Is screening for osteoporosis useful?

Osteoporotic fractures present a major public health problem, for individuals, healthcare systems, and society. Current estimates suggest that, in developed countries, around one in three women and one in five men aged 50 years or older will have a fragility fracture during their remaining lifetime. While, in the last four decades, remarkable progress has been made in terms of our understanding of osteoporosis (we have a definition, diagnostic test (DXA), comprehensive risk assessment tools and affordable, effective treatments), but many individuals with osteoporosis are not recognized or treated - there is a huge treatment gap. Would screening for osteoporosis in the general population help to reduce fracture rates? In this session, we will discuss the current evidence for and against population based screening for high fracture risk. A large UK randomized trial of fracture risk screening using FRAX in primary care (SCOOP) demonstrated a reduction in hip fracture risk consequent to the screening intervention, and meta-analysis with two other screening trials from Denmark and the Netherlands has confirmed this effect. We will consider the evidence provided by these studies and how they may inform the practical implementation of osteoporosis screening. With a screening program comes a variety of challenges. It is cost-effectiveness must be proven and it must be acceptable to patients, doctors, and politicians alike-implementing change in overburdened healthcare systems with aging populations and in the wake of the COVID-19 pandemic is difficult. We will discuss how screening can be made economically viable, and present approaches to automated casefinding which will require minimal input from clinicians in primary care. We all want the best for our patients-we know that many are suffering fractures which could have been prevented through appropriate risk assessment and treatment-but is screening the most useful approach.

The incidence and characteristics of inpatient child protection concern cases during the COVID-19 lockdown

Background: Known risk factors for child maltreatment, including parental unemployment and domestic violence (1, 2), were compounded by social isolation from school closures and restriction of home visitors during the COVID-19 lockdown. Data on the incidence of child maltreatment during the pandemic is limited. Aim: Our study aimed to compare the incidence of and characterize the types of child protection concerns among inpatients during the 2020 lockdown versus the same period in 2019. Methods: We carried out a retrospective chart review of inpatients at Children's Health Ireland (CHI) at Crumlin and CHI at Tallaght assessed for child protection concerns during the lockdown from March 13 to August 31, 2020, and the same timeframe in 2019. Results: Fewer patients with child protection concern were admitted in 2020 (n=86) compared to 2019 (n=163). Total admissions were also less in 2020 (n=4609) compared to 2019 (n=7728). Patients assessed for child protection concerns accounted for a smaller percentage of inpatients in 2020 (1.8% versus 2.1% in 2019 (p=0.35)). In 2020, there was a greater percentage of physical (52.3% versus 11% in 2019 (p<.001)) and emotional (6.9% versus 1.2% in 2019 (p=0.014)) abuse concern cases. There was also a greater percentage of neglect and sexual abuse concern cases and a lower percentage of welfare concern cases in 2020, but these differences were not statistically significant. The cases in 2020 were more complex, with 48.8% involving more than one concern type per case versus 13.4% in 2019 (p<.001). Child protection concerns increased steadily during the lockdown, peaking in July. In 2020, there were more unwitnessed injuries (34.8% versus 17.7% in 2019 (p=.002)) and parental use of physical discipline (6.9% versus 0.6% in 2019 (p=.003)). No statistically significant differences in delayed presentation and domestic violence were observed. Conclusions: While fewer inpatients were assessed for child protection concerns during the 2020 lockdown versus 2019, the 2020 cases were more complex. An increase in physical and emotional abuse concerns, unwitnessed injuries and physical disciplining highlights child protection issues specific to the pandemic.

Ocular adverse events following vaccination: overview and update.

The Food and Drug Administration has licensed, approved, and expanded guidelines for dozens of vaccines since 2010. Although advancements in biotechnology have made vaccines more effective and safer, none are completely free from adverse effects. Many vaccines have been implicated in causing ocular adverse events based on the temporal association of exposure and putative complication. Determination of causality is difficult. We provide an overview of vaccine side effects and also examine the English literature and the Vaccine Adverse Events Reporting System (VAERS) from 2010 through 2020 for vaccine-implicated ocular adverse events. While reactions of eyelids and conjunctiva are commonly reported, the most frequently implicated serious adverse events are optic neuritis and various patterns of intraocular inflammation. Live attenuated vaccines have the potential to cause ocular infection from vaccine-strain organisms, particularly in those immunosuppressed. While postmarketing registries for suspect vaccination adverse events, such as VAERS, are unable to determine causal associations, they are a mainstay in signaling suspected trends that require investigation. The majority of probable and possible serious ocular adverse effects are distinctly uncommon.

Proposed guidance on cost-avoidance studies in pharmacy practice.

