Implementation of a Fracture Liaison Service in a tertiary hospital in Malaysia: a feasibility study.

Fracture Liaison Service is a coordinator-based model effective in addressing the fragility fracture care gap. This study found that the service was feasible in Malaysia and could improve the delivery of secondary fracture prevention. Local adaptations and reactive responses addressed challenges, enhancing feasibility. PURPOSE: To assess the feasibility of a Fracture Liaison Service in Malaysia and to benchmark our service against the International Osteoporosis Foundation Best Practice Framework. METHODS: This feasibility study was conducted at a tertiary hospital in Malaysia from March 2021 to March 2022. Patients aged ≥ 50 years admitted with fragility fractures were recruited. Excluded were those with poor prognosis or transferred out from the hospital during admission. Patients were screened, assessed, and followed up at months 4 and 12 post-fracture presentations. Data was collected using Microsoft Excel and the REDCap database. The feasibility of the Fracture Liaison Service was evaluated using the typology of feasibility. RESULTS: A total of 140 patients (female (93/140, 66.4%), median age 77 (IQR 72, 83), hip fractures (100/140, 65.8%)) were recruited into the Fracture Liaison Service. The recruitment rate was (140/215, 65.1%), as some patients were "missed" due to the COVID-19 pandemic. The completion rate was high (101/114, 88.6%). Among those indicated for antiosteoporosis medication, 82/100 (82%) were initiated on treatment. Various "Best Practice Standards," such as patient evaluation (140/140, 100%), fall prevention (130/140, 92.9%), and medication review standards (15/15, 100%) were high. Complicated referral pathways, inexperienced staff, lack of resources, and communication issues were some of the barriers identified while implementing the Fracture Liaison Service. Challenges were overcome by modifying the service workflow and coordinating with different departments. CONCLUSION: The Fracture Liaison Service was found to be feasible in Malaysia. It demonstrated promise in improving bone health management; however, several changes were needed to adapt the service to suit our environment.

Should major trauma fractures be part of a fracture liaison service's remit: a cost-benefit estimate.

The refracture rate after major trauma is approximately half (57%) the refracture rate after a minimal trauma injury. Extending Fracture Liaison Service activity to include major trauma patients creates significant additional direct cost, but remains essentially cost neutral if notional savings through refracture risk reduction are taken into account. PURPOSE: To compare the 3-year refracture rate following minimal trauma (MT) and non-minimal trauma (non-MT) injuries and evaluate the cost of extending fracture liaison service (FLS) operations to non-MT presentations. METHODS: Patients aged 50, or above presenting to the John Hunter Hospital with a fracture in calendar year 2018 were identified through the Integrated Patient Management System (IPMS) of the Hunter New England Health Service's (HNEHS), and re-presentation to any HNEHS facility over the following 3 years monitored. The refracture rate of MT and non-MT presentations was compared and analysed using Cox proportional hazards regression models. The cost of including non-MT patients was estimated through the use of a previously conducted micro-costing analysis. The operational fidelity of the FLS to the previous estimate was confirmed by comparing the 3-year refracture rate of MT presentations in the two studies. RESULTS: The 3-year refracture rate following a MT injury was 8% and after non-MT injury 4.5%. Extension of FLS activities to include non-MT patients in 2022 would have cost an additional $198,326 AUD with a notional loss/saving of $ - 26,625/ + 26,913 AUD through refracture risk reduction. No clinically available characteristic at presentation predictive of increased refracture risk was identified. CONCLUSION: The 3-year refracture after a non-MT injury is about half (57%) that of the refracture rate after a MT injury. Extending FLS activity to non-MT patients incurs a significant additional direct cost but remains cost neutral if notional savings gained through reduction in refracture risk are taken into account.

Outcome disparities in acute coronary syndrome patients from rural versus urban settings: A narrative review of causes, and strategies to minimize them.

Acute coronary syndrome (ACS) remains an important cause of morbidity and mortality worldwide. Critical elements of improving outcomes in ACS patients include timely access to acute care including prompt revascularization if indicated, and subsequent ongoing secondary prevention and risk factor modification, ideally with cardiovascular specialists. It is being increasingly realized that ACS patients from rural settings suffer from inferior outcomes compared to their urban counterparts due to factors such as delayed diagnosis, delayed access to acute care, and less accessibility to specialized follow up. This narrative review will examine the importance of timely access to care in ACS patients, particularly in ST-elevation myocardial infarction; how barriers in access to care affects outcomes in various rural populations; and strategies that have been shown to improve such access, and therefore hopefully achieve more equitable health outcomes compared to patients who live in urban settings.

