Surgery for a fracture of the hip within 24 hours of admission is independently associated with reduced short-term post-operative complications

AIMS

We aimed to characterise the effect of expeditious hip fracture surgery in elderly patients within 24 hours of admission on short-term post-operative outcomes.

PATIENTS AND METHODS

Patients age 65 or older that underwent surgery for closed femoral neck and intertrochanteric hip fractures were identified from the American College of Surgeons National Surgical Quality Improvement Program between 2011 and 2014. Multivariable propensity-adjusted logistic regressions were performed to determine associations between early surgery within 24 hours and post-operative complications, controlling for selection bias in patients undergoing early surgery based on observable characteristics.

RESULTS

A total of 26 051 patients were included in the study; 5921 (22.7%) had surgery within 24 hours of admission, while 20 130 (77.3%) patients had surgery after 24 hours. Propensity-adjusted multivariable logistic regressions demonstrated that surgery within 24 hours was independently associated with lower odds of respiratory complications including pneumonia, failure to extubate, or reintubation (odds ratio (OR) 0.78, 95% confidence interval (CI) 0.67 to 0.90), and extended length of stay (LOS) defined as ≥ 6 days (OR 0.84, 95% CI 0.78 to 0.90).

CONCLUSION

In elderly patients with hip fractures, early surgery within 24 hours of admission is independently associated with less pulmonary complications including pneumonia, failure to extubate, and reintubation, as well as shorter LOS. Cite this article: Bone Joint J 2017;99-B:1216-22.

Osteoporosis drug therapy strategies in the setting of disease-modifying agents for autoimmune disease

The purpose of this systematic review is to evaluate the effects of methotrexate (MTX) and tumor necrosis factor-alpha (TNF-α) inhibitors on bone mineral properties in the clinical literature. A systematic review of the literature identifying relevant case reports, population-based studies, cohort studies, case control studies, and randomized controlled trials in Pubmed and Web of Science databases from inception to December 31, 2011 was conducted. The following keywords were used: "bone turnover," "bone mineral density," "TNF-α inhibitors," "infliximab," "adalimumab," "etanercept," and "MTX." The bibliographies of all retrieved studies were also reviewed to identify additional articles. Based on these results, a rational drug therapy strategy was suggested for treating osteoporosis in patients with inflammatory disease. MTX and TNF-α inhibitors do not appear to have an adverse effect on BMD in patients with inflammatory disease. Their negative effects on BMD and bone turnover in pre-clinical models appear to be outweighed by their anti-disease effects in clinical studies. Treatment with MTX or TNF-α inhibitors has no adverse effect on BMD in patients with inflammatory disease. Future studies will focus on developing optimal drug strategies when combining DMARDs with anti-osteoporotic agents in this patient population.

The association between school-based physical activity, including physical education, and academic performance: a systematic review of the literature

OBJECTIVE

The purpose of this review is to synthesize the scientific literature that has examined the association between school-based physical activity (including physical education) and academic performance (including indicators of cognitive skills and attitudes, academic behaviors, and academic achievement).

METHOD

Relevant research was identified through a search of nine electronic databases using both physical activity and academic-related search terms. Forty-three articles (reporting a total of 50 unique studies) met the inclusion criteria and were read, abstracted, and coded for this synthesis. Findings of the 50 studies were then summarized.

RESULTS

Across all the studies, there were a total of 251 associations between physical activity and academic performance, representing measures of academic achievement, academic behavior, and cognitive skills and attitudes. Slightly more than half (50.5%) of all associations examined were positive, 48% were not significant, and 1.5% were negative. Examination of the findings by each physical activity context provides insights regarding specific relationships.

CONCLUSION

Results suggest physical activity is either positively related to academic performance or that there is not a demonstrated relationship between physical activity and academic performance. Results have important implications for both policy and schools.

Scanning electron microscope study of early lichen synthesis

In the early stages of cellular interaction between the symbionts of Lecidea albocaerulescens, the phycobiont produced an extracellular sheath which bound to it hyphae of the mycobiont. Such a sheath may be a means by which the symbionts recognize each other. Hyphae of the mycobiont formed flattened appressoria as they grew over the algal cells and in this way secured the autotrophic population necessary for the development of a lichen thallus.

