More-than-minimal-trauma fractures are associated with low bone density: an 8-year prospective study

Few studies have examined the relationship between more-than-minimal-trauma fractures and bone density. This study demonstrated that more-than-minimal-trauma fractures are associated with lower bone density similar to that seen in minimal trauma fractures. Men and women over 50 years with a more-than-minimal-trauma fracture should be investigated to exclude low bone density.

INTRODUCTION

The aim of this study was to assess the prevalence and predictors of low bone density in men and women with more-than-minimal-trauma fractures.

METHODS

In an Australian hospital, 630 community-dwelling men and women, 20 years of age or older, sustained a fracture due to more-than-minimal-trauma (force greater than a fall from standing height but less than high trauma). We studied 349 individuals who agreed to have a bone mineral density (BMD) scan. These participants were compared with 472 men and women with minimal trauma fractures.

RESULTS

Men and women with more-than-minimal-trauma fractures had significantly lower bone density than expected for their age, gender and weight (Z-score_spine = -0.4 SD, 95 % confidence interval (CI), -0.5 to -0.3; Z-score_hip = -0.5 SD, 95 % CI, -0.6 to -0.4). Almost 1 in 4 of those over 50 years of age had osteoporosis by BMD criteria. The independent predictors of low bone density (T-score <-2.0 SD) were age equal to or over 50 years (odds ratio (OR) = 5.97, 95 % CI, 3.34 to 10.65), low body weight <20 kg/m² (OR = 3.44, 95 % CI, 1.32 to 8.94), a prior minimal trauma fracture (OR = 2.76, 95 % CI, 1.17-6.52) and in those over 50 years of age, an osteoporosis-associated condition (OR = 4.51, 95 % CI, 1.69 to 12.06). Men and women with more-than-minimal-trauma fractures had similar bone density (Z-score) compared to those with minimal trauma fractures.

CONCLUSIONS

Men and women over 50 years with a more-than-minimal-trauma fracture, especially those with low body weight, prior minimal trauma fracture or an osteoporosis-associated condition, should be investigated to exclude low bone density and its associated risk of subsequent fractures.

Surgical approaches to pancreatic cancer

Pancreatic cancer continues to be a significant health problem. Recent advances in medical technologies allow patients with pancreatic cancer to undergo diagnosis, staging, treatment, and palliation, and to minimize the traditional use of laparotomy as a method of obtaining information to facilitate treatment planning. Pancreatic surgery, which can impact duration and quality of life, can be reserved for that subset of patients likely to benefit from a surgical approach tailored to the specific needs of the individual patient.

Cost and utilization impact of a clinical pathway for patients undergoing pancreaticoduodenectomy

BACKGROUND

When implemented in several common surgical procedures, clinical pathways have been reported to reduce costs and resource utilization, while maintaining or improving patient care. However, there is little data to support their use in more complex surgery. The objective of this study was to determine the effects of clinical pathway implementation in patients undergoing elective pancreaticoduodenectomy (PD) on cost and resource utilization.

METHODS

Outcome data from before and after the development of a clinical pathway were analyzed. The clinical pathway standardized the preoperative outpatient care, critical care, and postoperative floor care of patients who underwent PD. An independent department determined total costs for each patient, which included all hospital and physician costs, in a blinded review. Outcomes that were examined included perioperative mortality, postoperative morbidity, length of stay, readmissions, and postoperative clinic visits.

RESULTS

From January, 1996 to December, 1998, 148 consecutive patients underwent PD or total pancreatectomy; 68 before pathway development (PrePath) and 80 after pathway implementation (PostPath). There were no significant differences in patient demographics, comorbid conditions, underlying diagnosis, or use of neoadjuvant therapy between the two groups. Mean total costs were significantly reduced in PostPath patients compared with PrePath patients ($36,627 vs. $47,515; P = .003). Similarly, mean length of hospital stay was also significantly reduced in PostPath patients (13.5 vs. 16.4 days; P = .001). The total cost differences could not be attributed solely to differences in room and board costs. Cost and length-of-stay differences remained when outliers were excluded from the analysis. Despite these findings, there were no significant differences between PrePath and PostPath patients in terms of perioperative mortality (3% vs. 1%), readmissions within 1 month of discharge (15% vs. 11%), or mean number of clinic visits within 90 days of discharge (3.3 vs. 3.4 visits).