Secondary fracture prevention in primary care: a narrative review.

The global burden of osteoporosis continues to rise with an ageing population. Untreated osteoporotic fractures not only heighten the risk of subsequent fractures but are associated with excess mortality. Although primary care guidelines consistently stress the importance of secondary fracture prevention, fewer than 20% of patients are appropriately treated for osteoporosis following an initial osteoporotic fracture. This worldwide phenomenon is known as the osteoporosis care gap. This literature review examines the barriers to secondary fracture prevention in primary care and evaluates the effectiveness of targeted primary care interventions. Common themes emerged from the majority of qualitative studies, including a need for improved communication between the hospital team and primary care, better defined responsibilities and osteoporosis-directed education for the primary care physicians. Quantitative studies demonstrated that most targeted, intensive interventions aimed at educating patients and their primary care physician about osteoporosis treatment significantly increased rates of investigation and treatment. Greater uptake of models of secondary fracture prevention in primary care is urgently needed to address the osteoporosis care gap.

Effectiveness of fracture liaison service in reducing the risk of secondary fragility fractures in adults aged 50 and older: a systematic review and meta-analysis.

To determine and appraise the certainty of fracture liaison service (FLS) in reducing the risk of secondary fragility fractures in older adults aged ≥ 50 years and to examine the nature of the FLS and the roles of various disciplines involved in the delivery of the FLS. Medline, EMBASE, PubMed, CINAHL, SCOPUS, and The Cochrane Library were searched from January 1st, 2010, to May 31st, 2022. Two reviewers independently extracted data. The risk of bias was evaluated using the Newcastle-Ottawa Scale for cohort studies and the PEDro scale for randomized trials, while the GRADE approach established the certainty of the evidence. Thirty-seven studies were identified of which 34 (91.9%) were rated as having a low risk of bias and 22 (59.5%) were meta-analyzed. Clinically important low certainty evidence at 1 year (RR 0.26, CI 0.13 to 0.52, 6 pooled studies) and moderate certainty evidence at ≥ 2 years (RR 0.68, CI 0.55 to 0.83, 13 pooled studies) indicate that the risk of secondary fragility fracture was lower in the FLS intervention compared to the non-FLS intervention. Sensitivity analyses with no observed heterogeneity confirmed these findings. This review found clinically important moderate certainty evidence showing that the risk of secondary fragility fracture was lower in the FLS intervention at ≥ 2 years. More high-quality studies in this field could improve the certainty of the evidence. Review registration: PROSPERO-CRD42021266408.

Return on investment of fracture liaison services: a systematic review and analysis.

Fracture liaison services (FLS) have been proven clinically effective and cost-effective in preventing subsequent fractures among patients with an existing fragility fracture. Little is known about their monetary benefits such as their return on investment (ROI). This systematic review aimed to investigate the ROI of FLS and identify the FLS characteristics with better ROI. Studies on the cost-effectiveness of FLS published between January 2000 and December 2022 were searched from MEDLINE, EMBASE, PubMed, and Cochrane Central. Two independent reviewers conducted study selection and data extraction. ROI was calculated based on the difference between monetary benefits and FLS costs divided by the FLS costs. Subgroup analysis of ROI was performed across FLS types and FLS design details. A total of 23 FLS were included in this review. The majority of them were targeting patients aged over 50 years having fractures without identified sites. The mean ROI of these FLS was 10.49 (with a median ROI of 7.57), and 86.96% of FLS had positive ROI. FLS making treatment recommendations yielded the highest ROI (with a mean ROI of 18.39 and a median of 13.60). Incorporating primary care providers (with a mean ROI of 16.04 and a median of 13.20) or having them as program leaders (with a mean ROI of 12.07 and a median of 12.07) has demonstrated a high ROI. FLS for specific fracture sites had great monetary return. Intensive FLS such as type A and B FLS programs had higher ROI than non-intensive type C and D FLS. This review revealed a 10.49-fold monetary return of FLS. Identified characteristics contributing to greater economic return informed value-for-money FLS designs. Findings highlight the importance of FLS and the feasibility of expanding their contribution in mitigating the economic burden of osteoporotic fracture and are conducive to the promotion of FLS internationally.

