Frailty and Cause-Specific Hospitalizations in Community-Dwelling Older Men

OBJECTIVES

The types of medical conditions leading to hospitalization in frail older people have not been investigated. The objectives were to evaluate associations between frailty and (a) risk of all-cause and cause-specific hospitalization, and (b) rate of all-cause and cause-specific hospitalizations.

DESIGN, SETTING AND PARTICIPANTS

Community-dwelling men aged 70+ years in the Concord Health and Ageing in Men Project (CHAMP) were assessed for frailty at baseline (2005-2007, n=1705).

MEASUREMENTS

Frailty was determined by both the Fried frailty phenotype (FP) and the Rockwood frailty index (FI). Non-elective and elective hospitalization data were accessed from the New South Wales (NSW) Admitted Patient Data Collection and mortality from the NSW Deaths Registry for the period 2005-2017. Causes of hospitalization were categorized using ICD-10 classification of principal diagnoses based on organ system involved into 14 major categories.

RESULTS

Nearly 80% of CHAMP men had at least one non-elective hospitalization and 63% had an elective hospitalization over a 9-year follow-up. Men with FP frailty were twice as likely to have a non-elective hospitalization (HR: 1.98, 95%CI: 1.61-2.44) and a greater number of non-elective hospitalizations (IRR: 1.44, 95%CI: 1.22-1.70). Similar relationships were found between FI frailty and non-elective hospitalizations. Men with frailty (either FP or FI) were more likely to have at least one non-elective hospitalization for 13 of the 14 cause-related admissions. In contrast, frailty was only associated with 3 cause-related elective hospitalizations. Men with frailty were also more likely to have an increased number of non-elective hospitalizations for all 14 causes, but only for 6 causes of elective hospitalizations.

CONCLUSIONS

Our findings suggest frailty increases the risk and number of non-elective hospitalizations in older men for a wide range of cause. Strategies on early identification of frailty, followed by appropriate preventative strategies to lower the risk of non-elective hospital admissions are warranted.

Oral health of community-dwelling older Australian men: the Concord Health and Ageing in Men Project (CHAMP)

BACKGROUND

The Concord Health and Ageing in Men Project (CHAMP) is a cohort study of the health of a representative sample of Australian men aged 70 years and older. The aim of this report is to describe the oral health of these men.

METHODS

Oral health was assessed when the men were all aged 78 years or older. Two calibrated examiners conducted a standardized intraoral assessment. Descriptive data were analysed by statistical association tests. Participants were excluded from the collection of some periodontal assessments if they had a medical contraindication.

RESULTS

Dental assessments of 614 participants revealed 90 (14.6%) were edentate. Men had a mean of 13.8 missing teeth and 10.3 filled teeth. Dentate participants had a mean of 1.1 teeth with active coronal decay. Those in the low-income group had a higher rate of decayed teeth and lower rate of filled teeth. Thirty-four participants (5.5%) had one or more dental implants, and 66.3% relied on substitute natural teeth for functional occlusion. Of those with full periodontal assessments; 90.9% had sites with pocket depths of 3 mm or more, 96.6% had sites with CAL of 5 mm or more, and 79.7% had three or more sites with GI scores of 2 or more.

CONCLUSIONS

There was a high prevalence of periodontal diseases and restorative burden of dentitions, which suggests that greater attention needs to be given to prevention and health maintenance in older Australian men.

Engineering silicon crystals for photovoltaics

In this highlight, we review the recent engineering efforts in the state-of-the art industrial production of customized silicon crystals, including quasi-mono and multi-crystalline silicon (mc-Si).

A comparison of the direct cost of care in an open-bay and single-family room NICU

OBJECTIVE

This research examined the proposition that the direct costs of care were no different in an open-bay (OPBY) as compared with a single-family room (SFR) neonatal intensive care (NICU) environment.

STUDY DESIGN

This was a sequential cohort study.

RESULT

General linear models were implemented using clinical and cost data for all neonates admitted to the two cohorts studied. Costs were adjusted to year 2007 U.S. dollars. Models were constructed for the unadjusted regression and subsequently by adding demographic variables, treatment variables, length of respiratory support and length of stay. With the exception of the last, none were found to achieve significance. The full model had R(2)=0.799 with P=0.0095 and predicted direct costs of care less in the SFR NICU.

CONCLUSION

For the time, location and administrative practices in place, this study demonstrates that care can be provided in the SFR NICU at no additional cost as compared with OPBY NICU.

