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News Article | February 15, 2017

Review identifies key challenges which hinder efforts to improve bone health and provide optimal prevention of osteoporosis and fragility fractures, a major cause of morbidity and mortality worldwide With the first of the baby boomer generation now entering their eighties, the next decade will see a significant increase in the number of people living with osteoporosis and experiencing the often devastating outcome of fragility fractures. A newly published narrative review in 'Osteoporosis International' considers the key global challenges facing healthcare professionals and policymakers responsible for providing care to populations in relation to bone health and fracture prevention. Referencing key studies, guidelines and audits, the review provides evidence of the chief care gaps, and outlines the solutions which will need to be implemented in order to address the growing burden of fragility fractures in the world's population. The authors identify four distinct themes which encompass challenges related to: (1) case finding and management of individuals at high risk of fracture; (2) public awareness of osteoporosis and fragility fractures; (3) reimbursement and health system policy; and (4) epidemiology of fracture in the developing world. Co-author Professor Eugene McCloskey, Director of the MRC ARUK Centre for Integrated Research in Musculoskeletal Ageing, Metabolic Bone Centre, Northern General Hospital, Sheffield, UK., stated: "This review identifies, among other challenges, the current gaps in delivery of best clinical practice, low levels of public awareness, and insufficient access and funding for diagnosis and treatment. Sadly, these gaps are a clear reflection of the low priority currently given to bone health and fracture prevention in healthcare policy." Professor Cyrus Cooper, Chair of the International Osteoporosis Foundation (IOF) Committee of Scientific Advisors, stated: "We cannot afford to ignore the current and growing burden that osteoporosis and fragility fractures impose upon societies around the world. As we now have the knowledge and tools needed to manage bone health optimally, I urge healthcare professionals, stakeholder organizations, and healthcare authorities to make a concerted effort to implement these tools. Prioritization of fragility fracture prevention must become a reality worldwide." The review "Mind the (treatment) gap: a global perspective on current and future strategies for prevention of fragility fractures" is an updated, referenced synopsis of the IOF illustrated report "Gaps and Solutions in Bone Health - A Global Framework for Improvement" which was published in nine languages on the occasion of World Osteoporosis Day. Harvey, N.C.W., McCloskey, E.V., Mitchell, P.J. et al. Mind the (treatment) gap: a global perspective on current and future strategies for prevention of fragility fractures. Osteoporos Int (2017). doi:10.1007/s00198-016-3894-y Gaps and Solutions in Bone Health - A Global Framework for Improvement (available in nine languages) An international multi-disciplinary journal which is a joint initiative between the International Osteoporosis Foundation (IOF) and the National Osteoporosis Foundation (NOF) of the USA, Osteoporosis International provides an interdisciplinary platform for the communication of high quality original, experimental or clinical papers on all aspects of osteoporosis and other metabolic bone diseases. It publishes studies pertaining to the diagnosis, prevention, treatment and management of osteoporosis, and the spectrum of disorders that deficiencies in bone density can produce. Co-Editors in Chief: John A. Kanis, Felicia Cosman ISSN: 0937-941X (print version) / ISSN: 1433-2965 (electronic version) The International Osteoporosis Foundation (IOF) is the world's largest nongovernmental organization dedicated to the prevention, diagnosis and treatment of osteoporosis and related musculoskeletal diseases. IOF members, including committees of scientific researchers as well as 234 patient, medical and research societies in 99 locations, work together to make fracture prevention and healthy mobility a worldwide heath care priority. http://www. / http://www. @iofbonehealth

McGrath E.E.,Northern General Hospital
Lung | Year: 2010

Nontuberculous mycobacteria (NTM) are resilient bacteria that grow in virtually any environment, especially those where competing microorganisms are destroyed, such as in chlorinated water. They have been discovered in soil, dust, food, water, and domestic and wild animals. Nontuberculous mycobacteria tend to infect individuals with local (e.g., damaged skin or lung) or systemic (e.g., HIV, drugs, malignancy) defects in host defence, and their incidence and prevalence have consistently increased in the last decade. Difficulty may arise in determining whether an isolated NTM from a microbiological sample is in fact a contaminant or a pathogenic organism. In this review, we discuss the important mycobacteria involved in lung disease, factors that predispose individuals to infection, and their diagnosis and treatment according to updated guidelines. English language publications in MEDLINE and references from relevant articles from January 1, 1990 to June 28, 2009 were reviewed. Keywords searched were "nontuberculous,""mycobacteria," "diagnosis," and "treatment."