Evaluación de las Unidades de Gestión de Fracturas en la prevención de fracturas secundarias / Evaluation of Fracture Liaison Services in the Prevention of Secondary Fractures

INTRODUCCIÓN: La osteoporosis se define como una enfermedad esquelética, caracterizada por una disminución de la resistencia ósea que predispone al paciente a un mayor riesgo de fractura (1). Puede dividirse en osteoporosis primaria y secundaria que, a su vez, puede ser de diversos tipos (2). La masa y densidad ósea se mantienen bastante constantes cuando se para el crecimiento y sigue hasta los 50 años aproximadamente (3). Existen 4 categorías de diagnóstico según la evaluación mediante DXA: masa ósea normal, baja masa ósea (osteopenia), osteoporosis y osteoporosis severa. Según la definición de osteoporosis de la OMS, la enfermedad afecta aproximadamente al 6,3% de los hombres mayores de 50 años y al 21,2% de las mujeres del mismo rango de edad en todo el mundo (4). En toda Europa en 2019 (Unión Europea, más Suiza y el Reino Unido), se estima que 32 millones de personas mayores de 50 años tienen osteoporosis, lo que equivale al 5,6% de la población europea total mayor de 50 años, o aproximadamente 25,5 millones de mujeres (22,1% de mujeres mayores de 50 años) y 6,5 millones de hombres (6,6% de los hombres mayores de 50 años) (5). Los principales factores de riesgo que contribuyen a la osteoporosis son factores antropométricos como la edad o el género, factores clínicos como enfermedades gastrointestinales, hematológicas o menopausia prematura y factores ambientales tales como el tabaquismo, la actividad física o la elevada ingesta de alcohol (3, 6, 7). OBJETIVOS: Evaluar las FLS en la prevención de nuevas fracturas por fragilidad en personas de ≥ 50 años que hayan tenido al menos una fractura por fragilidad (prevención secundaria) en términos de eficacia/efectividad, económicos y organizativos. MATERIAL Y MÉTODOS: Para evaluar la eficacia/efectividad de las FLS, se realizó una revisión sistemática (RS) de la evidencia disponible para evaluar las FLS en la prevención de fracturas secundarias. Se incluyeron ensayos clínicos aleatorizados (ECA) y estudios observacionales (cohortes prospectivas y retrospectivas, controlados antes y después y no controlados antes y después) publicados en castellano, catalán o inglés, que evaluaran a personas mayores o con edad igual a 50 años que hubieran tenido al menos una fractura por fragilidad. Se excluyó pacientes con fractura con traumatismo de alta energía, sin fractura o con fractura patológica o secundaria (por ejemplo, a enfermedades neoplásicas, iatrogénicas u otras). Se incluyó atención en FLS de cualquier tipo de acuerdo a la clasificación de Ganda et al. 2013 (13): A, B, C y D. Se excluyeron las atenciones geriátricas generales. Se incluyeron estudios cuyo comparador fuera la atención mediante otros dispositivos asistenciales diferentes a la FLS y cuyos desenlaces de interés fueran: inicio del tratamiento, adherencia al tratamiento, caídas, nuevas fracturas, mortalidad, calidad de vida y realización de densitometría ósea. La evaluación de riesgo de sesgo de los estudios se realizó en cuanto a los desenlaces y varió según el diseño del estudio primario. RESULTADOS: Eficacia/Efectividad de las FLS: La RS de la literatura llevada a cabo en el presente informe para evaluar las FLS en comparación a la práctica clínica habitual en la prevención de fracturas secundarias identificó un total de 92 estudios en 100 referencias: 21 ECA reportados en 24 estudios (26-49), un estudio antes y después controlado (50), 21 estudios de cohorte en 22 artículos (51-73) y 49 estudios antes y después no controlados en 53 artículos (54, 62, 74-124). En pacientes de ≥50 