Fracture liaison services in Ireland-how do we compare to international standards?

In this first na tional survey of public hospitals in The Republic of Ireland, we found fracture liaison services (FLS) to be heterogeneous, limited in many cases and poorly supported. A national strategy is urgently needed to support the implementation and operation of an FLS, and thus help reduce the burden of fragility fractures for patients and the healthcare system.

INTRODUCTION

Fragility/low-trauma fractures are a global concern, whose incidence is rising as the population ages. Many are preventable, and people with a prior fragility fracture are at particularly high risk of further fractures. This patient group is the target of the International Osteoporosis Foundation (IOF) Capture the Fracture campaign, advocating global adoption of fracture liaison services (FLS), with the aim of preventing secondary fragility fractures. We wished to determine the current availability and standards of an FLS in Ireland, ahead of the launch of a National FLS database.

METHODS

We devised a questionnaire encompassing the thirteen IOF standards for an FLS and asked all 16 public hospitals with an orthopaedic trauma unit in Ireland, to complete for the calendar year 2019 in patients aged ≥ 50 years.

RESULTS

All sites returned the questionnaire, i.e. 100% response rate. Nine hospitals stated that they have an FLS, additionally one non-trauma hospital running a FLS responded, and were included. These 10 FLS had identified and managed 3444 non-hip fractures in the year 2019. This figure represents 19% of the expected non-hip fragility fracture numbers occurring annually in Ireland. Implementation of the IOF standards was very variable. All sites reported being inadequately resourced to provide a high-quality service necessary to be effective.

CONCLUSION

The existence and functioning of FLS in Ireland are heterogeneous and suboptimal. A national policy to support the implementation of this programme in line with international standards of patient care is urgently needed.

The Patient's Second Hip Fracture - One in Ten

Introduction The number of fragility hip fractures (>60 years) are estimated to triple/quadruple by 2050. It is estimated that the prevalence of patient's contralateral hip fractures (HF2s) will increase also. Methods Single hospital, Retrospective review, 2013-2017, Radiograph review, n = 822. Results Management of patient's 2nd hip fractures accounted for 10.5% of all hip fracture surgeries. ~50% occurred within 3 years of the 1st hip fracture. There was no statistically significant difference in discharge destination, length-of-stay or mortality between the HF1 and HF2 cohorts. Discussion Patients with HF2s comprised a significant and stable proportion of all hip fractures treated. We advocate for the provision of a Fracture Liaison Service in each of the 16 hip fracture operating hospitals in Ireland to optimise the secondary prevention of hip fractures.

New targets for anticoagulation and future perspectives

Unfractionated heparin (UFH) and the vitamin K antagonists (VKA), have been standard anticoagulants for the last 70 years. They have a widespread effect on many coagulation factors, the serine proteases for UFH and the vitamin K dependent factors for the VKAs. Refinements in the heparin molecule have occurred with the development of low molecular weight heparins and eventually, fondaparinux, the latter of which, has only indirect anti-Xa activity. In the last two decades, more target-specific drugs such as the parenteral direct thrombin inhibitors have been introduced into clinical practice (lepirudin, bivalirudin, argatroban, and desirudin) and are widely used for selected indications in hospitalized patients. More recently, the trend in anticoagulant development continues to target a specific factor either directly or indirectly. Of great interest is the recent development of many oral direct factor inhibitors, the first new agents poised to replace the VKAs. Of these, the oral direct Xa and IIa inhibitors are most promising and are far along in development. However, other coagulation factors have been considered suitable targets for drug development. The following paper discusses these agents and their selected targets, heparin.

Catalytic asymmetric synthesis of an HIV integrase inhibitor

An efficient synthesis of HIV integrase inhibitor (S)-(-)-1 via a unique asymmetric hydrogenation of a mixture of imines/enamine 5a-5b/5c is described. Hydrogenation of the imines/enamine by a Rh(I)-Josiphos complex afforded 6 in 90% yield and 90% ee. Amide formation completed the synthesis of 1 in 58% overall yield from 2, which is readily available from 3,4-dihydro-2H-pyran in a seven-step sequence. A deuterium labeling study suggests the asymmetric hydrogenation proceeds predominantly via the enamine tautomer.

Factors affecting parenting stress among biologically vulnerable toddlers

Parenting a child with, or at risk for, a developmental delay or disability can be stressful. Abidin's parenting stress model was used as a framework to examine how several maternal, child, and family factors predict parent stress outcomes. Stepwise regression models revealed that maternal and child factors were significant contributors to parenting stress. However, family factors (income and family functioning) were not retained. Parenting stress was lower when child (cognitive and adaptive ability) and maternal (depression and child care competence) characteristics were more positive. Child cognitive ability was a strong contributor to total parenting stress and two parenting stress subscales. Findings suggest that these parents need stress lowering interventions such as supportive child care, respite relief, and a child behaviour-focused program.

Synthesis of a β-Amino Acid Pharmacophore via a β-Lactam Intermediate

A stereoselective synthesis of (R)-beta-amino acid 1 via a beta-lactam intermediate is discussed.

