The Quality of Dying in Frail Institutionalized Older Patients After Nonoperative and Operative Management of a Proximal Femoral Fracture: An In-Depth Analysis

Proximal femoral fractures in frail patients have a poor prognosis. Despite the high mortality, little is known about the quality of dying (QoD) while this is an integral part of palliative care and could influence decision making on nonoperative- (NOM) or operative management (OM). To identify the QoD in frail patients with a proximal femoral fracture. Data from the prospective FRAIL-HIP study, that studied the outcomes of NOM and OM in institutionalized older patients ≥70 years with a limited life expectancy who sustained a proximal femoral fracture, was analyzed. This study included patients who died within the 6-month study period and whose proxies evaluated the QoD. The QoD was evaluated with the Quality of Dying and Death (QODD) questionnaire resulting in an overall score and 4 subcategory scores (Symptom control, Preparation, Connectedness, and Transcendence). In total 52 (64% of NOM) and 21 (53% of OM) of the proxies responded to the QODD. The overall QODD score was 6.8 (P25-P75 5.7-7.7) (intermediate), with 34 (47%) of the proxies rating the QODD 'good to almost perfect'. Significant differences in the QODD scores between groups were not noted (NOM; 7.0 (P25-P75 5.7-7.8) vs OM; 6.6 (P25-P75 6.1-7.2), P = .73). Symptom control was the lowest rated subcategory in both groups. The QoD in frail older nursing home patients with a proximal femoral fracture is good and humane. QODD scores after NOM are at least as good as OM. Improving symptom control would further increase the QoD.

The value of preoperative diagnostic testing and geriatric assessment in frail institutionalized elderly with a hip fracture; a secondary analysis of the FRAIL-HIP study

PURPOSE

The aim of this study was to provide a comprehensive overview of (preoperative and geriatric) diagnostic testing, abnormal diagnostic tests and their subsequent interventions, and clinical relevance in frail older adults with a hip fracture.

METHODS

Data on clinical consultations, radiological, laboratory, and microbiological diagnostics were extracted from the medical files of all patients included in the FRAIL-HIP study (inclusion criteria: hip fracture, > 70 years, living in a nursing home with malnourishment/cachexia and/or impaired mobility and/or severe co-morbidity). Data were evaluated until hospital discharge in nonoperatively treated patients and until surgery in operatively treated patients.

RESULTS

A total of 172 patients (88 nonoperative and 84 operative) were included, of whom 156 (91%) underwent laboratory diagnostics, 126 (73%) chest X-rays, and 23 (13%) CT-scans. In 153/156 (98%) patients at least one abnormal result was found in laboratory diagnostics. In 82/153 (50%) patients this did not result in any additional diagnostics or (pharmacological) intervention. Abnormal test results were mentioned as one of the deciding arguments for operative delay (> 24 h) for 10/84 (12%) patients and as a factor in the decision between nonoperative and operative treatment in 7/172 (4%) patients.

CONCLUSION

A large number and variety of diagnostics were performed in this patient population. Abnormal test results in laboratory diagnostics were found for almost all patients and, in majority, appear to have no direct clinical consequences. To prevent unnecessary diagnostics, prospective research is required to evaluate the clinical consequences and added value of the separate elements of preoperative diagnostic testing and geriatric assessment in frail hip fracture patients.

The Effectiveness of Adductor Canal Block Compared to Femoral Nerve Block on Readiness for Discharge in Patients Undergoing Outpatient Anterior Cruciate Ligament Reconstruction: A Multi-Center Randomized Clinical Trial

This study evaluated the effect of adductor canal block (ACB) versus femoral nerve block (FNB) on readiness for discharge in patients undergoing outpatient anterior cruciate ligament (ACL) reconstruction. We hypothesized that ACB would provide sufficient pain relief while maintaining motor strength and safety, thus allowing for earlier discharge. This was a randomized, multi-center, superiority trial. From March 2014 to July 2017, patients undergoing ACL reconstruction were enrolled. The primary outcome was the difference in readiness for discharge, defined as Post-Anesthetic Discharge Scoring System score ≥ 9. Twenty-six patients were allocated to FNB and twenty-seven to ACB. No difference in readiness for discharge was found (FNB median 1.8 (95% CI 1.0 to 3.5) vs. ACB 2.9 (1.5 to 4.7) hours, p = 0.3). Motor blocks and (near) falls were more frequently reported in patients with FNB vs. ACB (20 (76.9%) vs. 1 (3.7%), p < 0.001, and 7 (29.2%) vs. 1 (4.0%), p = 0.023. However, less opioids were consumed in the post-anesthesia care unit for FNB (median 3 [0, 21] vs. 15 [12, 42.5] oral morphine milligram equivalents, p = 0.004) for ACB. Between patients with FNB or ACB, no difference concerning readiness for discharge was found. Despite a slight reduction in opioid consumption immediately after surgery, FNB demonstrates a less favorable safety profile compared to ACB, with more motor blocks and (near) falls.

