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.

Low-density lipoprotein cholesterol in adolescents and young adults with type 1 diabetes: Data from the Australasian Diabetes Data Network registry

AIM

To determine low-density lipoprotein cholesterol (LDL-C) screening frequency and levels, and factors associated with elevated LDL-C, in Australasian youth with type 1 diabetes (T1D).

METHODS

Data were extracted from the Australasian Diabetes Data Network (ADDN), a prospective clinical quality registry, on all T1D healthcare visits attended by young people aged 16-25 years (with T1D duration of >1 year) between January 2011 and December 2020. The primary outcomes were elevated LDL-C > 2.6 mmol/L (100 mg/dL) and threshold for treatment: >3.4 mmol/L (130 mg/dL), according to consensus guidelines. Multivariable Generalised Estimated Equations (GEE) were used to examine factors associated with elevated LDL-C across all visits.

RESULTS

A cohort of 6338 young people (52.6% men) were identified, of whom 1603 (25.3%) had ≥1 LDL-C measurement documented. At last measurement, mean age, age at T1D diagnosis and T1D duration were 18.3 ± 2.4, 8.8 ± 4.5 and 8.9 ± 4.8 years, respectively. LDL-C was elevated in 737 (46.0%) and at the treatment threshold in 250 (15.6%). In multivariable GEE elevated LDL-C continuously was associated with older age (OR = 0.07; 0.01-0.13, p = 0.02), female sex (OR = 0.31; 0.18-0.43; p < 0.001), higher HbA1c (OR = 0.04; 0.01-0.08; p = 0.01) and having an elevated BMI (OR = 0.17, 0.06-0.39, p < 0.001).

CONCLUSIONS

LDL-C screening and levels are suboptimal in this cohort, increasing future cardiovascular complication risk. There is an urgent need to understand how healthcare services can support improved screening and management of dyslipidaemia in this population.

Do cardiopulmonary resuscitation real-time audiovisual feedback devices improve patient outcomes? A systematic review and meta-analysis

BACKGROUND

Cardiac arrest is a leading cause of mortality in America and has increased in the incidence of cases over the last several years. Cardiopulmonary resuscitation (CPR) increases survival outcomes in cases of cardiac arrest; however, healthcare workers often do not perform CPR within recommended guidelines. Real-time audiovisual feedback (RTAVF) devices improve the quality of CPR performed. This systematic review and meta-analysis aims to compare the effect of RTAVF-assisted CPR with conventional CPR and to evaluate whether the use of these devices improved outcomes in both in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA) patients.

AIM

To identify the effect of RTAVF-assisted CPR on patient outcomes and CPR quality with in- and OHCA.

METHODS

We searched PubMed, SCOPUS, the Cochrane Library, and EMBASE from inception to July 27, 2020, for studies comparing patient outcomes and/or CPR quality metrics between RTAVF-assisted CPR and conventional CPR in cases of IHCA or OHCA. The primary outcomes of interest were return of spontaneous circulation (ROSC) and survival to hospital discharge (SHD), with secondary outcomes of chest compression rate and chest compression depth. The methodological quality of the included studies was assessed using the Newcastle-Ottawa scale and Cochrane Collaboration's "risk of bias" tool. Data was analyzed using R statistical software 4.2.0. results were statistically significant if P < 0.05.

RESULTS

Thirteen studies (n = 17600) were included. Patients were on average 69 ± 17.5 years old, with 7022 (39.8%) female patients. Overall pooled ROSC in patients in this study was 37% (95% confidence interval = 23%-54%). RTAVF-assisted CPR significantly improved ROSC, both overall [risk ratio (RR) 1.17 (1.001-1.362); P = 0.048] and in cases of IHCA [RR 1.36 (1.06-1.80); P = 0.002]. There was no significant improvement in ROSC for OHCA (RR 1.04; 0.91-1.19; P = 0.47). No significant effect was seen in SHD [RR 1.04 (0.91-1.19); P = 0.47] or chest compression rate [standardized mean difference (SMD) -2.1; (-4.6-0.5)]; P = 0.09]. A significant improvement was seen in chest compression depth [SMD 1.6; (0.02-3.1); P = 0.047].