CONCLUSIONS

The establishment of a clinical pathway for PD patients dramatically reduced costs and resource utilization without any apparent detrimental effect on quality of patient care. These findings support the implementation of clinical pathways for PD patients, as well as investigation into pathway care for other complex surgical procedures.

A biomechanical comparison of the Z step-cut and basilar crescentic osteotomies of the first metatarsal

The basilar crescentic osteotomy is a popular procedure for the correction of moderate to severe hallux valgus deformity. Dorsiflexion due to malposition of the osteotomy, fixation failure, or late contracture of the soft tissues can lead to lateral metatarsalgia. This study compares the mechanical properties of the Z step cut osteotomy Scarff to those of the crescentic osteotomy in cantilever-bending. The ultimate load, maximum bending moment and energy absorbed were significantly greater for the Scarff osteotomy compared to those in the crescentic osteotomy (p < 0.001). Values for stiffness did not differ between the two osteotomies. Failure of the cortical bone-bridge between the screw-hole and the osteotomy was observed in all crescentic osteotomies, while fracture of the proximal dorsal bridge was seen in all Scarff osteotomies.

Relative contributions of technetium Tc 99m sestamibi scintigraphy, intraoperative gamma probe detection, and the rapid parathyroid hormone assay to the surgical management of hyperparathyroidism

HYPOTHESIS

Technetium Tc 99m sestamibi scintigraphy, intraoperative gamma probe detection, and the rapid parathyroid hormone assay have been used to permit a directed operation in patients with hyperparathyroidism. We hypothesized that the coordinated use of these techniques might be particularly useful in patients who require a second operation for hyperparathyroidism.

DESIGN

Retrospective analysis was performed to determine the specific contribution of these technologies to the surgical management of patients with hyperparathyroidism who underwent evaluation by at least 2 of these techniques between April 1996 and October 1999.

SETTING

Patients were evaluated and treated by an endocrine tumor surgery group within a tertiary care referral center.

PATIENTS

Coordinated application of 99mTc-sestamibi scintigraphy, intraoperative gamma probe detection, and/or the rapid parathyroid hormone assay was performed in 32 patients.

RESULTS

Twenty-eight of 32 patients had primary hyperparathyroidism, 3 had multiple endocrine neoplasia type 1, and 1 had secondary hyperparathyroidism. The surgical procedure was an initial cervical exploration in 19 and a second operative procedure in 13. Parathyroidectomy was successful in all patients. A directed anatomic operation was performed in 24 patients, including 11 patients who underwent second operative procedures and 9 patients who underwent minimally invasive procedures under local anesthesia. A directed operation was facilitated by sestamibi scan in 22 of 24 patients, intraoperative gamma probe detection in 5 of 23 patients, and the rapid parathyroid hormone assay in 15 of 15 patients.

CONCLUSIONS

Coordinated application of 99mTc-sestamibi scintigraphy, intraoperative gamma probe detection, and the rapid parathyroid hormone assay allows for successful directed reoperative parathyroidectomy; a minimally invasive procedure may be performed in selected patients.

Screening for MEN1 mutations in patients with atypical endocrine neoplasia

BACKGROUND

Most patients from typical multiple endocrine neoplasia type 1 (MEN1) kindreds harbor mutations in the MEN-1 gene, MEN1. We hypothesized that some patients with atypical endocrine neoplasia would also have mutations in MEN1.

METHODS

DNA sequencing analysis of mutations in the coding region of MEN1 was performed with genomic DNA obtained from peripheral blood lymphocytes in a total of 21 patients who had: typical MEN1 (n = 8), clinical features suggestive of MEN1 but without a family history of endocrinopathy (n = 7), and atypical endocrine neoplasia and a family history of endocrinopathy suggestive of MEN1 (n = 6).