Nonoperative versus operative management of frail institutionalized older patients with a proximal femoral fracture: a cost-utility analysis alongside a multicenter prospective cohort study

Hip fractures are associated with significant healthcare costs. In frail institutionalized patients, the costs of nonoperative management are less than operative management with comparable short-term quality of life. Nonoperative management of hip fractures in patients at the end of life should be openly discussed with SDM.

PURPOSE

The aim was to describe healthcare use with associated costs and to determine cost-utility of nonoperative management (NOM) versus operative management (OM) of frail institutionalized older patients with a proximal femoral fracture.

METHODS

This study included institutionalized patients with a limited life expectancy aged ≥ 70 years who sustained a proximal femoral fracture in the Netherlands. Costs of hospital- and nursing home care were calculated. Quality adjusted life years (QALY) were calculated based on EuroQol-5D-5L utility scores at day 7, 14, and 30 and at 3 and 6 months. The incremental cost-effectiveness ratio (ICER) was calculated from a societal perspective.

RESULTS

Of the 172 enrolled patients, 88 (51%) patients opted for NOM and 84 (49%) for OM. NOM was associated with lower healthcare costs at 6 months (NOM; €2425 (SD 1.030), OM; €9325 (SD 4242), p < 0.001). The main cost driver was hospital stay (NOM; €738 (SD 841) and OM; €3140 (SD 2636)). The ICER per QALY gained in the OM versus NOM was €76,912 and exceeded the threshold of €20,000 per QALY. The gained QALY were minimal in the OM group in patients who died within 14- and 30-day post-injury, but OM resulted in more than triple the costs.

CONCLUSION

OM results in significant higher healthcare costs, mainly due to the length of hospital stay. For frail patients at the end of life, NOM of proximal femoral fractures should be openly discussed in SDM conversations due to the limited gain in QoL.

TRIAL REGISTRATION

Netherlands Trial Register (NTR7245; date 10-06-2018).

Shared decision-making for the treatment of proximal femoral fractures in frail institutionalised older patients: healthcare providers' perceived barriers and facilitators

INTRODUCTION

Proximal femoral fractures are common in frail institutionalised older patients. No convincing evidence exists regarding the optimal treatment strategy for those with a limited pre-fracture life expectancy, underpinning the importance of shared decision-making (SDM). This study investigated healthcare providers' barriers to and facilitators of the implementation of SDM.

METHODS

Dutch healthcare providers completed an adapted version of the Measurement Instrument for Determinants of Innovations questionnaire to identify barriers and facilitators. If ≥20% of participants responded with 'totally disagree/disagree', items were considered barriers and, if ≥80% responded with 'agree/totally agree', items were considered facilitators.

RESULTS

A total of 271 healthcare providers participated. Five barriers and 23 facilitators were identified. Barriers included the time required to both prepare for and hold SDM conversations, in addition to the reflective period required to allow patients/relatives to make their final decision, and the number of parties required to ensure optimal SDM. Facilitators were related to patients' values, wishes and satisfaction, the importance of SDM for patients/relatives and the fact that SDM is not considered complex by healthcare providers, is considered to be part of routine care and is believed to be associated with positive patient outcomes.

CONCLUSION

Awareness of identified facilitators and barriers is an important step in expanding the use of SDM. Implementation strategies should be aimed at managing time constraints. High-quality evidence on outcomes of non-operative and operative management can enhance implementation of SDM to address current concerns around the outcomes.

Evaluation of Quality of Life After Nonoperative or Operative Management of Proximal Femoral Fractures in Frail Institutionalized Patients: The FRAIL-HIP Study

Importance

Decision-making on management of proximal femoral fractures in frail patients with limited life expectancy is challenging, but surgical overtreatment needs to be prevented. Current literature provides limited insight into the true outcomes of nonoperative management and operative management in this patient population.

Objective

To investigate the outcomes of nonoperative management vs operative management of proximal femoral fractures in institutionalized frail older patients with limited life expectancy.

Design, Setting, and Participants

This multicenter cohort study was conducted between September 1, 2018, and April 25, 2020, with a 6-month follow-up period at 25 hospitals across the Netherlands. Eligible patients were aged 70 years or older, frail, and institutionalized and sustained a femoral neck or pertrochanteric fracture. The term frail implied at least 1 of the following characteristics was present: malnutrition (body mass index [calculated as weight in kilograms divided by height in meters squared] <18.5) or cachexia, severe comorbidities (American Society of Anesthesiologists physical status class of IV or V), or severe mobility issues (Functional Ambulation Category ≤2).