Emergency physicians cannot inflate or estimate endotracheal tube cuff pressure using standard techniques

Study objectives: Tracheal necrosis and stenosis may result from an overinflated endotracheal tube cuff. Safe, appropriate pressure in endotracheal tube cuffs is considered to be between 15 and 25 cm H₂O, pressures below normal capillary perfusion pressure. We seek to determine the ability of emergency medicine residents and attending physicians in accredited emergency medicine residency training programs to inflate an endotracheal tube cuff to appropriate pressure using standard syringe technique and assess appropriateness of pressure of previously inflated endotracheal tube cuffs by palpating the pilot balloon.

Methods: This institutional review board–approved descriptive survey of resident and attending physicians in accredited emergency medicine residency training programs in New York City used a previously tested, tracheal simulation model with a 7.5-mm endotracheal tube with a high-volume low-pressure cuff (Mallinkrodt, St. Louis, MO). Using their choice of a 5-mL or 10-mL plastic syringe with standard Luer Lock (Beckton-Dickson, Franklin Lakes, NJ), participants inflated the endotracheal tube cuff by standard method of injecting air as they deemed appropriate in conjunction with palpating the pilot balloon to estimate cuff pressure. Subsequently, the endotracheal tube cuff pressure was measured using a highly sensitive and accurate analog manometer (Boehringer Laboratories, Norristown, PA). Later, participants palpated the pilot balloon of 9 endotracheal tubes with cuffs previously inflated to known pressures ranging from 0 to 120 cm H₂O and reported whether the pressure was low, appropriate, or high.

Results: Twenty-five resident physicians and 42 attending physicians from 5 emergency medicine residency training programs were surveyed. Only 0.4% (n=3) of participants inflated the cuff to a safe pressure; all were attending physicians. The average cuff pressure generated by emergency medicine attending physicians was greater than 98 cm H₂O (attending physicians >93 cm H₂O, residents >106 cm H₂O). The true mean could not be determined because 57% (n=38) inflated to pressures greater than the upper limit of manometer sensitivity (>120 cm H₂O). Using palpation, participants were only 33% sensitive detecting inappropriately inflated endotracheal tube cuffs (attending physicians 22% sensitive, residents 53% sensitive), and they were only 26% sensitive in detecting overinflated endotracheal tube cuffs (attending physicians 22%, residents 33%). Average experience as an attending emergency physician was 9 years; average experience as a resident was 2.1 years.

Conclusion: This group of emergency physicians had little ability to inflate an endotracheal tube cuff to safe pressure, little ability to accurately estimate pressure of a previously inflated cuff using standard technique, and minimal ability to detect overinflated endotracheal tube cuffs. Nearly all inflated the cuff to dangerously high pressures. Clinicians should consider using devices that permit safe and accurate inflation and measurement of endotracheal tube cuff pressure rather than relying on standard palpation technique, which is potentially unsafe and highly inaccurate.

Optical systems for in vivo molecular imaging of cancer

Progress toward a molecular characterization of cancer would have important clinical benefits; thus, there is an important need to image the molecular features of cancer in vivo. In this paper, we describe a comprehensive strategy to develop inexpensive, rugged and portable optical imaging systems for molecular imaging of cancer, which couples the development of optically active contrast agents with advances in functional genomics of cancer. We describe initial results obtained using optically active contrast agents to image the expression of three well known molecular signatures of neoplasia: including over expression of the epidermal growth factor receptor (EGFR), matrix metallo-proteases (MMPs), and oncoproteins associated with human papillomavirus (HPV) infection. At the same time, we are developing inexpensive, portable optical systems to image the morphologic and molecular signatures of neoplasia noninvasively in real time. These real-time, portable, inexpensive systems can provide tools to characterize the molecular features of cancer in vivo.

Use of antithymocyte globulin for treatment of steroid-refractory acute graft-versus-host disease: an international practice survey

Antithymocyte globulin (ATG) is accepted as a treatment option for steroid-refractory acute graft-versus-host disease (GVHD). We conducted an international survey to determine how steroid refractoriness is defined and how ATG is used in clinical practice. Responses were received from 153 centers in 36 countries. The most common threshold steroid dose to define steroid refractoriness was 2 mg/kg/day (67% of respondents), and the median duration of treatment before failure was declared varied from 3 to 5.5 days, depending on whether failure was defined as 'progressed', 'not improved' or 'not resolved'. The threshold corticosteroid dose was significantly higher in pediatric centers than in adult or combined programs (P = 0.003). ATG was used routinely for treatment of steroid-refractory GVHD by 67% of the respondents. Horse ATG was used more frequently than rabbit ATG overall (50% vs 24%, P < 0.001), and predominance of horse ATG was most evident in the western hemisphere, in small- to medium-sized centers, and in pediatric centers. A wide variety of dose schedules for both drugs was reported. We conclude that there is some degree of variation in the definition of steroid refractoriness, especially between pediatric and nonpediatric programs, and no consensus has emerged in identifying the optimal ATG dose schedule in this setting.

