Survival bias may explain the appearance of the obesity paradox in hip fracture patients

Patients with low-energy hip fractures do not follow the obesity paradox as previously reported. In datasets where injury mechanism is not available, the use of age >50 years (as opposed to commonly used >65 years) as a surrogate for a low-energy hip fracture patients may be a more robust inclusion criterion.  PURPOSE: In elderly patients with a hip fracture, limited data suggests that obese patients counterintuitively have improved survival compared to normal-weight patients. This "obesity paradox" may be the byproduct of selection bias. We hypothesized that the obesity paradox would not apply to elderly hip fracture patients.

METHODS

The National Surgical Quality Improvement Project dataset identified 71,685 hip fracture patients ≥50 years-of-age with complete body mass index (BMI) data that underwent surgery. Patients were stratified into under and over 75-year-old cohorts (n=18,956 and 52,729, respectively). Within each age group, patients were stratified by BMI class and compared with respect to preoperative characteristics and 30-day mortality. Significant univariate characteristics (p<0.1) were included in multivariate analysis to determine the independent effect of obesity class on 30-day mortality (p<0.05).

RESULTS

Multivariate analysis of <75-year-old patients with class-III obesity were more likely to die within 30-days than similarly aged normal-weight patients (OR 1.91, CI 1.06-3.42, p=0.030). Multivariate analysis of ≥75-year-old overweight (OR 0.69, CI 0.62-0.77, p<0.001), class-I obese (OR 0.62, CI 0.51-0.74, p<0.001), or class-II obese (OR=0.69, CI 0.50-0.95, p=0.022) patients were less likely to die within 30-days when compared to similarly aged normal-weight patients.

CONCLUSIONS

Our data suggest that obesity is a risk factor for mortality in low-energy hip fracture patients, but the appearance of the "obesity paradox" in elderly hip fracture patients results from statistical bias that is only evident upon subgroup analysis.

Chronic candida endophthalmitis as a cause of intermediate uveitis

Intermediate uveitis is a subset of intraocular inflammation where vitritis is the most consistent sign, with or without snowball opacities or snow banks over the pars plana. Some patients will have an associated underlying systemic disease such as sarcoidosis, multiple sclerosis, ocular tuberculosis, inflammatory bowel disease, possibly Behçet's disease and intraocular lymphoma, whereas some will be classified as pars planitis in case of the lack of an identifiable systemic disease association. Our patient, a 47-year-old woman, developed intermediate uveitis after cataract surgery in her right eye, was misdiagnosed as pars planitis, and received steroid monotherapy for 8 months. Her inflammation only fully resolved after vitrectomy with removal of the intraocular lens (IOL) and capsular bag. Oral fluconazole and intravitreal amphotericin B injection had failed to resolve her inflammation when Candida albicans was identified as the cause of her persistent intermediate uveitis.

Integrated management of childhood illness in Lahej, Yemen: a qualitative analysis from the perspective of health providers

Health providers' perceptions about the Integrated Management of Childhood Illness (IMCI) in Lahej governorate, Yemen, were explored in a qualitative analysis of 12 in-depth interviews in 2007. The following themes emerged: appreciation of clinical aspects of IMCI but unclear about community IMCI; IMCI working better in peripheral than central health facilities; inflexible rules; lack of integration of services; poor supervision; multiple roles for one person; success of immunization; basic equipment and drug supplies deficient; conflicting views about health committees and community participation; and solutions for community health problems. After 4 years of IMCI experience in Yemen, the gaps identified would endanger the positive influence of IMCI unless action is undertaken at different levels.

Complete clinical responses to neoadjuvant chemotherapy for uterine serous carcinoma

Three cases of serous carcinoma of the uterus with radiographically documented widespread metastases are presented. Following confirmation of histopathology, all were treated with a standard regimen of carboplatin and paclitaxel for eight courses with complete resolution of distant metastases on CT scan prior to postchemotherapy surgical exploration. Two patients had gross disease at laparotomy, and one had only microscopic tumor found in the uterine specimen. This experience offers rationale for treatment of patients with widely metastatic uterine serous carcinoma or other relative contraindications to surgery with primary carboplatin and paclitaxel. In addition, we believe this experience supports the hypothesis that this regimen may result in prolonged disease-free survival when employed as postsurgical adjuvant therapy.

Aortoduodenal fistula. Two case reports and a review of the literature

Aortoduodenal fistulas (ADF) are relatively rare causes of fatal exsanguination. They occur predominantly in the third and fourth parts of the duodenum. Symptoms of ADF consist of flank or abdominal pain, hematemesis, melena, and an abdominal mass. We report two fatal cases of ADF, one of which includes the afferent loop of a Billroth II anastomosis, an event previously unrecognized, as well as a more conventional case of ADF, involving the third portion of the duodenum.