Nelson R.L.,Northern General Hospital
Cochrane database of systematic reviews (Online) | Year: 2011

Clostridium difficile is recognized as a frequent cause of antibiotic-associated diarrhea and colitis. The aim of this review is to investigate the efficacy of antibiotic therapy for C. difficile-associated diarrhea (CDAD). MEDLINE (1966 to March 24, 2010), EMBASE (1980 to March 24, 2010), Cochrane Central Register of Controlled Trials and the Cochrane IBD/FBD Review Group Specialized Trials Register were searched using the following search terms: "pseudomembranous colitis and randomized trial"; "Clostridium difficile and randomized trial"; "antibiotic associated diarrhea and randomized trial". Only randomized, controlled trials assessing antibiotic treatment for CDAD were included in the review. The following outcomes were sought: initial resolution of diarrhea; initial conversion of stool to cytotoxin and/or culture negative; recurrence of diarrhea; recurrence of fecal evidence of CDAD; patient response to cessation of prior antibiotic therapy; emergent surgery; and death. Three authors independently assessed abstracts and full text articles for inclusion. The risk of bias was independently rated by two authors. For dichotomous outcomes, relative risks (RR) and 95% confidence intervals (CI) were derived from each study and summary statistics obtained when appropriate, using a fixed effects model, except where significant heterogeneity was detected, at which time a random effects model was used. Fifteen studies (total of 1152 participants) with CDAD were included. Nine different antibiotics were investigated: vancomycin, metronidazole, fusidic acid, nitazoxanide, teicoplanin, rifampin, rifaximin, bacitracin and fidaxomicin (OPT-80). Most of the studies were active comparator studies comparing vancomycin with other antibiotics. The risk of bias was rated as high for 12 of 15 included studies. Patients with severe CDAD were often excluded from the included studies. In the only placebo-controlled trial vancomycin was found to be superior to placebo for treatment of CDAD for initial symptomatic cure. Initial symptomatic cure was achieved in 41% of vancomycin patients compared to 4% of placebo patients (1 study; 44 patients; RR 9.00; 95% CI 1.24 to 65.16). Vancomycin was significantly superior to placebo for initial bacteriologic response. Initial bacteriologic response was achieved in 45% of vancomycin patients compared to 4% of placebo patients (1 study; 44 patients; RR 10.00; 95% CI 1.40 to 71.62). The results of this study should be interpreted with caution due to the small number of patients and high risk of bias. No statistically significant differences in efficacy were found between vancomycin and metronidazole, vancomycin and fusidic acid, vancomycin and nitazoxanide, or vancomycin and rifaximin.

Morgan J.,Northern General Hospital
Cochrane database of systematic reviews (Online) | Year: 2011

Colonoscopy is considered the gold-standard investigation for screening and diagnosis of colorectal cancer. It is also becoming increasingly desirable for assessment, management, diagnosis and follow-up of other colorectal diseases, such as inflammatory bowel diseases and acute diverticulitis. Hence, due to the increasing demand for colonoscopy, devices to advance examination techniques are highly sought-after and the colonoscope with the transparent cap could be one of these. To identify and review all relevant data in order to determine whether colonoscopy with a transparent cap is a more effective diagnostic tool than colonoscopy. We searched the MEDLINE, EMBASE and CINAHL databases, and the Cochrane Central Register of Controlled Trials for all randomised controlled trials (RCTs) comparing the use of colonoscopy with a transparent cap with standard colonoscopy. Studies were included if they were randomised controlled trials which compared the use of colonoscopy with a transparent cap with standard colonoscopy. Data on study methods, participants, interventions used and outcomes measured was extracted from each study. Data was entered into the Cochrane Review Manager software (RevMan 5.0, 2008) and analysed using Cochrane MetaView. In the present meta-analysis, we considered for the first time all five randomised controlled trials so far performed. The findings of our work indicate that colonoscopy with transparent cap has a faster caecal intubation time when compared with standard colonoscopy. Reviewing studies individually would also seem to favour colonoscopy with transparent cap for polyp detection rate and pain during procedure but due to lack of comparable data meta-analysis was not feasible. This review suggests that a transparent cap on the end of the colonoscope may give a marginally faster caecal intubation time compared with standard colonoscopy. It also suggests that there is a better polyp detection rate and less pain with the cap. However, the authors feel that further randomised controlled trials in this area would provide more clinically significant information on this adjunct to colonoscopy.