años que hubieran tenido al menos una fractura por fragilidad, las FLS poseen efectos positivos en comparación a la práctica clínica habitual para el inicio del tratamiento y la realización de densitometría ósea (certeza de la evidencia baja según GRADE). Las FLS de tipo A, B y D podrían ser efectivas y aumentar el número de pacientes que empiezan el tratamiento con fármacos antiosteoporóticos. Las FLS tipo A, B, C y D aumentarían la realización de densitometrías óseas en estos pacientes. En pacientes de ≥50 años que hubieran tenido al menos una fractura por fragilidad, las FLS tipo A en comparación con la práctica clínica habitual sugieren que podrían no tener efecto en la adherencia al tratamiento y la calidad de vida de los pacientes (certeza de la evidencia baja según GRADE). Para los desenlaces de nuevas fracturas, mortalidad y caídas, la evidencia actual es muy incierta para medir su efecto en las FLS en relación con la práctica clínica habitual (certeza de la evidencia muy baja según GRADE). Aspectos económicos: La RS de la literatura identificó un total de 21 estudios (125-145), 10 de los cuales pudieron clasificarse como una intervención mediante FLS de tipo A (125-129, 131-133, 141, 145), 4 como FLS de tipo B (134-136)(130), 4 como FLS de tipo C (137-140) y ninguna de FLS de tipo D. Aspectos organizativos: Los aspectos organizativos que impactan en la implementación de las FLS son la existencia de la figura de un coordinador, la ubicación de la FLS y su intensidad asistencial. Asimismo, la duración del seguimiento en las FLS, el tipo de ubicación de la fractura y el género de los pacientes atendidos que podrían impactar en las decisiones de manejo clínico. Las FLS españolas se encuentran mayoritariamente en hospitales y centros sanitarios de titularidad pública. Las fracturas por fragilidad más atendidas en España son las de cadera, seguidas por las fracturas vertebrales clínicas y las de antebrazo y húmero. En la mayoría de FLS españolas, existe una estructura organizativa bien establecida que favorece la atención de las fracturas por fragilidad, aunque se identifican áreas de mejora como el seguimiento a largo plazo de los pacientes y los registros de actividad de las FLS. CONCLUSIONES: En pacientes ≥50 años con al menos una fractura por fragilidad y en comparación a la práctica clínica habitual, las FLS de tipo A, B y D podrían aumentar el número de pacientes que inician tratamiento antiosteoporótico, mientras que en las FLS de tipo C podrían no tener efecto. Las FLS de cualquier tipo (A, B, C y D) podrían aumentar la realización de densitometría ósea en estos pacientes. En cuanto a la adherencia al tratamiento y la calidad de vida, las FLS de tipo A podrían no tener ningún efecto en estos pacientes. Finalmente, la evidencia es muy incierta acerca de los efectos de las FLS para la aparición de nuevas fracturas, mortalidad y caídas. En relación con los aspectos económicos, los estudios sugieren que las FLS tipo A, B y C son coste-efectivas para el abordaje de pacientes ≥50 años con al menos una fractura por fragilidad en comparación a la práctica clínica habitual. En las FLS tipo D no se ha encontrado evidencia, mientras que en las de tipo desconocido los estudios económicos respaldan su coste-efectividad fundamentalmente en pacientes menores de 80 años. La adopción de FLS por parte del Sistema Nacional de Salud tendría un impacto presupuestario total de alrededor de 1.066 millones de euros (2023-2027). En España las FLS, con una estructura organizativa bien establecida, se encuentran mayoritariamente en hospitales y centros sanitarios de titularidad pública, donde se atienden mayoritariamente fracturas de cadera, vertebrales, de antebrazo y húmero.