Exposures

Shared decision-making (SDM) followed by nonoperative or operative fracture management.

Main Outcomes and Measures

The primary outcome was the EuroQol 5 Dimension 5 Level (EQ-5D) utility score by proxies and caregivers. Secondary outcome measures were QUALIDEM (a dementia-specific quality-of-life instrument for persons with dementia in residential settings) scores, pain level (assessed by the Pain Assessment Checklist for Seniors With Limited Ability to Communicate), adverse events (Clavien-Dindo classification), mortality, treatment satisfaction (numeric rating scale), and quality of dying (Quality of Dying and Death Questionnaire).

Results

Of the 172 enrolled patients with proximal femoral fractures (median [25th and 75th percentile] age, 88 [85-92] years; 135 women [78%]), 88 opted for nonoperative management and 84 opted for operative management. The EQ-5D utility scores by proxies and caregivers in the nonoperative management group remained within the set 0.15 noninferiority limit of the operative management group (week 1: 0.17 [95% CI, 0.13-0.29] vs 0.26 [95% CI, 0.11-0.23]; week 2: 0.19 [95% CI, 0.10-0.27] vs 0.28 [95% CI, 0.22-0.35]; and week 4: 0.24 [95% CI, 0.15-0.33] vs 0.34 [95% CI, 0.28-0.41]). Adverse events were less frequent in the nonoperative management group vs the operative management group (67 vs 167). The 30-day mortality rate was 83% (n = 73) in the nonoperative management group and 25% (n = 21) in the operative management group, with 26 proxies and caregivers (51%) in the nonoperative management group rating the quality of dying as good-almost perfect. Treatment satisfaction was high in both groups, with a median numeric rating scale score of 8.

Conclusions and Relevance

Results of this study indicated that nonoperative management of proximal femoral fractures (selected through an SDM process) was a viable option for frail institutionalized patients with limited life expectancy, suggesting that surgery should not be a foregone conclusion for this patient population.

Patella related problems as common reason for revision of NexGen PS® total knee arthroplasty without patella resurfacing: An analysis of 5911 primary total knee arthroplasties registered in the Dutch Arthroplasty Register

BACKGROUND

Patella resurfacing remains controversial in primary total knee arthroplasty (TKA).The aim of this study was to investigate if there was a difference in revision rate and reason for revision within 8 years after single brand primary cemented TKA with or without patella resurfacing, using data from the Dutch Arthroplasty Register.

METHODS

All primary TKA surgeries with a posterior stabilized cemented primary NexGen®, between 2010 and 2013 with diagnosis osteoarthritis were analyzed (n = 5911). Multivariate cox regression analyses were performed to analyze differences in revision rate between TKA with or without patella component, and was adjusted for age and previous surgery.

RESULTS

Of 5911 TKA surgeries, 4795 were performed without patella resurfacing (81.1%) and 1116 with patella resurfacing (18.9%). There was a significant difference in patellar problems as reason for revision between patients after primary TKA with patella resurfacing (9.3%) and without patella resurfacing (29.9%) (p = 0.01). This was mostly caused by patellar pain (28.0%). There was no significant difference in cumulative revision rate within between TKA with patella resurfacing and without patella resurfacing.

CONCLUSION

In conclusion, 30% of patients who need revision surgery after TKA using NexGen® PS without patella resurfacing the reason for revision is patella related problems, compared to 9% after TKA NexGen® PS with patella resurfacing. There was no difference in cumulative incidence of revision after primary surgery of all TKA's using NexGen® PS with or without patella. To reduce the probability of reoperation for patella related problems, our data suggest the patella should be resurface during primary TKA.

The value of nonoperative versus operative treatment of frail institutionalized elderly patients with a proximal femoral fracture in the shade of life (FRAIL-HIP); protocol for a multicenter observational cohort study

Background

Proximal femoral fractures are strongly associated with morbidity and mortality in elderly patients. Mortality is highest among frail institutionalized elderly with both physical and cognitive comorbidities who consequently have a limited life expectancy. Evidence based guidelines on whether or not to operate on these patients in the case of a proximal femoral fracture are lacking. Practice variation occurs, and it remains unknown if nonoperative treatment would result in at least the same quality of life as operative treatment. This study aims to determine the effect of nonoperative management versus operative management of proximal femoral fractures in a selected group of frail institutionalized elderly on the quality of life, level of pain, rate of complications, time to death, satisfaction of the patient (or proxy) and the caregiver with the management strategy, and health care consumption.