CONCLUSION

RTAVF-assisted CPR increases ROSC in cases of IHCA and chest compression depth but has no significant effect on ROSC in cases of OHCA, SHD, or chest compression rate.

Sciducio: a practical framework for guiding the development and leadership of the academic research environment

The goal of this paper is to introduce Sciducio, a practical framework for guiding the development and leadership of an academic research environment. The principal audience for this framework is new academics, that is individuals beginning a tenure-track position in the U.S or a lecturing position elsewhere in the world. However, we also believe this framework will be of use to established academics searching for structure, academics moving to a new institution, and can serve as a training tool for doctoral and postdoctoral mentees. We briefly describe the theory supporting Sciducio, outline the framework and its individual components (blocks), then provide suggested instructions for use. We provide suggested instructions (i.e., descriptive rather than prescriptive), because there is no one-size-fits-all approach for ensuring success. Sciducio incorporates three domains (Plan, Manage, and Deliver), encompasses eight blocks, and is intended to fit on one-sheet of paper or one screen. The Plan domain includes the blocks: value, strategy, and leadership. The Manage domain includes the blocks: activities, key resources, and finances. The Deliver domain includes the blocks: solution and channels. Considering each of the framework blocks is complex, we cannot provide full justice to each component. This paper serves as a general overview and subsequent papers will be more topic specific. Additionally, we encourage others to contribute to and advance this framework.

Suction Assisted Protein Lipectomy (SAPL) Even for the Treatment of Chronic Fibrotic and Scarified Lower Extremity Lymphedema

Chronic lymphedema results from the accumulation of adipose tissue and fibrotic solids and poses a significant challenge for the treating clinician. Despite its many challenges, chronic lymphedema can be safely and effectively treated using a minimally invasive technique known as suction assisted protein lipectomy (SAPL). We present the use of SAPL in a 65-year-old female with a history of chronic, congenital, non-compressible, solid predominant lymphedema for over 40 years. Her lymphedema was complicated by multiple episodes of severe cellulitis that often required hospitalization and treatment with intravenous antibiotics. The patient also had an excisional procedure designed to debulk the lymphedema swelling performed over 35 years prior by an outside provider. The procedure resulted in substantial scarring and fibrosis between the skin and underlying fascia over a significant area of the leg with only minimal improvement in symptoms. Following SAPL, a stable excess volume reduction of 86% was achieved along with a significant improvement in range of motion of the knee. Furthermore, the patient had no further episodes of recurrent cellulitis. We have found SAPL to be effective even in patients with complex, chronic lymphedema presentations with extensive preexisting scarring from prior surgery..

Fibulin-5 regulates keloid-derived fibroblast-like cells through integrin beta-1

OBJECTIVE

Keloid scar is pathological tissue that appears after skin injury, and that is more aggressive than hypertrophic scars. Keloid scars are characterized by increased proliferation of fibroblast-like cells (FLCs) and the accumulation of extracellular matrix, mainly collagen. Fibulin-5, a glycoprotein secreted by many cell types, is a component of the extracellular matrix. We investigated the effect of fibulin-5 on the adhesion and proliferation of FLCs derived from keloid scars and the role of integrin beta-1 in these activities.

METHODS

Fibroblast-like cells were isolated from six keloid scars and cultured on plates coated with fibulin-5 or with gelatin. Cells were incubated for 72-96 h to examine proliferation rates and incubated for 240 min, with washings at 20, 40, 60, 90, 120, 180 min, to assess adhesion rates. To examine the role of integrin beta-1, the anti-human integrin beta-1 (CD29) antibody was added to the culture medium.