Through a mother's eyes: Sources of bias when mothers with co-occurring disorders assess their children

Mothers are the principal informants on children's emotional and behavioral functioning. Maternal assessments of child functioning can be influenced by a mother's own psychological state. The magnitude and valence of distortion in maternal assessments associated with current maternal mental health and substance abuse symptoms were explored in a clinical sample of 253 mothers with co-occurring disorders and histories of trauma. Analyses estimated the correlation between current maternal symptoms and child assessments after controlling for maternal history of disorders, child's history of service utilization for emotional and behavioral problems, and demographic characteristics. Current maternal psychological distress was associated with more pessimistic assessments on the problem-focused Child Behavior Checklist, whereas current maternal substance abuse problems were associated with more optimistic assessments on both problem-focused and strength-based measures. Clinicians and researchers may choose to take distortion into account when treatment plans or measures of change are based on maternal assessments.

Service use and costs for women with co-occurring mental and substance use disorders and a history of violence

OBJECTIVES

This study examined the 12-month cost of the array of services used by women with co-occurring mental health and substance use disorders and a history of violence and trauma who participated in the Women, Co-occurring Disorders, and Violence Study (WCDVS). The study compared costs of the intervention and external services for women in the WCDVS intervention in outpatient and residential settings-which provided comprehensive, integrated, and trauma-informed services-with the costs for women in the usual-care comparison group. The study also compared costs with recorded clinical outcomes.

METHODS

Costs of service use were examined for 2,026 women who participated in the WCDVS (N=1,018) and in the comparison group (N=1,008). Women were interviewed three, six, nine, and 12 months after baseline about any service use in the past three months. Costs for these services, along with indirect costs (participants' time and transportation) were estimated by using a variety of sources. A number of cost estimates were analyzed by using either ordinary least squares regression or two-part models.

RESULTS

The average participant had almost 43,000 dollars in costs related to their service use during the 12 months after baseline. Women in the intervention group had lower service costs and higher overall costs than those in the comparison group, but the null hypotheses of no difference in any cost measure between groups was not rejected. Also, the null hypothesis of no difference in the probability of accessing services external to the study intervention was not rejected.

CONCLUSIONS

Because no differences were detected in costs but improvements were seen in clinical outcomes, the interventions offered in the WCDVS may be more efficient than usual care.

Tangled in a web of affiliation: social support networks of dually diagnosed women who are trauma survivors

The goal of this article is to describe the social support networks of women with co-occurring substance abuse and mental health problems who are survivors of interpersonal abuse, using baseline interview data from 2 sites (n = 644) from the national Women Co-occurring Disorders and Violence Study. The size and composition of women's networks, the tangible and socioemotional support available, and the stance of the support network toward substance use, treatment, and trauma are described. Family members are described by women as offering less emotional support and less encouragement for healing from trauma than friends. Analyses demonstrated only modest support in either sample for the hypothesis that support network characteristics moderate the effects of traumatic stress on mental health and trauma symptoms among these samples of very burdened and poor women. The results point to the need for using caution in relying on women's existing social support network to help them heal.

Building resilience in children of mothers who have Co-occurring Disorders and histories of Violence

Historically, children of parents with co-occurring substance abuse and mental health disorders and histories of violence/trauma have been overlooked in behavioral health treatment systems. The Women, Co-occurring Disorders and Violence Study (WCDVS) was a 5-year initiative funded by the United States Substance Abuse and Mental Health Services Administration (SAMHSA) that included a Children's Study that explored the treatment needs of children of women with these multiple disorders. This article describes the development of the Children's Study intervention that included clinical assessment, group intervention, and resource coordination/advocacy for children aged 5-10 to build resilience through increasing coping skills, improving interpersonal relationships, and helping coalesce positive identity and self-esteem. Innovative procedures, including the participation of consumer/survivor/recovering women and mothers, in the planning, implementation, and administrative applications of this intervention and study are also highlighted. It is recommended that programs begin to implement family-focused integrated treatment approaches that can potentially increase protective factors for children affected by parental mental illness, substance abuse, and violence.

The Dawn Project: a model for responding to the needs of children with emotional and behavioral challenges and their families

Systems of care represent a fundamental departure from traditional service provision by espousing genuine family-centered, culturally competent philosophies and blending the funding streams of multiple payers (e.g., education, mental health, child welfare). In Marion County, Indiana, local leaders created a system of care based on these principles called the Dawn Project. Currently, a comprehensive, multidisciplinary evaluation is being implemented to evaluate the program. Preliminary findings from initial evaluation efforts suggest that for youth in the project, there is significant clinical improvement during the first year of receiving services, a reduction in the use of more restrictive settings, and a decrease in recidivism among those who successfully complete the program.