Methods

This is a multicenter, observational cohort study. Frail institutionalized elderly (70 years or older with a body mass index < 18.5, a Functional Ambulation Category of 2 or lower pre-trauma, or an American Society of Anesthesiologists score of 4 or 5), who sustained a proximal femoral fracture are eligible to participate. Patients with a pathological or periprosthetic fractures and known metastatic oncological disease will be excluded. Treatment decision will be reached following a structured shared decision process. The primary outcome is quality of life (Euro-QoL; EQ-5D-5 L). Secondary outcome measures are quality of life measured with the QUALIDEM, pain level (PACSLAC), pain medication use, treatment satisfaction of patient (or proxy) and caregivers, quality of dying (QODD), time to death, and direct medical costs. A cost-utility and cost-effectiveness analysis will be done, using the EQ-5D utility score and QUALIDEM score, respectively. Non-inferiority of nonoperative treatment is assumed with a limit of 0.15 on the EQ-5D score. Data will be acquired at 7, 14, and 30 days and at 3 and 6 months after trauma.

Discussion

The results of this study will provide insight into the true value of nonoperative treatment of proximal femoral fractures in frail elderly with a limited life expectancy. The results may be used for updating (inter)national treatment guidelines.

Trial registration

The study is registered at the Netherlands Trial Register (NTR7245; date 10-06-2018).

Prosthesis retention after an infected hip prosthesis: hip fractures versus primary total hip prosthesis, data from 1998 - 2015

Background: A prosthetic joint infection (PJI) is a serious complication and specifically a burden for patients after hip fracture surgery, as they are mostly frail elderly patients with multiple comorbidities. Since treatment protocols are lacking there is a need to evaluate current practice. Aim: To evaluate the difference in prosthesis retention after an infected primary total hip replacement (THR) compared to PJI after hip prosthesis surgery performed for a hip fracture. Methods: We retrospectively collected data of patients who developed PJI after primary THR or after hip fracture surgery (THR or hemiarthroplasty) in the Westfriesgasthuis Hospital between 1998 and 2015. Main outcome variables were DAIR treatment and prosthesis retention. Findings: A PJI developed in 48 patients after primary THR and in 23 patients after hip fracture surgery. DAIR was performed in all patients after primary THR and in 87.0% of patients after hip fracture surgery (p<0.05). In 11.4% of patients after primary THR, revision surgery was performed within 1 year after PJI compared to 34.8% after hip fracture surgery (p<0.05). Only 2.1% of patients deceased within 1 year after infection of primary THR compared to 34.8% after hip fracture surgery (p<0.05). Conclusion: Our results showed that prosthesis retention in patients with a PJI after hip fracture surgery is 23% lower than in patients with a PJI after primary THR. This is probably due to the fact that patients who experience a hip fracture are mostly frail elderly with multiple comorbidities and therefore less able to conquer a PJI.

Applications of 99mTC-Sestamibi in Oncology

Hexakis (2-methoxyisobutylisonitrile) technetium-99m (99mTc-SestaMIBI) is a radiopharmaceutical used in nuclear medicine for myocardial perfusion imaging. In the literature different non-cardiac applications of 99mTc-SestaMIBI have been reported. Clinical studies have been performed also in non-oncologic diseases (such as thyroid adenoma, diabetic foot, osteomyelitis, pulmonary actinomycosis, aneurysmal bone cyst, Sudeck's atrophy). Several models for the uptake mechanism of this radiopharmaceutical have been proposed such as binding to an 8-10 kDa cytosolic protein, simple lipid partitioning, or a membrane translocation mechanism involving diffusion and passive transmembrane distribution. Most evidence points in the direction of the third hypothesis. Many studies have indicated that uptake of hexakis (alkylisonitrile) technetium complexes is dependent on mitochondrial and plasma membrane potentials like other lipophilic cations. This explains the initial biodistribution of 99mTc-SestaMIBI to tissues with negative plasma membrane potentials and with a relatively high mitochondrial content (like heart, liver, kidney and skeletal muscle tissue). Malignant tumours also possess these properties in order to maintain their increased metabolism. This behaviour encouraged the study of 99mTc-SestaMIBI as an interesting tracer imaging various tumour types: osteosarcoma, brain, lung, breast, nasopharyngeal, parathyroid, and thyroid cancer. Recent research on cell cellular physiology has further revealed an active transport of 99mTc-SestaMIBI out of the tumour cells, against the potential gradient. The same mechanism is also responsible for resistance to a structurally and functionally different group of cytotoxic agents, such as vinca alkaloids, epipodophyllotoxins, anthracyclins and actinomycin D. This peculiar type of resistance is due to amplification of the mammalian MDR1 gene, located on chromosome 7. For this reason the 99mTc- SestaMIBI uptake in vivo could permit the prediction of the response to the chemotherapy, when the decreased accumulation of 99mTc-SestaMlBI implies the presence of P-gp enriched tissues. In the next future a particular attention should be dedicated to this matter since one of the most important goals of the clinical trials is the demonstration of the usefulness of 99mTc-SestaMIBI for in vivo assessment of multidrug resistance.

