Postoperative blood transfusion strategy in frail,anemic elderly patients with hip fracture

Background and purpose — Hip fracture (HF) in frail elderly patients is associated with poor physical recovery and death. There is often postoperative blood loss and the hemoglobin (Hb) threshold for red blood cell (RBC) transfusions in these patients is unknown. We investigated whether RBC transfusion strategies were associated with the degree of physical recovery or with reduced mortality after HF surgery.

Patients and methods — We enrolled 284 consecutive post-surgical HF patients (aged ≥ 65 years) with Hb levels < 11.3 g/dL (7 mmol/L) who had been admitted from nursing homes or sheltered housing. Allocation was stratified by residence. The patients were randomly assigned to either restrictive (Hb < 9.7 g/dL; < 6 mmol/L) or liberal (Hb < 11.3 g/dL; < 7 mmol/L) RBC transfusions given within the first 30 days postoperatively. Follow-up was at 90 days.

Results — No statistically significant differences were found in repeated measures of daily living activities or in 90-day mortality rate between the restrictive group (where 27% died) and the liberal group (where 21% died). Per-protocol 30-day mortality was higher with the restrictive strategy (hazard ratio (HR) = 2.4, 95% CI: 1.1–5.2; p = 0.03). The 90-day mortality rate was higher for nursing home residents in the restrictive transfusion group (36%) than for those in the liberal group (20%) (HR = 2.0, 95% CI: 1.1–3.6; p = 0.01).

Interpretation — According to our Hb thresholds, recovery from physical disabilities in frail elderly hip fracture patients was similar after a restrictive RBC transfusion strategy and after a liberal strategy. Implementation of a liberal RBC transfusion strategy in nursing home residents has the potential to increase survival.     

Perception of sexuality and fertility in women living with HIV: a questionnaire study from two Nordic countries

Introduction

As the human immunodeficiency virus (HIV)-positive population ages, issues concerning sexuality and fertility, among others, are becoming relevant. HIV is still surrounded by stigma and taboos, and there have been few studies conducted in industrialized settings concerning these questions. We therefore wanted to investigate the perception of sexuality and fertility in women living with HIV (WLWH) in an industrialized setting, using a questionnaire.

Methods

WLWH were recruited at their regular outpatient clinic visits, at the major Departments of Infectious Diseases in Denmark and Finland, from January 2012 to October 2013. A questionnaire was developed, study participants were informed of the nature of study and, if they agreed to participate and signed a consent form, they filled in the questionnaire. Demographic information on the participants was obtained from patient files (in Finland) or from a national HIV cohort (in Denmark). Statistical analysis was performed using STATA^®, version 11.

Results

In total, 560 women were included in the study. The median age was 44 years. The majority were of white European origin, with fully suppressed HIV viral load, CD4 cell count >350 µL and mild or no symptoms of their HIV infection. A total of 62% were sexually active, stating condom use as their sole form of contraception. Of the sexually inactive women, one-third were in steady relationships. Eighty percent reported prior pregnancies, of which the majority had one or more children. Most children were born prior to the women''s HIV diagnosis and the mode of conception was predominantly natural. One-quarter of the participating women desired pregnancy, while more than half did not. The remaining quarter either stated that they already had the desired number of children or chose not to answer the question. Fourteen percent stated that their HIV diagnosis ended their wish for children; of these women, the median time of diagnosis was between 1995 and 1996. Pregnancy had been attempted unsuccessfully in one-quarter of study participants. The final question inquired what the risk of mother-to-child transmission was, with all precautions taken. Fifteen percent estimated the risk to be above two percent.

Conclusions

In conclusion, the majority of WLWH in industrialized settings in Denmark and Finland have few HIV-related symptoms, are sexually active and have a strong desire for children.     

Treatment of severe temporomandibular joint clicking with botulinum toxin in the lateral pterygoid muscle in two cases of anterior disc displacement

A novel treatment procedure is introduced for severe clicking of the temporomandibular joint (TMJ) associated with anterior disc displacement (ADD), using injections with botulinum toxin (BTX-A) in the lateral pterygoid muscle (LP). It has been suggested that ADD may be caused, precipitated, or maintained by LP activity, but the role of the LP in the dynamics of the TMJ clicking is uncertain. The case report includes 2 women, followed with clinical examinations, TMJ imaging, and electromyography (EMG), in whom local anesthetics in the LP could abolish the clicking for several days. BTX-A block of the LP (30 U Botox, given twice under EMG guidance with 6-month interval) temporarily reduced the action of the muscle, but the clicking was permanently eliminated and did not return during the observation period of 1 year, and a small but distinctive positional improvement in the disc-condyle relationship was obtained. However, the precise mechanisms behind the favourable treatment outcome are unclear.     