Multiple primary neoplasms. Ovarian carcinoid tumor, mucinous cystadenoma of low malignant potential tumor of left ovary, and adenocarcinoma of the colon

We describe a case of primary left ovarian carcinoid tumor with metastases to the right paraovarian tissue, left fallopian tube, the right lung, omentum, cul-de-sac, pericolonic fat, and, most likely, metastasis to the contralateral ovary, as well as a simultaneous left ovarian mucinous cystadenoma of low malignant potential and a well-differentiated colonic adenocarcinoma. Primary ovarian carcinoids are almost always unilateral. Metastases from such tumors to the lung and adrenal gland are very rare. To our knowledge, no such combination of all the above tumors has been reported.

p53, retinoblastoma gene product, and cyclin protein expression in human papillomavirus virus DNA-positive cervical intraepithelial neoplasia and invasive cancer

Human papillomavirus interacts with cyclin protein and tumor suppressor genes, p53, and retinoblastoma gene (Rb). Expression of these gene products was examined in 69 formalin-fixed, paraffin-embedded cervical biopsies by immunohistochemistry utilizing antibodies against p53, Rb, and proliferating cell nuclear antigen (PCNA) and by human papillomavirus DNA in-situ hybridization assays. Samples selected for this study included 27 normal/reactive atypia cases that were all human papillomavirus DNA in-situ hybridization negative, 37 cervical intraepithelial neoplasia (CIN) lesions, and 5 invasive carcinomas. The CIN and invasive carcinoma cases were all human papillomavirus DNA in-situ hybridization positive. p53 protein expression was detected in approximately one-third of the reactive atypia and CIN lesions and in 60% of invasive cancers. Neither the amount or the location of p53 staining was correlated with the histologic diagnosis. Rb staining was more frequently found in the CIN/invasive carcinoma cases compared to the normal/reactive atypia samples (39/42 [93%] versus 21/27 [78%], respectively; P < 0.05 by chi 2. PCNA staining was detected in virtually all samples tested. However, the location of both PCNA and Rb staining differed when the normal/reactive atypia cases were compared to the CIN cases. Only 10% of the former group demonstrated Rb staining throughout the basal two-thirds layer or full thickness of the epithelium compared with 65% of the latter group (P < 0.001 by chi2). Likewise, PCNA staining of the basal two-thirds or full-thickness of the epithelium was found in only 58% of normal/reactive atypia cases, but in 97% of the CIN group (P < 0.001). Our results suggest that the location of Rb and PCNA staining is quite different between normal/reactive atypia cervical biopsies and CIN lesions.

A survey of blood transfusion practices of gynecologic oncologists

OBJECTIVE

To survey the attitudes of gynecologic oncologists about indications for blood transfusion, and compare them to current recommendations about transfusion practice.

METHODS

With the permission of the Society of Gynecologic Oncologists (SGO), a study questionnaire was mailed to 548 members and candidates in their directory. The questions asked about transfusion threshold before chemotherapy, following ovarian debulking, and after endometriosis surgery. Indications for transfusion were assessed using a qualitative/quantitative scale. Responses were analyzed with respect to years of SGO membership and practice setting using the chi 2 test and analysis of variance. Results were compared to the 1992 guidelines for transfusion of the American College of Physicians (ACP).

RESULTS

Two hundred eighty-five forms were returned (52% of total). Fifty-one percent of respondents were in full-time academic positions; 36% were in private practice. Sixty-one percent were full SGO members, and 35% were candidates. The average prechemotherapy transfusion threshold (TT) was a hemoglobin concentration (hgb) of 7.9 +/- 0.7 g/dl (g). At that level the mean transfusion was 1.9 +/- 0.5 units of packed red blood cells (U). For the ovarian debulking scenario, the mean postoperative TT was 8.1 +/- 0.8 g with a mean transfusion of 1.9 +/- 0.4 U. For the endometriosis case, the mean TT was 7.0 +/- 0.8 g, with a mean transfusion of 1.9 +/- 0.5 U. Analysis showed no difference in practice based on years of SGO membership or practice setting.

CONCLUSION

A majority of the gynecologic oncologists surveyed offers transfusion at levels of anemia similar to ACP recommendations, but frequently transfuse more units than recommended. A substantial minority does not follow the guidelines at all.

Identification of human T cell leukemia/lymphoma virus type I antibodies, DNA, and protein in patients with polymyositis

OBJECTIVE

To investigate a possible association between human T cell leukemia/lymphoma virus type I (HTLV-I) and polymyositis (PM).

METHODS

Sera and muscle biopsy samples from 9 Jamaican PM patients were compared with specimens from American HTLV-I-positive PM patients and normal controls. Sera were evaluated for HTLV antibodies by enzyme-linked immunosorbent assay and Western blot. The biopsy samples were analyzed for HTLV-I/II DNA by polymerase chain reaction and were also immunohistochemically stained for HTLV gp46 envelope protein.

