Calculating fracture risk

With the help of a new guide, clinicians can estimate their patients' 10-year fracture risk and initiate medical therapy when appropriate. The WHO algorithm, called FRAX, is based on bone mineral density (BMD) and 9 specific clinical risk factors for osteoporosis and related fractures. The National Osteoporosis Foundation (NOF) has adapted this algorithm for the United States, incorporating fracture outcome and mortality data from US women and men as well as a cost effectiveness analysis to determine when it is cost effective to treat a person with a therapeutic agent to prevent a fracture.

According to the NOF, this absolute fracture risk methodology provides a markedly improved method to assure that patients with the highest fracture risk receive treatment. Those at the highest risk include postmenopausal women and older men with a diagnosis of osteoporosis (BMD test T-score of -2.5 or lower), or those with a clinical diagnosis based on having sustained a hip or spine fracture. It is most useful when identifying a subset of patients in the low-bone-mass category who are most likely to benefit from treatment.

Additional recommendations for identifying postmenopausal women and men aged 50 years and over who should be treated include:

· A hip or vertebral (clinical or morphometric) fracture

· Other prior fractures and low bone mass (BMD T-score from -1.0 to -2.5 at the femoral neck, total hip, or spine)

· T-score less than -2.5 at the femoral neck, total hip, or spine after appropriate evaluation to exclude secondary causes

· Low bone mass (T-score from -1.0 to -2.5 at the femoral neck, total hip, or spine) and  secondary causes associated with high risk of fracture (such as glucocorticoid use or total  immobilisation)

· Low bone mass (T-score from -1.0 to -2.5 at the femoral neck, total hip, or spine) and 10-year probability of hip fracture greater than or equal to 3% or a 10-year probability of any major osteoporosis-related fracture greater than or equal to 20% based on the US-adapted algorithm for evaluating 10-year fracture risk

It is important to note that the algorithm should only be used for untreated patients to help decide when to treat, and it does not apply to patients already taking a pharmacologic agent for osteoporosis.

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MRSA screening

The authors set out to  determine whether introducing a rapid test for methicillin resistant Staphylococcus aureus (MRSA) screening leads to a reduction in MRSA acquisition on hospital general wards.

This was a Cluster randomised crossover trial set in medical, surgical, elderly care, and oncology wards of a London teaching hospital on two sites and included all patients admitted to the study wards who were MRSA negative on admission and screened for MRSA on discharge.

The main outcome measure was the MRSA acquisition rate (proportion of patients negative for MRSA who became MRSA positive). Rapid polymerase chain reaction based screening test for MRSA compared with conventional culture was used to test for the bacterium.

Of 9608 patients admitted to the study wards, 8374 met entry criteria and 6888 had full data (82.3%); 3335 in the control arm and 3553 in the rapid test arm. The overall MRSA carriage rate on admission was 6.7%. Rapid tests led to a reduction in median reporting time from admission, from 46 to 22 hours (P<0.001).

Rapid testing also reduced the number of inappropriate pre-emptive isolation days between the control and intervention arms (399 v 277, P<0.001). This was not seen in other measurements of resource use. MRSA was acquired by 108 (3.2%) patients in the control arm and 99 (2.8%) in the intervention arm. When predefined confounding factors were taken into account the adjusted odds ratio was 0.91. Rates of MRSA transmission, wound infection, and bacteraemia were not statistically different between the two arms.

The authors concluded that a rapid test for MRSA led to the quick receipt of results and had an impact on bed usage. No evidence was found of a significant reduction in MRSA acquisition and on these data it is unlikely that the increased costs of rapid tests can be justified compared with alternative control measures against MRSA.

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Personal online health records

Patients in the US may soon be able to store and manage their own health records online. Microsoft, Google, and a consortium of large US employers have already developed online repositories where in theory people can upload and store their own health data and share it as they see fit.

Pilot testing is still at an early stage, says one national correspondent, but the long term goal is for users to build up a secure and lifelong record that will help them manage healthy lifestyles as well as illnesses and improve the coordination of complex care.

These initiatives have the potential to improve health care and may even cut costs, he writes, but will they be secure? As yet, online repositories are not subject to the same US security regulations as other electronic records, which leaves personal health data open to misuse or commercial exploitation.

Without new legislation, the privacy promises made by Google, Microsoft, and others will not be legally enforceable. There are other challenges—hospitals, clinics, and laboratories have yet to agree to release data for online use by patients; paper is still popular and electronic data formats are not standardised; and it is hard to be certain of users’ identities online

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