency was confirmed and investigations for gynaecomastia revealed normal testosterone with mildly elevated luteinising hormone level and normal prolactin. The combination of primary adrenal insufficiency (likely childhood onset), partial testicular failure (leading to gynaecomastia) and spastic paraparesis suggested X-ALD as a unifying diagnosis. A serum VLCFA panel was consistent with X-ALD. Subsequent genetic testing confirmed the diagnosis. Treatment with replacement doses of corticosteroid resulted in improvement in blood pressure and increased energy levels. We have reported the case of a 57-year-old man with a very late diagnosis of X-ALD manifested by childhood onset of primary adrenal insufficiency followed by paraparesis and primary hypogonadism in adulthood. Thus, X-ALD should be considered as a possibility in a patient with non-autoimmune primary adrenal insufficiency and neurological abnormalities. LEARNING POINTS: Adult patients with X-ALD may be misdiagnosed as having multiple sclerosis or idiopathic spastic paraparesis for many years before the correct diagnosis is identified.Screening for X-ALD with a VLCFA panel should be strongly considered in male children with primary adrenal insufficiency and in male adults presenting with non-autoimmune primary adrenal insufficiency.Confirmation of a genetic diagnosis of X-ALD can be very useful for a patient's family as genetic testing enables detection of pre-symptomatic female heterozygotes who can then be offered pre-natal testing to avoid transmission of the disease to male offsprings.

Gender disparity in BMD conversion: a comparison between Lunar and Hologic densitometers.

UNLABELLED: Female-derived inter-conversion and standardised BMD equations at the lumbar spine and hip have not been validated in men. This study of 110 male subjects scanned on Hologic and Lunar densitometers demonstrates that published equations may not applicable to men at the lumbar spine. Male inter-conversion equations have also been derived. PURPOSE: Currently, available equations for inter-manufacturer conversion of bone mineral density (BMD) and calculation of standardised BMD (sBMD) are used in both males and females, despite being derived and validated only in women. Our aim was to test the validity of the published equations in men. METHODS: One hundred ten men underwent lumbar spine (L2-4), femoral neck (FN) and total hip (TH) dual X-ray absorptiometry (DXA) using Hologic and Lunar scanners. Hologic BMD was converted to Lunar using published equations derived from women for L2-4 and FN. Actual Lunar BMD (A-Lunar) was compared to converted (Lunar equivalent) Hologic BMD values (H-Lunar). sBMD was calculated separately using Hologic (sBMD-H) and Lunar BMD (sBMD-L) at L2-4, FN and TH. Conversion equations in men for Hologic to Lunar BMD were derived using Deming regression analysis. RESULTS: There was a strong linear correlation between Lunar and Hologic BMD at all skeletal sites. A-Lunar BMD was however significantly higher than derived H-Lunar BMD (p < 0.001) at L2-L4 (mean difference, 0.07 g/cm(2)). There was no significant difference at the FN (mean difference, 0.01 g/cm(2)). sBMD-L at the spine was significantly higher than sBMD-H (mean difference, 0.06 g/cm(2), p < 0.001), whilst there was little difference at the FN and TH (mean difference, 0.01 g/cm(2)). CONCLUSION: Published conversion equations for Lunar BMD to Hologic BMD, and formulae for lumbar spine sBMD, derived in women may not be applicable to men.

Vitamin D status and its predictive factors in pregnancy in 2 Australian populations.

BACKGROUND: High prevalence rates of suboptimal vitamin D levels have been observed in women who are not considered 'at risk'. The effect of behavioural factors such as sun exposure, attire, sunscreen use and vitamin D supplementation on vitamin D levels in pregnancy is unknown. AIM: To determine prevalence and predictive factors of suboptimal vitamin D levels in 2 antenatal clinics in Australia--Campbelltown, NSW and Canberra, ACT. METHODS: A cross-sectional study of pregnant women was performed with a survey of demographic and behavioural factors and a mid-pregnancy determination of maternal vitamin D levels. RESULTS: The prevalence of vitamin D deficiency (≤25 nmol/L) and insufficiency (26-50 nmol/L) was 35% in Canberra (n=100) and 25.7% in Campbelltown (n=101). The majority of participants with suboptimal D levels had vitamin D insufficiency. Among the vitamin D-deficient women, 38% were Caucasian. Skin exposure was the main behavioural determinant of vitamin D level in pregnancy in univariate analysis. Using pooled data ethnicity, season, BMI and use of vitamin D supplements were the main predictive factors of suboptimal vitamin D. Vitamin D supplementation at 500 IU/day was inadequate to prevent insufficiency. CONCLUSIONS: Behavioural factors were not as predictive as ethnicity, season and BMI. As most participants had one of the predictive risk factors for suboptimal vitamin D, a case could be made for universal supplementation with a higher dose of vitamin D in pregnancy and continued targeted screening of the women at highest risk of vitamin D deficiency.