RESULTS

Seven of the 8 Jamaican PM patients from whom sera were available were HTLV-I seropositive. The muscle biopsies of all 9 Jamaican patients demonstrated severe lymphocytic infiltration, cellular degeneration, myofiber atrophy, and fibrosis. Each muscle biopsy specimen contained HTLV-I DNA. Two of 6 samples demonstrated intense staining for HTLV-I gp46 in many of the invading mononuclear cells and weak staining for HTLV-I gp46 in many of the invading mononuclear cells and weak staining in the adjacent myocytes. Two other specimens were weakly positive for gp46 in rare mononuclear cells. All control specimens were negative for the presence of HTLV-I DNA and protein.

CONCLUSION

HTLV-I is associated with an inflammatory muscle disease characterized by direct invasion of the affected muscle by HTLV-I-infected mononuclear cells.

Prostate biopsy in patients after proctectomy

Until the discovery of prostate specific antigen as a tool to detect prostate carcinoma, the rectum has always been necessary to allow the best evaluation and biopsy of the prostate, whether by digital examination or transrectal ultrasound. We describe a simple, accurate, computerized tomography-guided method to biopsy the prostate in men who have undergone proctectomy.

Virucidal efficacy of various lens cleaning and disinfecting solutions on HIV-I contaminated contact lenses

The virucidal efficacy of various commercially available contact lens care cleaning regimens on human immunodeficiency virus (HIV-1) contaminated contact lenses using either cursory or meticulous cleaning with a rubber policeman was evaluated. Levels of infectious HIV-1 remaining on individual contact lenses were determined by cultivating the lenses with target HUT-78 cells and subsequently analyzing the cultures for the production of HIV-1 p24 by antigen capture and for HIV-1 gag gene DNA content by the polymerase chain reaction. The data indicate that most of the lens care regimens tested, when coupled with meticulous rubbing, were capable of safely decontaminating the contact lenses, that is, they reduce the amount of infectious HIV-1 on the lenses by greater than a 10 log concentration (10(-10], relative to standard controls. Most tested lens care regimens, if properly followed, would virtually eliminate any chance of the lens serving as a vector for HIV.

Endocrine crises. Hypoglycemia

Hypoglycemia is defined as the occurrence of a wide variety of symptoms in association with a plasma glucose level of 40 mg/dL or less. The conditions associated with hypoglycemia in hospitalized patients include exogenous insulin administration, ethanol, drugs (especially chlorpropamide), renal insufficiency, liver disease, infections, total parenteral nutrition, treatment of hyperkalemia with insulin, extensive burns, neoplasia, pregnancy, and a wide variety of less common causes. Although clinical features are helpful in making a diagnosis, a significant proportion of the patients are either asymptomatic or present with symptoms of altered mental status. The diagnosis of hypoglycemia should be considered in all hospitalized patients presenting with adrenergic or neuroglycopenic symptoms and signs suggestive of hypoglycemia. A detailed history along with a physical examination and appropriate laboratory investigations usually identify the specific cause of the hypoglycemia. An episode of hypoglycemia, especially if severe, should be treated with prolonged intravenous infusion of glucose. Prompt recognition and management of hypoglycemia are necessary to prevent significant morbidity and mortality.

Phosphoinositide turnover in human platelets is stimulated by albumin

The effect of human serum albumin (HSA) on the hydrolysis of phosphatidylinositides in human platelets labeled with myo(3H)inositol was studied. Incubation of platelets with HSA (4 gm/dl) for 10 seconds increased IP2, and IP3, by 169% and 217% respectively. 93% of IP3 accumulated within the first 10 seconds. This effect was also shared by bovine serum albumin, although no changes in IP3 levels occurred with ovalbumin. All albumin species used induced 45Ca+2 release from platelets irrespective of its effect on IP3 accumulation. These findings indicate that albumin may function in biological systems by inducing intracellular signaling.

Detection of L-forms of Neisseria gonorrhoeae in pure and mixed culture suspensions by an enzyme immunoassay

An enzyme immunoassay (EIA) (Gonozyme, Abbott Laboratories, Chicago, IL) was evaluated for its ability to detect L-forms of Neisseria gonorrhoeae in pure and mixed culture suspensions. A total of 15 L-form strains that were induced from fresh clinical isolates of N. gonorrhoeae on an L-form medium were tested by EIA at antigen levels equivalent to those found in 2 X 10(5), 3 X 10(4), and 2 X 10(3) parental cells per milliliter. The results showed the sensitivity of the EIA for L-forms and parental cells to be the same, exhibiting positive results in all pure culture suspensions of parental cells at 2 X 10(5) and 3 X 10(4) cells per milliliter and their corresponding L-form preparations. At 2 X 10(3) cells per milliliter, three parental and two of their respective L-form preparations yielded positive EIA results. Incorporation of a mixture of heterologous organisms that can be found in the normal human genital flora, each at a concentration of 1 X 10(7) cells per milliliter into the L-form preparations, did not affect the sensitivity of the EIA for detection of L-forms. The results of the present study indicate that the EIA is an equally sensitive method for detecting gonococcal L-forms and parental cells. A further study, however, is needed to ascertain its usefulness under actual clinical conditions.