In patients undergoing fast track total knee arthroplasty, addition of buprenorphine to a femoral nerve block has no clinical advantage: A prospective, double-blinded, randomized, placebo controlled trial

BACKGROUND

Several adjuvants have been proposed to prolong the effect of peripheral nerve blocks, one of which is buprenorphine. In this randomized double blinded placebo controlled trial we studied whether the addition of buprenorphine to a femoral nerve block prolongs analgesia in patients undergoing total knee arthroplasty in a fast track surgery protocol.

METHODS

The treatment group (B) was given an ultrasound-guided femoral nerve block with ropivacaine 0.2% and 0.3mg buprenorphine. We choose to use 2 control groups. Group R was given a femoral nerve block with ropivacaine 0.2% only. Group S also received 0.3 mg buprenorphine subcutaneously. Only patients with a successful block were enrolled in the study.

RESULTS

We found no difference in our primary outcome parameter of time to first rescue analgesic. We found lower opioid use and better sleep quality the first postoperative night in patients receiving buprenorphine perineurally or subcutaneously. Buprenorphine did not lead to any significant change in pain or mobilization. We found a high overall incidence of nausea and vomiting.

CONCLUSION

In patients undergoing total knee arthroplasty, in the setting of a fast track surgery protocol, the addition of buprenorphine to a femoral nerve block did not prolong analgesia.

The Effectiveness of Debridement, Antibiotics and Irrigation for Periprosthetic Joint Infections after Primary Hip and Knee Arthroplasty. A 15 Years Retrospective Study in Two Community Hospitals in the Netherlands

The aim of our study was to evaluate the effectiveness of debridement, antibiotics, irrigation and retention (DAIR) in patients who developed a periprosthetic joint infection (PJI) after primary hip or knee arthroplasty in two community hospitals in the Netherlands. We retrospectively collected data in two hospitals in the Netherlands on all episodes of PJI after primary hip (THA) and knee arthroplasty (TKA) from 1998-2012. In 109 of 8234 THA (1.32%) and 65 of 5752 TKA (1.13%) a PJI developed. DAIR was used as treatment in 84 patients after THA (77.1%) and 56 patients after TKA (86.2%). 34 Patients only received antibiotics or were immediately revised. After 1 year follow-up, prosthesis retention was achieved in 81 THA patients (74.3%) and 48 TKA patients (73.8%). Acute infections showed a better survival compared to late infections (84.0% vs 46.6% respectively; p<0.01). Furthermore, a young age was associated with an increased revision risk (p<0.01). In conclusion, debridement, antibiotics and irrigation in acute PJI may lead to retention of the prosthesis in a majority of cases. Large patient cohort studies can provide data on PJI outcome, complementing National Registries which have limited detail.

[Bifid rib: the importance of good radiological procedure]

BACKGROUND

Bifid rib is a congenital abnormality occurring in about 0.6% of the healthy population.

CASE DESCRIPTION

A 5-year-old boy attended the Orthopaedics outpatient clinic with a swelling on the right of his sternum that was increasing in size. A chest x-ray did not reveal any abnormalities. However, on the CT scan that was then performed we saw a bifurcation of the fourth rib, for which we adopted a watchful waiting treatment strategy. With hindsight, the bifurcation was also visible on the x-ray image but we had not initially recognised it as such.

CONCLUSION

Bifurcation of a rib is not always recognised as such. Unnecessary supplementary diagnostics can be avoided with the use of a correctly implemented radiological procedure.

Recto-colonic reflex is impaired in patients with irritable bowel syndrome

Motor and sensory dysfunction of the gut are present in a subset of patients with irritable bowel syndrome (IBS). Recent studies have demonstrated the presence of a recto-colonic inhibitory reflex in healthy humans. It is not known whether this reflex exists in IBS. We studied rectal compliance, perception and the recto-colonic reflex by measuring volume responses of the descending colon to rectal distentions by barostat in 26 IBS patients and 13 healthy controls under both fasting and postprandial conditions. In the fasting state, rectal distention inhibited colonic tone and phasic motility to a similar extent in health and IBS. After a meal, rectal distention inhibited colonic tone and phasic motility to a lesser degree (P < 0.05) in IBS than health. Under postprandial but not fasting conditions, rectal distentions of increasing intensity were associated with higher pain scores in IBS than in health. Rectal distention inhibits tonic and phasic motility of the descending colon in healthy controls and in IBS patients. Postprandially this recto-colonic inhibitory reflex is impaired and attenuated in IBS patients compared with controls. These findings point to an altered reflex function in IBS and have implications for pathophysiology and therapy.