INTRODUCTION: Osteoporosis is a skeletal disease, characterized by a decrease in bone strength that predisposes the patient to an increased risk of fracture (1). Osteoporosis can be classified as primary or secondary. Moreover, both categories can be of various types (2). Bone mass and density remain moderately constant once growth stops and until about the age of 50 years (3). There are four diagnostic categories as assessed by DXA (Dual-energy X-ray absorptiometry): normal bone mass, low bone mass (osteopenia), osteoporosis and severe osteoporosis. According to the World Health Organisation (WHO) osteoporosis: the disease affects approximately 6.3% of men over 50 years of age and 21.2% of women in the same age range worldwide (4). Across Europe, in 2019 (European Union, Switzerland, and the United Kingdom), an estimated 32 million people over the age of 50 had osteoporosis. This is equivalent to 5.6% of the total European population over the age of 50, or approximately 25.5 million women (22.1% of women over 50) and 6.5 million men (6.6% of men over 50) (5). The main risk factors contributing to osteoporosis are anthropometric factors such as age or gender, clinical factors -gastrointestinal diseases, haematological diseases or premature menopause-, and environmental factors -smoking, physical activity or high alcohol intake- (3,6,7). OBJECTIVES: To evaluate FLS in the prevention of new fragility fractures in people aged ≥50 years who have had at least one fragility fracture (secondary prevention) in terms of efficacy/effectiveness, economic and organizational. MATERIAL AND METHODS: To evaluate the efficacy/effectiveness of FLS, a systematic review (SR) of the available evidence to evaluate FLS in the prevention of secondary fractures was carried out. We included randomized clinical trials (RCT) and observational studies (prospective and retrospective cohorts, controlled before-andafter, and uncontrolled before- and-after studies) published in Spanish, Catalan or English, which evaluated people over the age of 50 years who had at least one fragility fracture. Patients with fracture with high-energy trauma, without fracture or with pathological or secondary fracture (for example, to neoplastic, iatrogenic or other diseases) were excluded. FLS care of any type was included according to the classification of Ganda et al. 2013 (13): A, B, C and D. General geriatric care was also excluded. We included studies whose comparator was health care through other care devices apart from FLS and whose outcomes of interest were the following ones: start of treatment, adherence to treatment, falls, new fractures, mortality, quality of life and bone densitometry. The risk of bias assessment of the studies was carried out at the level of the outcomes and varied according to the design of the primary study. RESULTS: Efficacy/Effectiveness of FLS: The SR of the literature conducted in this report to evaluate FLS compared to usual clinical practice in the prevention of secondary fractures. A total number of 92 studies in 100 references were identified: 21 RCT reported in 24 studies (26-49), one controlled before-and-after study (50), 21 cohort studies in 22 articles (51-73) and 49 uncontrolled before-andafter studies in 53 articles (54,62,74-124). In patients aged ≥50 years who have had at least one fragility fracture, FLS had positive effects compared to standard clinical practice for initiation of treatment and performance of bone densitometry (low certainty of evidence according to GRADE). Type A, B and D FLS could be effective and increase the number of patients starting treatment with anti-osteoporotic drugs. FLS type A, B, C and D would increase the performance of bone densitometry in these patients. In patients aged ≥50 years who have had at least one fragility fracture, FLS type A compared to standard clinical practice suggests that they may have no effect on patients' adherence to treatment and quality of life (low certainty of evidence according to GRADE). For the outcomes of new fractures, mortality and falls, the current evidence is very uncertain to measure their effect on FLS in relation to usual clinical practice (very low certainty of evidence according to GRADE). Organisational aspects: The organizational aspects that impact on the implementation of FLS are the existence of the figure of a coordinator, the location of the FLS and its care intensity. Moreover, the duration of follow-up in FLS, the type of location of the fracture and the gender of the patients attended could have an impact on clinical management decisions. The majority of Spanish FLS are in public hospitals and health care centres. The most common fragility fractures treated in Spain are those of the hip, followed by vertebral fractures and those of the forearm and humerus. In the majority of Spanish FLS, there is a well-established organizational structure which supports the health care of fragility fractures, although as well as the long-term follow-up of patients and the activity registers of the FLS. CONCLUSIONS: In patients aged ≥50 years w ith at least one fragility fracture and com pared to usual clinical practice, FLS types A, B and D may increase the number of patients who start anti-osteoporotic treatment, while FLS type C may have no effect. In terms of treatment adherence and quality of life, FLS type A may have no effect in these patients. Finally, the evidence is very uncertain about the effects of FLS on the appearance of new fractures, mortality and falls. In relation to economic aspects, studies suggest that FLS types A, B and C are cost-effective for the management of patients ≥50 years with at least one fragility fracture compared to standard clinical practice. No evidence was found for type D FLS, while for those of unknown type, economic studies support their cost-effectiveness mainly in patients under 80 years of age. The adoption of FLS by the Spanish National Health System would have a total budgetary impact of around 1,066 million euros (2023-2027). In Spain, FLS, with a well-established organizational structure, are mainly in public owned hospitals and health care centres where hip, vertebral, forearm and humerus fractures are mainly treated.