RESULTS

All 8 patients with typical MEN1 had mutations in MEN1. None of the 7 patients with features of MEN1, but without a family history of endocrinopathy, had a MEN1 mutation. In contrast, 4 of 6 patients with atypical endocrine neoplasia that included components of MEN1 and a family history of endocrinopathy had mutations in MEN1, including 2 patients with pheochromocytoma.

CONCLUSIONS

Genomic mutations in MEN1 may frequently be identified in patients with atypical endocrine neoplasia, especially in the setting of a family history of endocrinopathy. Atypical presentations of MEN1 may include pheochromocytoma.

Stereological estimation of the total number of neurons in the murine hippocampus using the optical disector

Using a stereological method, the optical disector, we examined three inbred strains of mice (NZB/BINJ, DBA/2, and C57BL/6J) for morphological differences in volume, neuronal number, and density of the pyramidal cell and dentate gyrus granule cell layers of the hippocampus. We found significant differences in volume and neuronal number for both regions between the three strains at 9 weeks of age, but only modest differences in neuronal density. The left dentate volume was 90% larger in the NZB strain and 70% greater in the DBA strain (P<0.0001), and the left pyramidal cell layer was 144% larger in the NZB strain and 150% larger in the DBA strain, than in the B6 strain (P<0.0001). Neuron number in the left dentate was 81% greater in NZB and 37% greater in DBA (P<0.001), and in the left pyramidal cell layer 118% greater in the NZB and 92% greater in the DBA (P<0.01). Differences in neuronal density of the left dentate were not significant (P = 0.060, ns). For the left pyramidal cell layer, neuronal density was 14% greater in B6 and 34% greater in NZB than the DBA strain (P = 0.016). No significant differences were found in left-right laterality, or according to sex. We found that strain accounted for 60% of the variance in hippocampal volume and 44% of neuron number. These differences thus mainly reflect genetic variation in hippocampal volume and may have important implications for brain evolution, behaviour, and human diseases where hippocampal degeneration is involved.

Pre-operative assessment for ophthalmic patients

This article discusses the role of pre-operative assessment for ophthalmic patients and outlines the role nurses can play in patients' preparation for day surgery.

Prospective, randomized trial of octreotide to prevent pancreatic fistula after pancreaticoduodenectomy for malignant disease

OBJECTIVE

This study was conducted to determine whether the perioperative administration of octreotide decreases the incidence of pancreatic anastomotic leak after pancreaticoduodenectomy for malignancy.

SUMMARY BACKGROUND DATA

Three multicenter, prospective, randomized trials concluded that patients who receive octreotide during and after pancreatic resection have a reduction in the total number of complications or a decreased incidence of pancreatic fistula. However, in the subset of patients who underwent pancreaticoduodenectomy for malignancy, either no analysis was performed or no benefit from octreotide could be demonstrated.

METHODS

A single-institution, prospective, randomized trial was conducted between June 1991 and December 1995 involving 120 patients who were randomized to receive octreotide (150 microg subcutaneously every 8 hours through postoperative day 5) or no further treatment after pancreaticoduodenectomy for malignancy. The surgical technique was standardized, and the pancreaticojejunal anastomosis was created using the duct-to-mucosa or invagination technique.

RESULTS

The two patient groups were similar with respect to patient demographics, treatment variables, and histologic diagnoses. The rate of clinically significant pancreatic leak was 12% in the octreotide group and 6% in the control group (p = 0.23). Perioperative morbidity was 30% and 25%, respectively. Patients who underwent reoperative pancreaticoduodenectomy had an increased incidence of pancreatic anastomotic leak, whereas those who received preoperative chemoradiation had a decreased incidence of pancreatic anastomotic leak.

CONCLUSIONS

The routine use of octreotide after pancreaticoduodenectomy for malignancy cannot be recommended.