The influence of endplate-to-endplate cement augmentation on vertebral strength and stiffness in vertebroplasty

STUDY DESIGN

Controlled in vitro trial.

OBJECTIVE

To study vertebral strength in relation to cement augmentation technique after vertebroplasty and to assess the influence of the biomechanical compression model on postoperative results.

SUMMARY OF BACKGROUND DATA

In the treatment of osteoporotic vertebral fractures, the role of vertebroplasty has been well established. Biomechanical compression models thus far used, compressing vertebrae by only 25% of their initial height, did not show a correlation between cement augmentation volumes and postoperative compression strength. In these studies, even very small volumes of cement seem effective. However, these models may not realistically simulate clinically relevant osteoporotic wedge fractures. We hypothesize that, in clinically relevant osteoporotic wedge fractures, postoperative vertebral body strength is strongly dependent on endplate-to-endplate cement augmentation.

METHODS

Twenty-five intact osteoporotic cadaver vertebrae were obtained (10 lumbar, 15 thoracic). In 21 vertebrae, anterior wedge fractures (AO type A1.2) were created by controlled external force, with preset height reduction by 35%. After height reconstruction, 9 vertebrae were augmented endplate-to-endplate and 12 vertebrae were partially augmented with polymethylmethacrylate (PMMA). Another 4 vertebrae were compressed by only 25%. Posttreatment strength and stiffness of the vertebrae were determined by a compression test identical to the pretreatment compression protocol.

RESULTS

In the 35% compression group, posttreatment strength was significantly decreased in vertebrae that were partially augmented with cement compared with the endplate-to-endplate augmented group (767 +/- 257 N vs. 1141 +/- 325 N, P < 0.01). Postoperative strength amounted 106% +/- 27% of preoperative strength values in the endplate-to-endplate augmented vertebrae, compared with 65% +/- 18% in the partially augmented vertebrae (P < 0.001). In the 25% compression group, results in height restored and augmented vertebrae were similar to the nontreated vertebrae.

CONCLUSIONS

Endplate-to-endplate PMMA augmentation restores the biomechanical properties of vertebrae in clinically relevant anterior wedge fractures. Our preliminary data suggest that biomechanical models with only 25% compressive deformation unlikely form a good model to assess the mechanical effects of cement augmentation in osteoporotic fractures.

Prospective evaluation of ileoanal pouch characteristics measured by barostat

PURPOSE

The aim of this study was to evaluate pouch sensory and motor characteristics prospectively during the first postoperative year and to compare those with rectal characteristics.

METHODS

Twelve patients with an ileoanal J-pouch were studied at 3 and 12 months postoperatively. The results were compared with those obtained in 12 healthy controls. Visceral compliance was assessed using an electronic barostat by a pressure distention procedure, during which sensitivity was also scored by visual analog scales. The response to a meal was assessed during set pressure.

RESULTS

During the first postoperative year, pouch compliance increased significantly from 7.2 +/- 0.6 to 10.7 +/- 0.9 ml/mmHg (rectal compliance 10.6 +/- 1.1 ml/mmHg). The increase in pouch compliance significantly influences the 24-hour stool frequency (P = 0.42). Visceroperception scores remained unchanged. Postprandial decrease in intrabag volume was more pronounced in patients (45 +/- 13 percent at 3 months, 32 +/- 15 percent at 12 months) than in controls (9 +/- 6 percent, < 0.05), and residual postprandial bag volumes were significantly lower in patients at 3 months compared with patients at 12 months.

CONCLUSIONS

Ileoanal pouch compliance increases significantly during the first postoperative year to values in the range of rectal compliance. The increase in pouch compliance is related to a decrease in 24-hour stool frequency. Postprandial bag volumes increase during the first postoperative year but remain significantly smaller than in the rectum. Pouch sensitivity does not change.

Compliance, tone and sensitivity of the rectum in different subtypes of irritable bowel syndrome

Irritable bowel syndrome (IBS) consists of various subtypes. It is not known whether these subtypes share a common pathophysiology. Evaluation of motor and sensory function of the rectum using a barostat may help to explore a common pathophysiological background or differences in pathophysiology in subtypes of IBS. We have evaluated compliance, tone and sensitivity of the rectum, in both fasting state and postprandially, using a computerized barostat in 15 patients with diarrhoea-predominant IBS (IBS-D), 14 patients with constipation-predominant IBS (IBS-C) and compared the results with those obtained in 12 healthy controls. Rectal compliance as calculated over the steep part of the pressure-volume curve (17-23 mmHg) was decreased in both IBS groups (IBS-D 8.0 +/- 1.4 mL mmHg-1; IBS-C 5.6 +/- 1.1 mL mmHg-1) compared with controls (24.7 +/- 3.5 mL mmHg-1). The perception of urge was increased only in IBS-D patients, whereas pain perception was significantly increased in both IBS groups. Spontaneous adaptive relaxation was decreased in IBS-D patients. Postprandially, rectal volume decreased significantly in the controls and in IBS-D patients, but not in IBS-C patients. In conclusion, both rectal motor and sensory characteristics are different between IBS-D and IBS-C patients. Therefore, testing of rectal visceroperception, adaptive relaxation and the rectal response to a meal may help distinguish groups of patients with different subtypes of irritable bowel syndrome.