RESULTS

Fibroblast-like cells from keloids cultured on a fibulin-5-coated surface showed a significantly reduced proliferation rate and a delayed adhesion rate, compared to cells cultured on gelatin-coated dishes. Adherence of these cells to fibulin-5 pre-coated wells was significantly reduced in the presence of anti-human integrin beta-1 (CD29) antibodies. Our current findings are similar to previously observed reduced proliferation in vascular smooth muscle cells overexpressing fibulin-5. We did not test the effects of fibulin-5 on normal fibroblasts.

CONCLUSION

This study demonstrates the pivotal role of the extracellular protein, fibulin-5, on the adhesion and proliferation of human keloid-derived cells, through binding to integrin beta-1.

Global citizenship is key to securing global health: the role of higher education

Despite growing public awareness, health systems are struggling under the escalating burden of non-communicable diseases. While personal responsibility is crucial, alone it is insufficient. We argue that one must place themselves within the broader/global context to begin to truly understand the health implications of personal choices. Global citizenship competency has become an integral part of the higher education discourse; this discourse can and should be extended to include global health. A global citizen is someone who is (1) aware of global issues, (2) socially responsible, and (3) civically engaged. From this perspective, personal health is not solely an individual, self-serving act; rather, the consequences of our lifestyle choices and behaviors have far-reaching implications. This paper will argue that, through consciously identifying global health within the constructs of global citizenship, institutions of higher education can play an instrumental role in fostering civically engaged students capable of driving social change.

A prognostic nomogram to predict overall survival in women with recurrent ovarian cancer treated with bevacizumab and chemotherapy

OBJECTIVE

To develop a nomogram to predict overall survival (OS) in women with recurrent ovarian cancer treated with bevacizumab and chemotherapy.

METHODS

A multicenter retrospective study was conducted. Potential prognostic variables included age; stage; grade; histology; performance status; residual disease; presence of ascites and/or pleural effusions; number of chemotherapy regimens, treatment-free interval (TFI) prior to bevacizumab administration, and platinum sensitivity. Multivariate analysis was performed using Cox proportional hazards regression. The predictive model was developed into a nomogram to predict five-year OS.

RESULTS

312 women with recurrent ovarian cancer treated with bevacizumab and chemotherapy were identified; median age was 59 (range: 19-85); 86% women had advanced stage (III-IV) disease. The majority had serous histology (74%), high grade cancers (93.5%), and optimal cytoreductions (69.5%). Fifty-one percent of women received greater than two prior chemotherapeutic regimens. TFI (AHR=0.98, 95% CI 0.97-1.00, p=0.022) was the only statistically significant predictor in a multivariate progression-free survival (PFS) analysis. In a multivariate OS analysis, prior number of chemotherapy regimens, TFI, platinum sensitivity, and presence of ascites were significant. A nomogram to predict five-year OS was constructed and internally validated (bootstrap-corrected concordance index=0.737).

CONCLUSION

Our multivariate model identified prior number of chemotherapy regimens, TFI, platinum sensitivity, and the presence of ascites as prognostic variables for OS in women with recurrent ovarian cancer treated with bevacizumab combined with chemotherapy. Our nomogram to predict five-year OS may be used to identify women who may benefit from bevacizumab and chemotherapy, but further validation is needed.

Applying research in nutrition education planning: a dietary intervention for Bangladeshi chronic kidney disease patients

BACKGROUND

Effective nutrition health interventions are theory-based, as well as being drawn from practice and research, aiming to successfully accomplish dietary behavioural changes. However, the integration of theory, research and practice to develop community dietary educational programmes is a challenge that many interventionists feel ill equipped to achieve.

METHODS

In the present study, a community-based education programme was designed for Bangladeshi patients with chronic kidney disease and hypertension. The goal of this programme was to reduce dietary salt intake in this population group, with a view to reducing their blood pressure and slowing kidney disease progression.

RESULTS

The present study sets out the first four steps of a six-step model for creating a behaviour change programme.

CONCLUSIONS

These four steps were concerned with the translation of theory and evidence into intervention objectives, and illustrate how a practical, community-based intervention was developed from behavioural theory, relevant research, knowledge of practice and the target patient group. Steps 5 and 6, which are concerned with implementation and evaluation, will be reported separately.