Gingival blood flow in periodontitis patients before and after periodontal surgery assessed in smokers and non-smokers

BACKGROUND: The aim of this study was to evaluate the gingival blood flow of smokers and non-smokers with periodontal disease before and after surgical periodontal treatment. METHODS: Nine smokers and six non-smokers with at least two periodontal lesions were included in the study. Laser Doppler flowmetry was used to measure blood flow in two gingival sites and two skin sites. Two intrabony defects were treated surgically at the same time; enamel matrix derivative was applied at random to one of the sites, whereas the other site received a placebo gel. We measured resting gingival blood flow (GBF) and responses to cold pressor test (CPT) and to smoking and made continuous measurements of blood pressure (BP). Resting GBF levels of 26 young healthy subjects were used as a reference value. RESULTS: Resting GBF was significantly lower for the periodontitis patients compared to the reference subjects, regardless of smoking habits. GBF and gingival vascular conductance (VC) decreased significantly pre- and postoperatively in response to smoking. CPT evoked significant decreases in VC in smokers and non-smokers. Skin blood flow decreased significantly in response to CPT, more so in the non-smokers. BP was significantly higher in the non-smokers. CONCLUSIONS: Resting GBF of periodontitis patients was not lower in smokers than in non-smokers, but it was significantly lower than in the younger reference subjects. In contrast to our earlier findings in healthy subjects, smoking one cigarette may cause a decrease in GBF and VC in periodontitis patients. These observations suggested the existence of a dysfunction in the gingival vasculature in smokers and non-smokers with periodontitis.     

Prevalence of malocclusion in mentally retarded young adults

Occlusal anomalies were recorded in 218 mentally retarded young adults, aged 13-19 yr. Down's syndrome was diagnosed in 37 cases. Among the Down's syndrome individuals 41% had mandibular overjet, 54% mesial molar occlusion, 38% frontal open bite and 65% crossbite. Also, the mentally retarded subjects without Down's syndrome had markedly increased frequencies of some of the anomalies when compared to normal individuals. Thus, 27% had extreme maxillary overjet, 6% mandibular overjet, 17% mesial molar occlusion, 23% frontal open bite and 29% crossbite. Orthodontic dental service for the mentally retarded has been neglected for a long time. Though many factors may contraindicate treatment, it should in many cases be possible to improve the dental situation for this group, thereby helping these patients to a better oral function.     

Molar bite force in relation to occlusion, craniofacial dimensions, and head posture in pre-orthodontic children

The present study examined bite force in relation to occlusion, craniofacial dimensions, and head posture. The sample comprised 88 children (48 girls, 40 boys) aged 7-13 years, sequentially admitted for orthodontic treatment of malocclusions entiling health risks. Bite force was measured in the molar region by means of a pressure transducer. Angle classification, number of teeth and contact in the intercuspal position (ICP) were recorded and dental arch widths were measured on plaster casts. Craniofacial dimensions and head posture were recorded from lateral cephalometric radiographs taken with the subject standing with their head in a standardized posture (mirror position). Associations were assessed by Spearman correlations and multiple stepwise regression analyses.The maximum bite force increased significantly with age in girls, with teeth in occlusal contact in boys, and with increasing number of erupted teeth in both genders. Bite force did not vary significantly between the Angle malocclusion types. Only in boys was there a clear correlation between bite force and craniofacial morphology: cranial base length (n-ba, n-ar), posterior face height (s-tgo, ar-tgo), vertical jaw relationship (NL-ML), mandibular inclination (NSL-ML), form (ML-RL) and length (pg-tgo), and inclination of the lower incisors (Ili-ML). Multiple regression analysis showed that the vertical jaw relationship (P < 0.001) and the number of teeth present (P < 0.01) were the most important factors for the magnitude of bite force in boys. In girls, the most important factor was the number of teeth present (P < 0.001). No correlations between bite force and head posture were found.