Ileoanal pouch function is related to postprandial pouch tone

BACKGROUND

Functional impairments are frequently observed in patients with an ileoanal pouch. Meal ingestion increases pouch tone and motility. Little is known, however, about the influence of meal-stimulated pouch characteristics on pouch function. The aim was to characterize basal and postprandial pouch motor and sensory characteristics in relation to clinical pouch function in patients with an ileoanal pouch.

METHODS

Nineteen patients with an ileoanal pouch, without faecal incontinence but with either a high stool frequency (n = 8) or an adequate stool frequency (n = 11), underwent pressure distension of the pouch, by which pouch compliance and sensitivity characteristics were assessed using an electronic barostat. A set pressure procedure was performed to assess the influence of a meal on pouch tone and motility.

RESULTS

Mean(s.d.) compliance was 10(6) and 11(4) ml/mmHg in the groups with poor and adequate pouch function respectively (P not significant). Mean(s.d.) visual analogue scale scores (0-10 cm) for urge at the highest pressure of 28 mmHg were 2.3(1.0) versus 2.3(2.4) cm respectively (P not significant); those for pain were 0.8(1.0) versus 0.5(0.7) (P not significant). Postprandially mean(s.d.) pouch volume decreased by 70(24) per cent in the group with poor pouch function and 29(25) per cent in the group with adequate pouch function (P < 0.01). The frequency and amplitude of phasic pouch contractions increased significantly postprandially, but no differences in motility characteristics were observed between the two groups.

CONCLUSION

In patients with uniform pouch design and follow-up after pouch construction, pouch compliance and sensitivity were no different between patients with normal and high stool frequency; however, postprandial pouch tone was increased significantly in patients with a high stool frequency.

Comparison of ileoanal pouch and rectal function measured by barostat

The aim of this study was to compare pouch and rectal sensory and motor characteristics and to assess the influence of a meal on pouch tone and motility. Fifteen patients with an ileoanal J-pouch, with adequate pouch function and 12 healthy controls were studied. Visceral compliance was assessed using an electronic barostat by a pressure distension procedure, during which also sensitivity was scored by visual analog scales (VAS). The response to a meal was assessed during set pressure. Pouch and rectal compliance were not significantly different (9.3+/-0.7 vs 10.6+/-1.1 ml/mm Hg). VAS score for urge at 28 mm Hg was reduced in patients: 2.4+/-0.5 cm vs 4.7+/-0.9 cm in controls (P < 0.05). The postprandial decrease in intra-bag volume was more pronounced in patients (44+/-11%) than in controls (9+/-6%, P < 0.01). Postprandial phasic contractions were also more pronounced in patients. In conclusion, compliance is not significantly different between ileoanal pouch and rectum; differences in sensitivity reach significance only at high pressure. Significant differences were especially observed in the postprandial state with an increase in tone and frequency of phasic contractions in pouch patients.

Motor and sensory function of the rectum in different subtypes of constipation

BACKGROUND

It is not known whether evaluation of motor and sensory function of the rectum using a barostat may help to distinguish subtypes of constipation.

METHODS

Motor and sensory function of the rectum have been evaluated using a barostat in 14 patients with slow transit constipation (STC), 12 patients with constipation-predominant irritable bowel syndrome (IBS) and 18 healthy controls. First minimal distending pressure was determined, after which spontaneous adaptive relaxation of the rectum was monitored. Then a step-wise isobaric distension procedure was performed, during which symptom perception was determined. The distension was followed by a 90-min barostat procedure: for 30 min in the basal state followed by ingestion of a semi-liquid meal (postprandial state).

RESULTS

Minimal distending pressure was not different between both patient groups and controls, neither was compliance different between constipated patients and controls. The degree of spontaneous adaptive relaxation was in the same range in all groups. During distensions with high pressures, the perception of urge was significantly reduced in STC patients compared to IBS and controls, while the perception of pain was significantly increased in IBS versus STC and controls. Postprandially, a small decrease of rectal volume was only observed in the control group, but not in the patients.