Identification of a novel receptor for B lymphocyte stimulator that is mutated in a mouse strain with severe B cell deficiency

BLyS (also called BAFF, TALL-1, THANK, and zTNF4), a TNF superfamily member, binds two receptors, TACI and BCMA, and regulates humoral immune responses [1-7]. These two receptors also bind APRIL [7-10], another TNF superfamily member. The results from TACI(-/-) and BCMA(-/-) mice suggest the existence of additional receptor(s) for BLyS. The TACI knockout gives the paradoxical result of B cells being hyperresponsive, suggesting an inhibitory role for this receptor [11, 12], while BCMA null mice have no discernable phenotype [13]. Here we report the identification of a third BLyS receptor (BR3; BLyS receptor 3). This receptor is unique in that, in contrast to TACI and BCMA, BR3 only binds BLyS. Treatment of antigen-challenged mice with BR3-Fc inhibited antibody production, indicating an essential role for BLyS, but not APRIL, in this response. A critical role for BR3 in B cell ontogeny is underscored by our data showing that the BR3 gene had been inactivated by a discrete, approximately 4.7 kb gene insertion event that disrupted the 3' end of the BR3 gene in A/WySnJ mice, which lack peripheral B cells.

Effect of sandblasting on the bond strength of the bondable molar tube bracket

This study examined the effect of surface treatment with sandblasting on bracket bonding strength. Extracted human tooth, base metal alloy and porcelain surfaces were treated with sandblasting. The bracket bonding strengths of sandblasted surfaces were evaluated and compared with the controls and etched enamel surfaces. Morphological observation of the treatment surfaces and the failure sites was conducted. Statistical analysis included one-way analysis of variance (ANOVA) and a Scheffe's F-test at the 95% confidence level was performed. The results indicated that mean bond strength values ranged from 3.6 MPa (the untreated control) to 20.4 MPa for the etched enamel surface. No statistically significant differences were determined among the etched enamel, sandblasted metal and sandblasted porcelain surfaces (P > 0.05). Most debonding specimens failed at either the resin-tooth interface or within the adhesive. In conclusion, sandblasting the metal and porcelain surfaces obtained a bracket bond strength comparable with that with the etched enamel surface.

Discrimination between NL1- and NL2-mediated nuclear localization of the glucocorticoid receptor

Glucocorticoid receptor (GR) cycles between a free liganded form that is localized to the nucleus and a heat shock protein (hsp)-immunophilin-complexed, unliganded form that is usually localized to the cytoplasm but that can also be nuclear. In addition, rapid nucleocytoplasmic exchange or shuttling of the receptor underlies its localization. Nuclear import of liganded GR is mediated through a well-characterized sequence, NL1, adjacent to the receptor DNA binding domain and a second, uncharacterized motif, NL2, that overlaps with the ligand binding domain. In this study we report that rapid nuclear import (half-life [t1/2] of 4 to 6 min) of agonist- and antagonist-treated GR and the localization of unliganded, hsp-associated GRs to the nucleus in G0 are mediated through NL1 and correlate with the binding of GR to pendulin/importin alpha. By contrast, NL2-mediated nuclear transfer of GR occurred more slowly (t1/2 = 45 min to 1 h), was agonist specific, and appeared to be independent of binding to importin alpha. Together, these results suggest that NL2 mediates the nuclear import of GR through an alternative nuclear import pathway. Nuclear export of GR was inhibited by leptomycin B, suggesting that the transfer of GR to the cytoplasm is mediated through the CRM1-dependent pathway. Inhibition of GR nuclear export by leptomycin B enhanced the nuclear localization of both unliganded, wild-type GR and hormone-treated NL1(-) GR. These results highlight that the subcellular localization of both liganded and unliganded GRs is determined, at least in part, by a flexible equilibrium between the rates of nuclear import and export.

