Responses to Treatment With Teriparatide in Patients With Atypical Femur Fractures Previously Treated With Bisphosphonates

If oversuppression of bone turnover explained the association between bisphosphonate use and atypical subtrochanteric femur fractures (AFF), this could be reversed with anabolic treatment such as teriparatide. We conducted a prospective, open‐label study in patients previously treated with bisphosphonates who sustained AFF, examining the response to 24‐month treatment with teriparatide on bone mineral density (BMD), trabecular bone score (TBS), bone turnover markers (BTM), and fracture healing as well as quantitative histomorphometry. We studied 14 patients. Baseline BMD, BTM, and TBS varied widely. On initial bone biopsies, 12 of 14 patients showed tetracycline labels, but mineralizing surface/bone surface was below published normal values in all but 2. Lumbar spine BMD increased significantly at month 24 (6.1% ± 4.3%, p < 0.05 versus baseline), whereas total hip BMD and TBS did not change significantly. Changes in BTM occurred as reported previously for patients without AFF treated with teriparatide after prior bisphosphonate treatment. At month 24, fractures were healed in 6 patients, showed partial healing in 3, were unchanged in 2, and showed nonunion in 1. In a patient with two fractures, the fracture that occurred before teriparatide treatment was reported as healed, but the fracture that occurred while on treatment showed only partial healing. Bisphosphonate‐treated patients who sustain AFF show heterogeneity of bone turnover. Treatment with teriparatide resulted in increases in BTM and lumbar spine BMD, as has been reported for patients without AFF. There was no significant effect of teriparatide on hip BMD, mineralizing surface to bone surface (MS/BS), or TBS and no consistent effect on fracture healing. In the context of a patient who has experienced an AFF after receiving bisphosphonate treatment, therapy with teriparatide for 24 months would be expected to increase BMD and BTM (and probably reduce the risk of fractures resulting from osteoporosis) but should not be relied on to aid in healing of the AFF. © 2017 American Society for Bone and Mineral Research.     

Risk Factors With Intravenous Sedation for Patients With Disabilities

The purpose of this study was to identify the risk factors associated with low peripheral oxygen saturation (SpO₂) and delayed recovery of dental patients with disabilities after intravenous sedation. A total of 1213 patients with disabilities were retrospectively investigated with respect to demographic parameters and sedation conditions. Multivariate logistic analyses were conducted for patients with an SpO₂ <90% and a recovery period of >60 minutes to identify the risk factors for poor sedation conditions. A significant odds ratio related to decreased SpO₂ was observed for age, sex, midazolam and propofol levels, concurrent use of nitrous oxide, cerebral palsy, Down syndrome, and mental retardation. The most problematic patients were those diagnosed with Down syndrome (odds ratio, 3.003–7.978; 95% confidence interval; P < .001). Decision tree analysis showed an increased risk of decreased SpO₂ in males with Down syndrome or after administration of >0.493 mg/kg propofol in combination with midazolam. An increased risk of delayed awakening was seen in patients aged less than 21 years and in males administered >0.032 mg/kg of midazolam. Intravenous sedation for dental patients with disabilities, particularly those with cerebral palsy, Down syndrome, or mental retardation, increases the risk of decreased SpO₂. In addition, delayed recovery is expected after midazolam administration.Key Words: Dental sedation, Low peripheral oxygen saturation, Delayed recoveryDental practices are currently challenged by the rapidly growing number of patients with intellectual or physical disabilities.^1,2 Excessive mental strain during dental treatment can cause systemic complications such as vasovagal reflex, neurogenic shock, pain shock, and hyperventilation. Furthermore, patients with cardiovascular diseases, including cerebrovascular disorders, or decreased vital organ reserve capacity can encounter serious complications. A strategy for relieving mental strain is important for safe dental treatment of such patients, and to this end, intravenous sedation is often used.^3,4 However, when using intravenous sedative drugs that have strong systemic actions on the central nervous, respiratory, and circulatory systems, systemic management to ensure patient safety is a prerequisite.^5,6Conscious sedation is generally preferred to maintain independent breathing and biological defense mechanisms such as coughing and swallowing reflexes. However, dental treatment of patients with disabilities may require behavioral control, especially in the case of mentally challenged individuals with strong treatment refusal reactions. In these cases, deeper levels of intravenous sedation are a safer option.Depending upon the individual case, increased drug doses can cause deep sedation until the patient becomes completely unconscious, which is a deeper degree of sedation compared with conscious sedation.^6,7 If this deep sedative state overrides the nervous system, basic defense mechanisms may also be lost. Therefore, careful perioperative management, similar to that for general anesthesia, is necessary.Therefore, dental treatment of mentally or physically impaired patients using intravenous anesthetics requires careful perioperative management, similar to general anesthesia. Unfortunately, there is little information available on the disabilities and sedation conditions particularly at risk of causing low peripheral oxygenation and delayed recovery.^8,9In this study, we investigated and analyzed the risk factors that may be involved in causing decreased peripheral oxygen saturation (SpO₂) and delayed recovery, including age, sex, treatment duration, type of disability or disease, and type and dose of anesthetic, in dental patients with disabilities.     