Howard L.S.,Imperial College London | Hughes R.J.,Northern General Hospital
Thorax | Year: 2013

The National Institute for Health and Clinical Excellence recently published a clinical guideline on the management of venous thromboembolic disease and thrombophilia testing. Several stand-out recommendations are made which may be practice changing for many physicians, such as catheter-directed thrombolysis for ilio-femoral deep venous thrombosis, routine cancer screening and extended duration of anticoagulation for unprovoked events. In this article, we summarise the key points of the guideline and discuss remaining areas of controversy.

Plummer A.,Northern General Hospital
Cochrane database of systematic reviews (Online) | Year: 2011

Respiratory disease is the major cause of mortality and morbidity in cystic fibrosis (CF). Life expectancy of people with CF has increased dramatically in the last 40 years. One of the major reasons for this increase is the mounting use of antibiotics to treat chest exacerbations caused by bacterial infections. The optimal duration of intravenous antibiotic therapy is not clearly defined. Individuals usually receive intravenous antibiotics for 14 days, but treatment may range from 10 to 21 days. A shorter duration of antibiotic treatment risks inadequate clearance of infection which could lead to further lung damage. Prolonged courses of intravenous antibiotics are expensive and inconvenient and the incidence of allergic reactions to antibiotics also increases with prolonged courses. The use of aminoglycosides requires frequent monitoring to avoid some of their side effects. However, some organisms which infect people with CF are known to be multi-resistant to antibiotics, and may require a longer course of treatment. To assess the optimal duration of intravenous antibiotic therapy for treating chest exacerbations in people with cystic fibrosis. We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which comprises references identified from comprehensive electronic database searches, handsearches of relevant journals, abstract books and conference proceedings.Most recent search of the Group's Cystic Fibrosis Trials Register: 3 December 2010. Randomised and quasi-randomised controlled trials comparing different durations of intravenous antibiotic courses for acute respiratory exacerbations in people with CF, either with the same drugs at the same dosage, the same drugs at a different dosage or frequency or different antibiotics altogether, including studies with additional therapeutic agents. No eligible trials were identified. No eligible trials were identified. There are no clear guidelines on the optimum duration of intravenous antibiotic treatment. Duration of treatment is currently based on unit policies and response to treatment. Shorter duration of treatment should improve quality of life and compliance; result in a reduced incidence of drug reactions; and be less costly. However, this may not be sufficient to clear a chest infection and may result in an early recurrence of an exacerbation. This systematic review identifies the need for a multicentre, randomised controlled trial comparing different durations of intravenous antibiotic treatment as it has important clinical and financial implications.

Song S.H.,Northern General Hospital
Advances in Experimental Medicine and Biology | Year: 2013

Type 2 diabetes mellitus (a disease normally appears in the post 40 age group people) now seems to emerging in young adults at the level of global epidemic driven by the increasing burden of obesity. Evidence is accumulating to suggest that this young diabet iccohort is an aggressive phenotype which leads to the premature development of complications that not only have impact on the quality of life but also unfavourably influence the long term outcome, raising the possibility of a serious public health challenge in the next few decades. This chapter reviews the current understanding of the phenomenon of T2DM in the young adults and discusses the clinical challen ges in managing this high risk group. © 2012 Landes Bioscience and Springer Science+Business Media.

Lee-Robichaud H.,Northern General Hospital
Cochrane database of systematic reviews (Online) | Year: 2010

BACKGROUND: Constipation is a common clinical problem. Lactulose and Polyethylene Glycol (PEG) are both commonly used osmotic laxatives that have been shown to be effective and safe treatments for chronic constipation. However, there is no definitive data as to which provides the best treatment. OBJECTIVES: To identify and review all relevant data in order to determine whether Lactulose or Polyethylene Glycol is more effective at treating chronic constipation and faecal impaction. SEARCH STRATEGY: We searched the MEDLINE, EMBASE and CINAHL databases, and the Cochrane Central Register of Controlled Trials for all randomised controlled trials (RCTs) comparing the use of lactulose and polyethylene glycol in the management of faecal impaction and chronic constipation. SELECTION CRITERIA: Studies were included if they were randomised controlled trials which compared lactulose with polyethylene glycol in the management of chronic constipation. DATA COLLECTION AND ANALYSIS: Data on study methods, participants, interventions used and outcomes measured was extracted from each study. Data was entered into the Cochrane Review Manager software (RevMan 5.0) and analysed using Cochrane MetaView. MAIN RESULTS: In the present meta-analysis, we considered for the first time all ten randomised controlled trials so far performed. The findings of our work indicate that Polyethylene glycol is better than lactulose in outcomes of stool frequency per week, form of stool, relief of abdominal pain and the need for additional products. On subgroup analysis, this is seen in both adults and children, except for relief of abdominal pain. AUTHORS' CONCLUSIONS: Polyethylene Glycol should be used in preference to Lactulose in the treatment of Chronic Constipation.