Autoimmune hemolytic anemia, primary adrenal insufficiency, and the antiphospholipid syndrome

Autoimmune hemolytic anemia and adrenal insufficiency are rarely associated with the antiphospholipid antibody syndrome. A 49-year-old woman with a history of deep venous thrombosis and recurrent miscarriages was found to have active autoimmune hemolytic anemia after being admitted to the hospital for cholelithiasis. The patient was treated with corticosteroids and underwent laparoscopic cholecystectomy 1 month later. Two weeks after surgery she had acute adrenal insufficiency. Activated partial thromboplastin time was prolonged, and antiphospholipid antibodies were detected in significant titer. Her illness responded well to corticosteroid therapy. Her direct Coombs' test remained positive. It appears that the antiphospholipid antibody syndrome contributed to the development of venous thrombosis, recurrent miscarriages, autoimmune hemolytic anemia, adrenal insufficiency, and indirectly, pigment stone cholelithiasis in this patient.

Recurrent substernal nodular goiter: incidence and management

BACKGROUND

Surgery for recurrent multinodular goiter is associated with an increased risk of complications. When recurrence occurs in a substernal location, difficulties associated with surgical removal may be even more significant.

METHODS

Information relating to indications for surgery, procedure performed, pathologic findings, and surgical complications was obtained from a prospective thyroid surgery database maintained in our unit for the past 39 years.

RESULTS

During the study period 234 patients underwent operation for retrosternal recurrence of a nodular goiter. In the majority of cases (51%) the indication for surgery was the presence of compressive symptoms. In only four cases was a sternal split required to remove substernal recurrence. Complications occurred in 35 patients, including four permanent recurrent laryngeal nerve palsies. No patient had permanent hypoparathyroidism.

CONCLUSIONS

Surgery for recurrent substernal goiter, although technically demanding, can be performed with a minimum of morbidity if appropriate attention is paid to anatomy and embryology. A sternal split is only rarely required.

Cell death regulation during multistep lymphomagenesis

The three most common genetic abnormalities occurring in malignant lymphomas involve alterations resulting in the deregulated expression of the c-myc and bcl-2 oncogenes and the inactivation of the p53 tumor suppressor gene. Relevant strains of genetically engineered mice, including bcl-2-Ig and E mu-myc transgenic mice and p53 knockout mice, have been used to prospectively examine the regulation of apoptotic cell death by these genes, individually and in combination, and their contribution to in vivo lymphomagenesis. The potential importance of the therapeutic induction of apoptosis is discussed.

Evidence that c-myc mediated apoptosis does not require wild-type p53 during lymphomagenesis

Deregulation of c-myc, frequently implicated in oncogenesis, is associated with increased cell proliferation and also cell death. Similarly, the p53 tumor suppressor gene commonly mutated in human tumors, is known to induce apoptosis or cell cycle arrest in its wild-type conformation. Genetically altered mice simultaneously overexpressing c-myc and possessing a disrupted p53 gene were used to investigate whether c-myc mediated apoptosis requires wild-type p53. The accelerated development of malignant lymphomas in these mice was found to be a consequence of enhanced proliferation and not reduced apoptosis resulting from the synergistic effect of c-myc overexpression and p53 inactivation.

The functional basis of c-myc and bcl-2 complementation during multistep lymphomagenesis in vivo

Oncogenes are known to be deregulated by chromosomal translocations occurring at high frequency in specific malignancies. Among the most well characterized of these are c-myc, associated with the t(8;14) in Burkitt's lymphomas, and bcl-2, associated with the t(14;18) in follicular lymphomas. In addition to their role in regulating rates of proliferation, it is known that oncogenes and tumor suppressor genes can also regulate rates of apoptotic cell death. The contribution of c-myc and bcl-2 to the regulation of cell death during lymphomagenesis in vivo is assessed using bcl-2-Ig and emu-myc trangenic mice and bcl-2/myc hybrid transgenic mice. Translocations between the endogenous c-myc gene and immunoglobulin loci, e.g., t(12;15), are common in lymphomas arising in the bcl-2-Ig mice. Furthermore, bcl-2/c-myc double transgenic mice exhibit accelerated lymphomagenesis, indicating cooperation between these two oncogenes. Genetic complementation of c-myc and bcl-2 during lymphomagenesis resulted from the suppression of c-myc-associated apoptosis. Other genes are likely involved in regulating cell death during multistep lymphomagenesis.