Treatment of relapse after allogeneic BMT with donor leukocyte infusions in 16 patients

Sixteen patients with relapse after allogeneic BMT were treated with donor leukocyte infusions (DLI) from the original donor. The diagnoses at relapse were: CML in chronic phase (CP) (two patients), CML in accelerated phase (AP) (four patients), AML (four patients), MDS (one patient), ALL (four patients) and relapse of Hodgkin's disease (one patient). The patients received a mean of 5.2 x 10(8) leukocytes/kg with a range of 1.4-12.3 x 10(8) leukocytes/kg. Six patients obtained complete remission (CR), one with CML in CP, three with CML in AP, one MDS and one ALL. Partial remission (PR) was seen in three patients, one patient with CML in AP, one with AML and one with Hodgkin's disease. Seven patients had no response (NR) to the infusions, including one patient with CML in CP transplanted with a syngeneic donor. Four patients developed marrow hypoplasia after DLI (three CR and one PR) and two patients (ALL with CR and MDS with CR) were hypoplastic at relapse and marrow hypoplasia continued after DLI. GVHD occurred without GVL, but GVL only occurred in one patient with absence of GVHD. Eleven patients died of leukemia, six patients are alive. Three patients with CML are in CR 12, 12 and 32 months after DLI and one patient with ALL is in CR 15 months after DLI.

Fine needle aspiration cytology of pulmonary Wegener's granulomatosis with biopsy correlation. A report of three cases

BACKGROUND

Pulmonary Wegener's granulomatosis frequently presents clinically as ill-defined nodules on chest radiographs or computed tomographic scans. With refinement of fine needle aspiration (FNA) cytology as a diagnostic tool, pathologists are sometimes asked to render this diagnosis on cytologic material rather than on the more invasive open lung biopsy. Experience is currently limited to a few case reports in the cytopathology literature. We add to this by reporting the findings from five FNA biopsies performed on three patients, with open lung biopsy correlation.

CASES

The cytologic findings included a background of necrotic debris, acute and chronic inflammatory cells, multinucleate giant cells and, in one case (case 2), numerous clusters of atypical epithelioid cells mimicking carcinoma. Correlation of the respective open lung biopsy specimens with the FNA material was instructive in revealing the nature of the findings on cytologic preparations. Two cases showed classic histopathologic findings. Case 3 showed a less common presentation, pulmonary hemorrhage, which was reflected in the FNA specimen.

CONCLUSION

FNA biopsy cytology is a useful alternative to open lung biopsy in the diagnosis of pulmonary Wegener's granulomatosis but requires careful correlation with the clinical and laboratory findings.

Bacillary angiomatosis in patients with AIDS: multiorgan imaging findings

PURPOSE

To describe the varied clinical manifestations and imaging findings encountered in bacillary angiomatosis, an infectious complication of the acquired immunodeficiency syndrome (AIDS).

MATERIALS AND METHODS

Clinical, imaging, and histopathologic findings in nine men (aged 26-50 years) with AIDS and bacillary angiomatosis were described. This condition often manifests as vascular skin lesions that resemble those of Kaposi sarcoma, fever, and anemia and is due to infection with Bartonella (Rochalimaea) henselae.

RESULTS

Common imaging findings included lung nodules, mediastinal adenopathy, peripheral adenopathy, pleural effusions, ascites, abdominal adenopathy, soft-tissue masses, and low-attenuation lesions in the liver and/or spleen. Most notably, nodes and soft-tissue lesions were dramatically enhanced with injection of contrast material, which is presumably because the lesions are composed to a large extent of well-formed capillaries.

CONCLUSION

Bacillary angiomatosis, a treatable infection, should be considered in patients with AIDS, particularly when Kaposi sarcoma is suspected clinically.

Challenges in medical staff credentialing

This article addresses the challenges faced by medical staffs in conducting their medical staff appointment and reappointment activities, including credentialing, privileging, establishing criteria for new procedures, crossover privileging, and creating credentialing systems for new facilities. In order to satisfy legal scrutiny, the cornerstone of all these activities must be quality patient care.

Circulating immune complexes with pulmonary hemorrhage during pregnancy in idiopathic pulmonary hemosiderosis

Circulating immune complexes occurred during pulmonary hemorrhage in a pregnant patient with idiopathic pulmonary hemosiderosis, an association not previously reported. The patient required mechanical ventilation, but recovered; after a prolonged hospitalization, she was delivered of a healthy infant without further complications.