Nelson R.L.,Northern General Hospital
Cochrane database of systematic reviews (Online) | Year: 2012

Because of the disability associated with surgery for anal fissure and the risk of incontinence, medical alternatives for surgery have been sought. Most recently, pharmacologic methods that relax the anal smooth muscle, to accomplish reversibly what occurs in surgery, have been used to obtain fissure healing. To assess the efficacy and morbidity of various medical therapies for anal fissure. Search terms include "anal fissure randomized". Timing from 1966 to August 2010. Further details of the search below. Studies in which participants were randomized to a non-surgical therapy for anal fissure. Comparison groups may include an operative procedure, an alternate medical therapy or placebo. Chronic fissure, acute fissure and fissure in children are included in the review. Atypical fissures associated with inflammatory bowel disease or cancer or anal infection are excluded. Data were abstracted from published reports and meeting abstracts, assessing method of randomization, blinding, "intention to treat" and drop-outs, therapies, supportive measures (applied to both groups), dosing and frequency and cross-overs. Dichotomous outcome measures included Non-healing of the fissure (a combination of persistence and recurrence), and Adverse events (including incontinence, headache, infection, anaphylaxis). Continuous outcome measures included measures of pain relief and anorectal manometry. In this update 23 studies including 1236 participants is added to the 54 studies and 3904 participants in the 2008 publication, however 2 studies were from the last version reclassified as un included, so the final number of participants is 5031.49 different comparisons of the ability of medical therapies to heal anal fissure have been reported in 75 RCTs. Seventeen agents were used (nitroglycerin ointment (GTN), isosorbide mono & dinitrate, Botulinum toxin (Botox), diltiazem, nifedipine (Calcium channel blockers or CCBs), hydrocortisone, lignocaine, bran, minoxidil, indoramin, clove oil, L-arginine, sitz baths, sildenafil, "healer cream" and placebo) as well as Sitz baths, anal dilators and surgical sphincterotomy. GTN was found to be marginally but significantly better than placebo in healing anal fissure (48.9% vs. 35.5%, p < 0.0009), but late recurrence of fissure was common, in the range of 50% of those initially cured. Botox and CCBs were equivalent to GTN in efficacy with fewer adverse events. No medical therapy came close to the efficacy of surgical sphincterotomy, though none of the medical therapies in these RCTs were associated with the risk of incontinence. Medical therapy for chronic anal fissure, currently consisting of topical glyceryl trinitrate, botulinum toxin injection or the topical calcium channel blockers nifedipine or diltiazem in acute and chronic fissure and fissure in children may be applied with a chance of cure that is marginally better than placebo. For chronic fissure in adults all medical therapies are far less effective than surgery. A few of the newer agents investigated show promise based only upon single studies (clove oil, sildenifil and a "healer cream") but lack comparison to more established medications.

Nahas M.E.,Northern General Hospital
Kidney International | Year: 2010

The perceived global rise in chronic kidney disease (CKD) has been met with apprehension and skepticism. It has been argued by some that we are facing a CKD epidemic and by others that the high prevalence of CKD observed in different communities may be the result of flawed screening methods and tools. Both estimation of glomerular filtration rate and determination of microalbuminuria as markers of CKD have been criticized. Also, many commented that CKD, as currently defined, was primarily a disease of elderly people with reduced kidney function. Some described this as a physiological age-related decline in kidney function while others consider it to be pathological, warranting the label of a disease. In this review, an attempt is made to reconcile different views by examining some of the available evidence and to conclude that the high prevalence of CKD in the elderly population is likely to reflect the underlying high prevalence of overt and subclinical atherosclerosis and cardiovascular disease. This leads to the conclusion that CKD is a reflection of diffuse and age-related Cardio-Kidney-Damage (C-K-D) that may not warrant the label of disease but certainly justifies attention with reduction of lifelong cardiovascular risks and careful evaluation and treatment. © 2010 International Society of Nephrology.

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