New Method for the Synthesis of Diversely Functionalized Imidazoles from N-Acylated α-Aminonitriles

[reaction: see text] A new general method for the synthesis of medicinally important diversely functionalized imidazoles from N-acylated alpha-aminonitriles has been developed. N-Acylated alpha-aminonitriles were reacted with triphenylphosphine and carbon tetrahalide to afford 2,4-disubstituted 5-halo-1H-imidazoles in good yield. This new methodology was applied for the synthesis of 2-butyl-4-chloro-5-hydroxymethylimidazole. These halo-imidazoles can be directly converted to 2,4,5-trisubstituted imidazoles through palladium-catalyzed coupling reactions.

Practical Synthesis of Sultams via Sulfonamide Dianion Alkylation: Application to the Synthesis of Chiral Sultams

[reaction: see text]. A practical synthesis of sultams was developed via intramolecular sulfonamide dianion alkylation. This method has been applied toward the synthesis of chiral sultams, which are synthetically valuable as chiral auxiliaries.

Molecular basis and functional consequences of the dominant effects of the mutant band 3 on the structure of normal band 3 in Southeast Asian ovalocytosis

Southeast Asian ovalocytosis (SAO) human red cell membranes contain similar proportions of normal band 3 and a mutant band 3 with a nine amino acid deletion (band 3 SAO). We employed specific chemical modification and proteolytic cleavage to probe the structures of band 3 in normal and SAO membranes. When the membranes were modified specifically at lysine residues with N-hydroxysulfosuccinimide-SS-biotin, band 3 Lys-851 was not modified in normal membranes but quantitatively modified in SAO membranes. Normal and SAO membranes showed different patterns of band 3 proteolytic cleavage. Notably, many sites cleaved in normal membranes were not cleaved in SAO membranes, despite the presence of normal band 3 in these membranes. The mutant band 3 changes the structure of essentially all the normal band 3 present in the SAO membranes, and these changes extend throughout the normal band 3 molecules. The results also imply that band 3 in SAO membranes is present as hetero-tetramers or higher hetero-oligomers. The dominant structural effects of band 3 SAO on the other band 3 allele have important consequences on the functional and hematological properties of human red cells heterozygous for band 3 SAO. Analysis of the altered profile of biotinylation and protease cleavage sites suggests the location of exposed surfaces in the band 3 membrane domain and identifies likely interacting regions within the molecule. Our approach provides a sensitive method for studying structural changes in polytopic membrane proteins.

Stereocontrolled preparation of a nonpeptidal (-)-spirobicyclic NK-1 receptor antagonist

The synthesis of a spirobicyclic NK-1 receptor (Substance-P) antagonist 1 antipode is described. Retrosynthetic analysis reveals an allylic halide A bearing the cyclopropoxy-substituted aryl group and a 2-phenyl-3-piperidone B. The stereochemistry in the spirobicyclic system bearing three chiral centers is initially set via a highly diastereoselective zinc-mediated coupling of the allylic bromide 23 to the optically active ketopiperidine 3. The remaining benzylic asymmetric center is set by a diastereoselective hydroboration followed by cyclization to the spirobicyclic system.

Advanced practice nursing in Canada: has the time really come?

Nurse practitioners in Canada have experienced many of the problems facing those in the UK. In this paper, first presented at this year's meeting of the Commonwealth Nurses' Federation, the authors explain the events.

Porcine liver esterase-catalyzed enantioselective hydrolysis of a prochiral diester into its optically pure (S)-ester acid, a precursor to a growth hormone secretagogue

A limited screen of several commercially-available and internally-produced lipases and esterases identified porcine liver esterase as a suitable biocatalyst for the enantioselective hydrolysis of a diester into its (S)-ester acid with high optical purity (99%). This (S)-ester acid is a precursor to an experimental growth hormone secretagogue. After identifying xanthan gum as the best emulsifier and optimizing the reaction conditions, hydrolysis rates of 1 g/l.h and final (S)-ester acid (ee > 99%) titers of about 8.5 g/l were routinely achieved. This process supported the production of preparative amounts of optically pure (S)-ester (ee > 99%) with a high reaction yield of 82%. Upon purification, the (S)-ester was successfully used in the subsequent synthetic steps to yield the growth hormone secretagogue.

NMR solution structure of a cytoplasmic surface loop of the human red cell anion transporter, band 3

The membrane domain of the human red cell anion transport protein, band 3, is too large to be studied by solution nuclear magnetic resonance spectroscopy (NMR), and its amphiphilic nature requires the use of detergents for solubilization. An alternative approach is to divide the protein into smaller (trans-membrane or surface loop) domains for NMR study. We report the structure of a 46-residue synthetic peptide that corresponds to the cytoplasmic surface loop connecting the putative 12th and 13th trans-membrane spans (residues 796-841) in the 14 span model of band 3. This peptide was shown by circular dichroism (CD) to be 38% helical in 30% trifluoroacetic acid. Two regions of helix (one close to the N-terminus of the peptide and one close to the C-terminus of the peptide) were identified by NMR. Long-range nuclear Overhauser effect (NOE) cross-peaks showed the two helices to be in near proximity. The helices were separated by a proline-rich loop that exhibited local order but was mobile with respect to the rest of the peptide. We discuss how the NMR structure of this loop fits the current models of band 3 structure and topology and the results of recent mutagenesis experiments. A cyclic version of this peptide was synthesized and studied by CD, but NMR studies were not possible due to the low solubility of this peptide.