The cytology of pediatric masses: a differential diagnostic approach

In the United States, fine-needle aspiration biopsy (FNAB) and other cytodiagnostic methods have been underutilized in the evaluation of masses in the pediatric age group. Cytopathologists and cytotechnologists are therefore relatively unfamiliar with the cellular features of lesions that occur in children. On the basis of the cytologic findings from 64 pediatric cases, including 56 FNABs and 8 intra-operative imprints, a differential diagnostic approach to lesions in this age group is presented. The majority of cases can be placed into 1 of 5 cytomorphologic categories: (1) round-cell pattern, (2) mixed inflammatory pattern, (3) spindle-cell pattern, (4) epithelial pattern, and (5) cystic pattern. Once a cytomorphologic category is determined, evaluation for unique cellular features, special studies, and clinical correlation allows a specific diagnosis to be made in most cases. Pitfalls in pediatric cytopathology are illustrated by discussion of the following cases: a renal Burkitt's lymphoma mimicking a Wilms' tumor, a traumatic neuroma masquerading as a recurrent malignant schwannoma, Langerhans-cell histiocytosis resembling granulomatous inflammation, and a cystic granuloma that mimicked a branchial cleft cyst. Consideration of these problems and use of the recommended diagnostic approach will aid in interpretation in this difficult area.

Fine needle aspiration biopsy of superficial masses in children

Fine needle aspiration biopsy (FNAB) is an underused diagnostic procedure in children, particularly in the evaluation of superficial masses. A total of 54 FNABs of superficial masses were performed in children aged 1 month to 15 years. Adequate material for diagnosis was obtained in 50 attempts. The cytologic diagnosis increased clinical understanding and provided a guide for treatment in 46 of the 50 cases. The cytologic diagnosis was confirmed in 15 of 19 patients who underwent an operation. Surgical intervention was obviated in 31 patients. There was one false-positive diagnosis of cancer. We describe the role of FNAB in children and its technique, accuracy, and diagnostic problems.

Cytologic interpretation of fine-needle aspiration biopsies from clinically occult breast masses

Fine-needle aspiration biopsy (FNAB) was performed on 39 occult breast masses of soft tissue density using standard mammographic guidance. All malignant tumors were diagnosed as either positive or suspicious for carcinoma, and there were no false-positive or false-suspicious diagnoses. These excellent results can be attributed to accurate cytologic interpretation based on consideration of problems unique to these lesions and the sampling method, such as scantier cellularity, potentially less confidence in needle placement, and the nature of the occult mass itself. The team approach between pathologist, radiologist, and clinician is emphasized.

Quantitative DNA patterns in human preneoplastic breast lesions

In 12 cases of human mammary carcinoma in which a preneoplastic atypical ductal hyperplasia was also identified, quantitative DNA (QDNA) measurements of thionein-stained samples from both lesions were performed using the Cell Image Analysis 100 system. The QDNA values in the preneoplastic and neoplastic lesions from each case showed concordance (six as euploid and six as aneuploid/hyperdiploid). Such congruence suggests a stable inheritance of the somatic mutation(s) that is involved in carcinogenesis and that affects ploidy. If this relationship between concurrent preneoplasia and neoplasia in the ipsilateral breast is confirmed, it offers the possibilities of (1) identifying individuals at risk for developing neoplasias with defined biologic characteristics and (2) developing therapeutic regimens more appropriate to the risk assessment of each patient. It may be possible to conceive of a rational preventive regimen for cancer of the breast.

Intradermal inoculation with Heptavax-B. Immune response and histologic evaluation of injection sites

The high cost of hepatitis B vaccine has limited its widespread use. Low-dose, intradermal injections of vaccine represent one option for reducing the cost. In this study, 92 nonimmune medical students were given three 0.1-mL intradermal injections of Heptavax-B containing 2 micrograms of hepatitis B surface antigen (HBsAg) at 0, 1, and 6 months. By 6 months, 90% of the subjects had developed protective levels of antibody to HBsAg (greater than or equal to 10 mIU/mL). Follow-up at 1 year showed a geometric mean concentration of antibodies to HBsAg of 396 mIU/mL for the group, and 95% had levels of antibody to HBsAg greater than or equal to 10 mIU/mL. A level of antibody to HBsAg of greater than 100 mIU/mL also was observed in more than 75% of subjects. Side effects included induration of the inoculation site in 18% at 6 months, which disappeared by 12 months, and macules that persisted at 1 year in 63%. The administration of hepatitis B vaccine intradermally is an attractive, low-cost alternative in the United States, where universal vaccination of preschool children or adolescents is being contemplated, and where booster doses are being considered.