Health literacy interventions for secondary prevention of coronary artery disease: a scoping review.

Deficits in health literacy are common in patients with coronary artery disease (CAD), and this is associated with increased morbidity and mortality. In this scoping review, we sought to identify health literacy interventions that aimed to improve outcomes in patients with CAD, using a contemporary conceptual model that captures multiple aspects of health literacy. We searched electronic databases for studies published since 2010. Eligible were studies of interventions supporting patients with CAD to find, understand and use health information via one of the following: building social support for health; empowering people with lower health literacy; improving interaction between patients and the health system; improving health literacy capacities of clinicians or facilitating access to health services. Studies were assessed for methodological quality, and findings were analysed through qualitative synthesis. In total, 21 studies were included. Of these, 10 studies aimed to build social support for health; 6 of these were effective, including those involving partners or peers. Five studies targeted interaction between patients and the health system; four of these reported improved outcomes, including through use of teach-back. One study addressed health literacy capacities of clinicians through communication training, and two facilitated access to health services via structured follow-up-all reporting positive outcomes. Health literacy is a prerequisite for CAD patients to self-manage their health. Through use of a conceptual framework to describe health literacy interventions, we identified mechanisms by which patients can be supported to improve health outcomes. Our findings warrant integration of these interventions into routine clinical practice.

Fracture Liaison Service for Hip Fractures: Is It A Game Changer?

BACKGROUND: Osteoporosis is a common medical condition in older ages. A devastating result of osteoporosis may be a hip fracture with up to 30% mortality rate in one year. The compliance rate of osteoporotic medication following a hip fracture is 20% in the western world. OBJECTIVES: To evaluate the impact of the fracture liaison service (FLS) model in the orthopedic department on patient compliance following hip fracture. METHODS: We performed a retrospective review of all patients with hip fracture who were involved with FLS. We collected data regarding kidney function, calcium levels, parathyroid hormone levels, and vitamin D levels at admission. We educated the patient and family, started vitamin D and calcium supplementation and recommended osteoporotic medical treatment. We phoned the patient 6-12 weeks following the fracture to ensure treatment initiation. RESULTS: From June 2018 to June 2019 we identified 166 patients with hip fracture who completed at least one year of follow-up. Over 75% of the patients had low vitamin D levels and 22% had low calcium levels at admission. Nine patients (5%) died at median of 109 days. Following our intervention, 161 patients (96%) were discharged with a specific osteoporotic treatment recommendation; 121 (73%) received medication for osteoporosis on average of < 3 months after surgery. We recommended on injectable medications; however, 51 (42%) were treated with oral biphsophonate. CONCLUSIONS: FLS improved the compliance rate of osteoporotic medical treatment and should be a clinical routine in every medical center.

Single Visit Evaluation and Tympanostomy Tube Placement for the Treatment of Acute Otitis Media in Children.

OBJECTIVE: To review our experiences with development of a single visit surgery (SVS) program for children with recurrent acute otitis media (AOM) undergoing tympanostomy tube (TT) placement the same day as their otolaryngology surgical consultation. STUDY DESIGN: Retrospective cohort analysis. METHODS: Retrospective series of patients participating in SVS from inception March 1, 2014 to April 30, 2020 were analyzed, with attention to factors associated with increasing interest and participation in SVS and parent experiences/satisfaction. RESULTS: A total of 224 children had TT placed through SVS for AOM management. The average age of patients was 18.1 months (standard deviation 7.8 months), and 130 (58.0%) were male. The median interval between initial contact to schedule SVS, and the SVS date was 15 days (interquartile range 9-23 days). When analyzing year-over-year volumes from inception of SVS, notable increases were seen in 2016 and 2017 after a radio advertisement was played locally. A marked increase in volume was noted after implementation of a Decision Tree Scheduling (DTS) algorithm for children with recurrent AOM. Sixty-six (28.8%) procedures were performed after institution of DTS. A parent survey demonstrated high levels of satisfaction with the SVS experience. Estimations of savings to families in terms of time away from work demonstrated potential for indirect healthcare benefits. CONCLUSIONS: SVS for TT placement was a successful, alternative model of care for management of children with AOM. Marketing strategies regarding SVS, and the inclusion of SVS pathway in DTS platforms increased rates of interest and choice of this option. Parents of children undergoing TT through SVS were satisfied with the overall experience. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2823-2829, 2021.

Fecal Microbiota Transplants Annually and Their Positive Clinical Impact.

INTRODUCTION: Although fecal microbiota transplantation (FMT) is a recommended, clinically efficacious, and cost-effective treatment for recurrent Clostridioides difficile infection (CDI), the scale of FMT use in the United States is unknown. METHODS: We developed a population-level CDI model. RESULTS: We estimated that 48,000 FMTs could be performed annually, preventing 32,000 CDI recurrences. DISCUSSION: Improving access to FMT could lead to tens of thousands fewer C. difficile episodes per year.

Motivational Interviewing Adapted to Group Setting for the Treatment of Relapse in the Behavioral Therapy of Obesity. A Clinical Audit.