PURPOSE: Cost-avoidance studies of pharmacist interventions are common and often the first type of study conducted by investigators to quantify the economic impact of clinical pharmacy services. The purpose of this primer is to provide guidance for conducting cost-avoidance studies pertaining to clinical pharmacy practice. SUMMARY: Cost-avoidance studies represent a paradigm conceptually different from traditional pharmacoeconomic analysis. A cost-avoidance study reports on cost savings from a given intervention, where the savings is estimated based on a counterfactual scenario. Investigators need to determine what specifically would have happened to the patient if the intervention did not occur. This assessment can be fundamentally flawed, depending on underlying assumptions regarding the pharmacists' action and the patient trajectory. It requires careful identification of the potential consequence of nonaction, as well as probability and cost assessment. Given the uncertainty of assumptions, sensitivity analyses should be performed. A step-by-step methodology, formula for calculations, and best practice guidance is provided. CONCLUSIONS: Cost-avoidance studies focused on pharmacist interventions should be considered low-level evidence. These studies are acceptable to provide pilot data for the planning of future clinical trials. The guidance provided in this article should be followed to improve the quality and validity of such investigations.

84 COVID-19 and Associations with Frailty and Multimorbidity: A Prospective Analysis of UK Biobank Participants

Introduction Frailty and multimorbidity have been suggested as risk factors for severe COVID-19 disease. We therefore investigated whether frailty and multimorbidity were associated with risk of hospitalisation with COVID-19 in the UK Biobank. Method 502,640 participants aged 40–69 years at baseline (54–79 years at COVID-19 testing) were recruited across UK 2006–10. A modified assessment of frailty using Fried’s classification was generated from baseline data. COVID-19 test results (England) were available 16/03/2020–01/06/2020, mostly taken in hospital settings. Logistic regression was used to discern associations between frailty, multimorbidity and COVID-19 diagnoses, adjusting for sex, age, BMI, ethnicity, education, smoking and number of comorbidity groupings, comparing COVID-19 positive, COVID-19 negative and non-tested groups. Results 4,510 participants were tested for COVID-19 (positive = 1,326, negative = 3,184). 497,996 participants were not tested. Compared to the non-tested group, after adjustment, COVID-19 positive participants were more likely to be frail (OR = 1.4 [95%CI = 1.1, 1.8]), report slow walking speed (OR = 1.3 [1.1, 1.6]), report two or more falls in the past year (OR = 1.3 [1.0, 1.5]) and be multimorbid (≥4 comorbidity groupings vs 0–1: OR = 1.9 [1.5, 2.3]). However, similar strength of associations were apparent when comparing COVID-19 negative and non-tested groups. Furthermore, frailty and multimorbidity were not associated with COVID-19 diagnoses, when comparing COVID-19 positive and COVID-19 negative participants. Conclusions Frailty and multimorbidity do not appear to aid risk stratification, in terms of a positive versus negative results of COVID-19 testing. Investigation of the prognostic value of these markers for adverse clinical sequelae following COVID-19 disease is urgently needed.

Managing and Monitoring Long-term Oral Corticosteroids – How Good Are We and Do We Follow Best Practice Guidelines?

Background: Long-term (defined as >1 month) oral corticosteroids are widely used for chronic inflammatory and autoimmune conditions. In cardiology, the primary indications are transplantation, cardiac sarcoidosis and large vessel vasculitis. Minimising organ-based complications including infection (Pneumocystis jiroveci pneumonia (PJP)), gastro-intestinal (GI) bleeding and osteoporosis warrant consideration but guidelines vary between specialties and co-existing treatments. The aim of this study was to assess prescribing patterns between specialties at Auckland, Waitemata and Counties Manukau District Health Boards. Method: An anonymised survey of cardiologists, respiratory, oncology, haematology, endocrinology, infectious diseases and rheumatologists with questions regarding prescribing and monitoring practices for: i) PJP prophylaxis, ii) proton pump inhibitor (PPI) for GI protection, iii) baseline bone mineral density (BMD) and iv) bisphosphonate use. Results: In total 44 responders;cardiology n=16 vs. other n=28. PJP prophylaxis was prescribed n= 5 (31%) of cardiologists compared to n=23 (96%) of other specialties. Cardiologists were less likely to prescribe bisphosphonates n=1 (6%) than other specialists n=10 (36%, p value = 0.01) but with similar prescription of PPI and baseline BMD (Figure 1). Conclusion: Prescription of PJP prophylaxis, bisphosphonates and PPIs are lower amongst cardiologists. PPI and bisphosphonates use were high particularly amongst non-cardiologists increasing the patient pill burden but may be unnecessary in the absence of previous GI complications or co-existing NSAID use and moderate-high risk of fracture on BMD. Consensus guidelines for cardiologists aimed at standardising pre-treatment assessment and prevention of prove patient care and prevent unnecessary therapy. [Formula presented]