1,2-Dibromo-3-chloropropane (DBCP)-induced nuclear atypia in rat kidney

The reversibility of the nematocide 1,2-dibromo-3-chloropropane (DBCP)-induced renal injury was studied in adult male F344 rats. After a single dose of 200 mg DBCP/kg body weight, rats were sacrificed at 1, 3, 6, 9, 14, 28, and 196 days. Twenty-four hours after DBCP treatment, the animals showed signs of acute renal insufficiency, which, based on serum chemistry and urinalysis results, was reversed by the 14th day. Morphologic findings consisted of severe acute tubular necrosis, which was localized to the juxtamedullary cortex. The lesion was recognizable at 24 hrs and fully developed at 3 days post-exposure. The proximal convoluted tubuli were primarily affected, but there were also spotty necroses in distal convoluted tubuli and loops of Henle. Beginning regeneration was evident at 3 days post-exposure. Multiple mitoses, some of them abnormal, were seen. Four weeks after treatment some mitotic activity was still present, but the regeneration of the tubular epithelium was largely completed. There were several dilated, distorted tubuli lined with abnormal epithelial cells with large, hyperchromatic nuclei. Interstitial fibrosis was mild and there was no interstitial inflammation. Twenty-eight weeks post-exposure the nuclear atypia persisted in the tubular epithelium. Glomerular findings were minimal and consisted of focal hyperplasia of the epithelial cells of the parietal layer of Bowman's capsule and shrinking of the glomerular tufts at 4 weeks post-exposure. At 28 weeks post exposure only rare foci of glomerulosclerosis were seen. Epithelial cells of the renal pelvis showed minimal nuclear and cytoplasmic swelling 24 hrs after DBCP exposure. Urothelial atypia was not present. The results indicate that a single dose of DBCP is capable of producing nuclear atypia that persists in the renal tubuli beyond the regenerative phase. Follow-up of patients that have been chronically exposed to DBCP with periodic examination of urinary cytology is suggested.

Cytodiagnosis of extrahepatic biliary duct tumors from specimens obtained during cholangiography

Two cases of cholangiocarcinoma of the extrahepatic biliary ducts, one case of bile duct adenoma, and one case of pancreatic carcinoma involving the common bile duct are presented to illustrate cytologic diagnoses from specimens obtained during endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography. Obtaining specimens during these procedures can be advantageous because the cells retrieved are well-preserved, surgery is not required, and patients with advanced disease can be managed conservatively once a diagnosis is rendered. Cytologic diagnosis can be difficult, since malignancies of the extrahepatic bile ducts are often well-differentiated. Cytologic findings with histologic correlation are presented to emphasize the subtle cellular features of these uncommon lesions.

Airway blood flow distribution and lung edema after histamine infusion in awake sheep

The present study was designed to evaluate the distribution of bronchial blood flow to major airways and peripheral lung and to quantitate lung edema during a 2-h histamine infusion (2 micrograms.kg-1.min-1) in unanesthetized sheep. By the use of radioactive microspheres, the blood flow to trachea and to tracheal cartilage, smooth muscle, and mucosa/submucosa was determined along with measurements of blood flow to different sized airway segments and the systemic blood flow to lung parenchyma. Histamine greatly increased blood flow to medium-sized (5- to 10-mm-diam) central airways in which blood flow increased 5-10 times base line, whereas in small (1- to 5-mm-diam) central airways the increase was 10-15 times. Blood flow in tracheal mucosa/submucosa increased six times base line, but in tracheal smooth muscle the increase was only three times base line, and in cartilage it remained at base line. Most of the systemic blood flow to the lung perfuses less than 1-mm-diam peripheral airways, and these airways demonstrated less vasodilation during histamine infusion. Mean blood flow to whole-lung parenchyma (whole lung minus trachea) was only two times base line during histamine infusion. Water content of trachea and main stem bronchi was significantly increased after histamine. Histopathologic findings after histamine infusions included congestion and edema of airways with only minor effects noted in alveoli. We conclude that histamine is a potent and selective vasodilator of bronchial vessels and particularly affects blood flow to central airways and to airway mucosal/submucosa.(ABSTRACT TRUNCATED AT 250 WORDS)