Motivational interviewing (MI) is devised to change unhealthy behaviors by increasing motivation. We adapted MI to a group format for the treatment of relapse during the behavioral treatment of obesity and performed a clinical audit to evaluate its effectiveness in stopping weight regain. The program was structured in seven weekly sessions, plus a 6-month follow-up. Patients (n = 86) completed a questionnaire on motivation to change in both healthy diet and physical activity, and a self-reported measurement of calorie intake and physical activity at baseline, at program end and at 6-month follow-up. The attendance to the program was high, with only 13 patients (15%) not completing the program and 24% not attending the 6-month follow-up. By the end of follow up, the prevalence of patients in either precontemplation or contemplation was reduced from over 60% at enrollment to approximately 20%, whereas the sum of patients in action or maintenance stages was increased from 9.5% in healthy diet and 14% in physical activity to 39.7% and 41.3%, respectively. These changes translated into significant behavioral changes (mean calorie intake, -13%; total physical activity, +125%; sedentary time, -8%) and finally into reduced body weight ( -3%). We conclude that MI programs adapted for groups may be used to stop relapse in individuals following a behavioral intervention for obesity.

A Prospective, Randomized, Open-Label Trial of Early versus Late Favipiravir Therapy in Hospitalized Patients with COVID-19.

Favipiravir is an oral broad-spectrum inhibitor of viral RNA-dependent RNA polymerase that is approved for treatment of influenza in Japan. We conducted a prospective, randomized, open-label, multicenter trial of favipiravir for the treatment of COVID-19 at 25 hospitals across Japan. Eligible patients were adolescents and adults admitted with COVID-19 who were asymptomatic or mildly ill and had an Eastern Cooperative Oncology Group (ECOG) performance status of 0 or 1. Patients were randomly assigned at a 1:1 ratio to early or late favipiravir therapy (in the latter case, the same regimen starting on day 6 instead of day 1). The primary endpoint was viral clearance by day 6. The secondary endpoint was change in viral load by day 6. Exploratory endpoints included time to defervescence and resolution of symptoms. Eighty-nine patients were enrolled, of whom 69 were virologically evaluable. Viral clearance occurred within 6 days in 66.7% and 56.1% of the early and late treatment groups (adjusted hazard ratio [aHR], 1.42; 95% confidence interval [95% CI], 0.76 to 2.62). Of 30 patients who had a fever (≥37.5°C) on day 1, times to defervescence were 2.1 days and 3.2 days in the early and late treatment groups (aHR, 1.88; 95% CI, 0.81 to 4.35). During therapy, 84.1% developed transient hyperuricemia. Favipiravir did not significantly improve viral clearance as measured by reverse transcription-PCR (RT-PCR) by day 6 but was associated with numerical reduction in time to defervescence. Neither disease progression nor death occurred in any of the patients in either treatment group during the 28-day participation. (This study has been registered with the Japan Registry of Clinical Trials under number jRCTs041190120.).

Considerations for the otolaryngologist in the era of COVID-19: a review of the literature.

PURPOSE OF REVIEW: The SARS-CoV-2 coronavirus pandemic, referred to as COVID-19, has spread throughout the globe since its first case in China in December 2019, leaving a significant number of people infected and clinically ill. The purpose of this review is to provide the current known clinical characteristics of and management for COVID-19 as it relates to otolaryngology. RECENT FINDINGS: COVID-19 is a highly transmissible respiratory disease with common presenting symptoms of fever, cough, and fatigue. In the absence of available vaccines or antiviral therapies, symptomatic and respiratory support is the current standard of therapy. Measures to prevent further transmission have been enacted globally including social distancing and cancellation of public events. Given elevated viral load in the upper aerodigestive tract, extra precautions in patients with otolaryngology needs have been recommended for protection of both healthcare workers and patients. SUMMARY: Otolaryngologists face unique risk from COVID-19. Maintaining appropriate preventive health measures and remaining updated on institutional clinical guidelines is paramount for both caretaker safety and patient care.

Applying normalization process theory and process mapping to understand implementation of a co-management program for older hip fracture patients in China: a qualitative study.