CONCLUSIONS

Rectal motor characteristics are not different between patients with constipation-predominant IBS, patients with STC and healthy controls while during isobaric distensions, sensations of urge were reduced in STC and sensations of pain were increased in IBS. Rectal visceroperception testing may help distinguish groups of patients with different subtypes of constipation.

Effects of very long chain versus long chain triglycerides on gastrointestinal motility and hormone release in humans

Fish oil (a very long chain triglycerides, VLCT) has received much attention because of its favorable metabolic properties; however, its effect on gastrointestinal function has not been studied. We investigated the effects of intraduodenally administered VLCT on gut-hormone release [cholecystokinin (CCK), neurotensin, peptide YY (PYY)], gallbladder emptying, antroduodenal motility, and small bowel transit time (SBTT) in comparison to intraduodenal administration of saline and long chain triglycerides (LCT, corn oil) in nine healthy volunteers. Gallbladder contraction duration was significantly shorter after VLCT than after LCT (138 +/- 16 min vs 233 +/- 38 min, P < 0.05). Both fats induced a fed motility pattern, while SBTT was not significantly altered. CCK secretion was significantly reduced after VLCT compared to LCT (36 +/- 12 pM x 120 min vs 78 +/- 15 pM x 120 min, P < 0.05), whereas PYY and neurotensin release were not significantly different. In conclusion, effects of triglycerides on CCK and gallbladder motility appear to be chain-length dependent, in contrast to the effects on distal gut-hormone release and intestinal motility and transit, which appear to be chain-length independent.

Limited influence of pouch function on quality of life after ileal pouch-anal anastomosis

BACKGROUND/AIMS

Despite a high frequency of pouch function disorders, most patients are satisfied with the outcome of ileo-anal pouch surgery. Aims of this study were: 1) To assess the influence of pouch function on quality of life and, 2) to determine which aspects of pouch dysfunction affect quality of life the most.

METHODOLOGY

Questionnaires, addressing current pouch function and quality of life (Rand-36, GIQLI), were sent to all (53) patients with intact ileo-anal pouches, operated on between 1987 and 1997 in our center.

RESULTS

Thirty-six of 53 patients responded. Compared to reference data, Rand-36 scores for role-limitations based on a physical problem, vitality and general health perception were significantly diminished (P < 0.01). Physical and social functioning were normal. The GIQLI score was slightly decreased (111.7 vs. 125.8, P < 0.01). Overall pouch function did not correlate with the overall Rand-36 score, but correlated well with the overall GIQLI score (r = -0.47). Both quality of life scores were diminished mainly by the night-time stool frequency.

CONCLUSIONS

1) Quality of life after IPAA, as measured with validated questionnaires, is only slightly decreased; 2) the GIQLI questionnaire is more sensitive to pouch dysfunction than the Rand-36; 3) night-time stool frequency influences quality of life the most.

The diagnostic utility of somatostatin receptor scintigraphy in oncology

Somatostatin receptor scintigraphy (SRS) with the diethylenetriaminopentaacetic-acid-conjugated somatostatin analogue [111In-DTPA-D-Phe1] octreotide, also known as 111In-pentetreotide, is a new non-invasive modality for the evaluation of tumours that express receptors for somatostatin. These receptors are present on neuroendocrine and other tumours, including lymphomas and some breast cancers. In oncology SRS is a promising diagnostic tool for localizing primary tumours, staging, control and follow-up after therapy, and for identification of patients who may benefit from therapy with unlabelled octreotide or, in the future, with radiolabelled octreotide. In the past few years many small and large studies investigating various aspects of SRS have been reported. In this review the value of SRS in the management of individual tumour types is explored. For many tumours the best sensitivity in lesion detection is only achieved by very careful imaging after the administration of at least 200 MBq 111In-pentetreotide. On the basis of the current experience the main value of SRS in oncology is in the staging and evaluation of gastroenteropancreatic tumours, paragangliomas, small-cell lung cancer and lymphomas. Promising areas for SRS are the evaluation of breast cancer, non-medullary thyroid cancer and melanoma, and initial results with targeted radionuclide therapy using radiolabelled octreotide have been reported.

Long-term sleep deprivation as a game. The wear and tear of wakefulness

We report here the first sleep deprivation study done on a group of 5 healthy students (1 female, 4 males, 23-24 years of age) while playing a game (Triviant). In 2 persons an EEG was recorded for 6 consecutive 24 h periods with an ambulatory monitor from the baseline night until 72 h after deprivation. The baseline night showed normal hypnograms. The students were deprived of sleep for 65 h following the baseline night. Sleep deprivation was complete and resulted in bradyphrenia, loss of memory and contact with reality, ataxia, decrease in body temperature and loss of body weight. The main sign of recuperation was a strongly increased slow-wave sleep synchronization during the first recuperation period (day-time sleep) only. There were no signs of REM rebound.