This qualitative study identified the barriers to the implementation of a multidisciplinary co-management program for older hip fracture patients and provided evidence for future intervention improvement and scale-up. INTRODUCTION: Multidisciplinary co-management has been recommended as an effective intervention for hip fracture management in older people. This study is a process evaluation of a multidisciplinary co-management program in an orthopaedic hospital in Beijing, China, to better understand the barriers to implementation. METHODS: Data collection involved semi-structured interviews with key implementers of the co-management intervention (surgeon, geriatrician, physician, nurse, physiotherapist and anaesthetist) and observations of patients' journey to map the care processes were conducted in Beijing Jishuitan Hospital. Data were transcribed, qualitatively coded and analysed using normalization process theory to understand the intervention process from four constructs: coherence, cognitive participation, collective action and reflexive monitoring. RESULTS: Ten stakeholder interviews were conducted. Despite multidisciplinary co-management intervention was meaningful and valued by participants, barriers to its implementation were identified. These included unmatched investment and benefit (cognitive participation), challenges of facing increased workload (collective action), deficient training and supervision system (collective action), limited accommodating capacity of hospital (collective action) and difficulties in accessing information about the effect of the intervention (reflexive monitoring). CONCLUSIONS: Multiple barriers to the effective implementation of the multidisciplinary co-management program in China were identified. The process evaluation highlights key aspects in less willingness to fully invest in the program, inappropriate workload allocation and lack of training and supervision which need to be addressed before scaling up.

Kidney health for everyone everywhere-from prevention to detection and equitable access to care.

The global burden of chronic kidney disease (CKD) is rapidly increasing with a projection of becoming the 5th most common cause of years of life lost globally by 2040. Aggravatingly, CKD is a major cause of catastrophic health expenditure. The costs of dialysis and transplantation consume up to 3% of the annual healthcare budget in high-income countries. Crucially, however, the onset and progression of CKD are often preventable. In 2020, the World Kidney Day campaign highlights the importance of preventive interventions-be it primary, secondary, or tertiary. This complementing article focuses on outlining and analyzing measures that can be implemented in every country to promote and advance CKD prevention. Primary prevention of kidney disease should focus on the modification of risk factors and addressing structural abnormalities of the kidney and urinary tracts, as well as exposure to environmental risk factors and nephrotoxins. In persons with pre-existing kidney disease, secondary prevention, including blood pressure optimization and glycemic control, should be the main goal of education and clinical interventions. In patients with advanced CKD, the management of comorbidities such as uremia and cardiovascular disease is a highly recommended preventative intervention to avoid or delay dialysis or kidney transplantation. Political efforts are needed to proliferate the preventive approach. While national policies and strategies for non-communicable diseases might be present in a country, specific policies directed toward education and awareness about CKD screening, management, and treatment are often lacking. Hence, there is an urgent need to increase awareness of the importance of preventive measures throughout populations, professionals, and policy makers.

Development of an implementation and evaluation strategy for the Australian 'Zero Childhood Cancer' (Zero) Program: a study protocol.

INTRODUCTION: Effective implementation of a research Program requires an actionable plan to guide execution. To assess the actionability and success of that plan, both scientific and implementation elements must be taken into account. The aim of this study is to assess the 'Zero Childhood Cancer Personalised Medicine Program' (the Zero Program), an Australian first-ever and most comprehensive personalised medicine programme for children with high-risk or relapsed cancer, in terms of its structure, process and implementational effect. METHODS AND ANALYSIS: We will assess Program delivery mechanisms. The development of the implementation and evaluation strategy will concentrate on the work of the Zero Program as a complex whole. This includes the structure of collaborative links across stakeholder groups involved in Program development and delivery, changes to collaborative relationships over time and the impact of group working on Program outcomes. We are applying a mixed-methods design including: a rapid ethnography (observations of stakeholder interactions and informal conversations), Program professionals' completion of a rapid health implementation proforma and a social network analysis. Formative evaluations of the implementation science effects, applying feedback techniques, for example, Formative Evaluation Feedback Loops and the Zero Program professionals' feedback, will determine where Program tailoring may be needed. A repeat of the social network analysis downstream will examine network changes over time, followed by an expert panel using the expert recommendations for implementing change to assess the integration of implementation strategies into the Program structure. A summative evaluation of the Program will bring the research elements together, leading to comprehensive data triangulation and determining the sustainability and implementational effects of Program delivery. ETHICS AND DISSEMINATION: Ethical approval for this study has been granted by Hunter New England Research Ethics Committee, New South Wales, Australia (approval ref: 2019/ETH12025). Knowledge translation will be achieved through publications, reports and conference presentations to healthcare professionals, patients, families and researchers. TRIAL REGISTRATION: NCT03336931; Pre-results.