Patients With Terminal Chronic Liver Pathology Faced With This Disease

Background“Anxious preoccupation” is a maladaptive coping strategy for patients with terminal chronic liver pathology causing psychopathologic emotional responses. The aim of this study was to identify “anxious preoccupation” as a coping strategy when faced with this disease and to investigate its relationship with emotional-type psychopathologic symptoms in patients awaiting a liver transplant (LT).MethodsA total of 63 patients awaiting an LT were evaluated. The instrument used to evaluate coping style was the Mental Adjustment to Cancer questionnaire. One of the coping scales of this questionnaire is “anxious preoccupation” (9 items). An Instrument for psychopathologic assessment was used, the SA-45 questionnaire, which assessed 9 psychopathologic dimensions: somatizations, obsessions-compulsions, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism.Results“Anxious preoccupation” was used as an inadequate coping style by 51% of patients when faced with the disease. Five psychopathologic dimensions were associated with this coping strategy: 1) obsessive-compulsivity: 75% of patients with “anxious preoccupation” had obsessive-compulsivity symptoms compared with 29% of patients with other coping strategies (P < .001); 2) interpersonal sensitivity: 25% vs 6%, respectively (P = .044); 3) depression: 59% vs 29% (P = .015); 4) anxiety: 75% vs 32% (P = .001); and 5) phobic anxiety: 19% vs 3% (P = .050).ConclusionsMore than one-half of the patients on the LT waiting list used “anxious preoccupation” as a coping style for this disease. This strategy was associated with a greater presence of emotional-type psychopathologic symptoms in these patients.     

Treatment With Ezetimibe in Kidney Transplant Recipients With Uncontrolled Dyslipidemia

Introduction

Cardiovascular disease is the leading cause of death in kidney transplant recipients. Hyperlipidemia is a cardiovascular risk factor present in over 70% of recipients. Ezetimibe has proved effective for the treatment of dyslipidemia in these patients.

Aim

To evaluate the efficacy and safety of treatment with ezetimibe in kidney transplant recipients with uncontrolled hyperlipidemia.

Materials and methods

We undertook a prospective study of 25 kidney transplant recipients with dyslipidemia who started treatment with 10 mg of ezetimibe. Statins were being taken by 96% of these patients. Monotherapy was used in one case. Measurements were made at baseline and after 3, 6, and 12 months of the lipid and hepatic profiles, CPK, lactose dehydrogenase, renal function and levels of immunosuppressive agents.

Results

A significant reduction was noted in total cholesterol, low-density lipoprotein cholesterol, and triglycerides. No patient had changes in the hepatic profile, increased CPK and lactose dehydrogenase levels, or important adverse effects. Renal function remained stable, with no significant variations in plasma levels of the different immunosuppressive agents.

Conclusions

The use of ezetimibe associated with statins is an efficient and safe therapeutic alternative for the treatment of poorly controlled dyslipidemia in recipients of a kidney graft.     

Case of Vasovagal Syncope With Asystole Associated With Propofol Sedation

Few cases of bradycardic complications occurring under intravenous sedation have been reported. Here, we report a case of vasovagal syncope with asystole (7.2 seconds) associated with propofol sedation.Key Words: Vasovagal syncope, Propofol sedationThe vasovagal response can be triggered by stress, prolonged standing, extreme emotions, or severe pain.¹ It is caused by reduced arterial pressure and blood supply to the brain and is mediated through neural mechanisms rather than primary cardiac dysfunction.² Most modern anesthetic agents do not have anticholinergic or sympathomimetic side effects. Simple vasovagal reflexes with bradycardia and transient asystole are more common.³ Bradycardic complications have been reported to occur after induction, during, or at the end of propofol-induced anesthesia. Abrupt, unpredictable, or progressive decreases in heart rate, as well as cases of sudden cardiac arrest, under general anesthesia have been reported.^4,5 However, few cases of bradycardic complications occurring under intravenous sedation have been reported. Here, we report a case of vasovagal syncope with asystole (7.2 seconds) associated with propofol sedation.     

Ankle Stabilization With Arthroscopic Versus Open With Suture Tape Augmentation Techniques

Ankle instability is a common problem that often leads to surgery to stabilize the ankle if conservative methods are unsuccessful in returning the patient to full activity. Surgical ankle stabilization, including arthroscopic and open methods, has been performed with overall excellent results reported. Although initial ligament strength after repair is weaker than the native ligament, new methods of augmentation with suture tape have yielded initial strength comparable to native ligament. The present study compares arthroscopic ankle stabilization and open stabilization with suture tape augmentation. A retrospective comparative trial was undertaken with a follow-up satisfaction survey. A total of 55 patients were ultimately included, consisting of 43 arthroscopic patients and 12 open with suture tape augmentation patients. Ancillary procedures are reported. The mean follow-up duration was 24.2 months in the arthroscopic group and 21 months in the open group. There was a statistically significantly faster return to activity/sports in the arthroscopic group (127.2 days vs 170 days; p?=?.008). Although not statistically significant, there was a trend toward favoring the open group in terms of revision surgery and patient satisfaction. Our data indicate that both methods of stabilization are reasonable for ankle instability repair.     

Factors Associated With Oral Problems Among Adults With Spinal Cord Injury

Objective:

To explore factors associated with self-reported current oral (tooth and gum) problems and oral pain in the past 12 months among adults with spinal cord injury.

Methods:

An online oral health survey on the South Carolina Spinal Cord Injury Association website. Respondents were 192 adult residents of the US who identified themselves as having spinal cord injury at least 1 year before the survey date.

Results:

Approximately 47% of respondents reported having oral problems at the time of the survey, and 42% reported experiencing oral pain in the 12 months before the survey date. Multiple predictor analyses (controlling for age, gender, income, and dental insurance) indicated that current oral problems were positively associated with dry mouth symptoms, financial barriers to dental care access, smoking, and paraplegia. Oral pain experienced in the past 12 months was positively associated with dry mouth symptoms, financial barriers to dental care access, minority race, and paraplegia.

Conclusions:

Adults with spinal cord injury reported a high prevalence of oral problems and oral pain. Those with paraplegia were more likely to report problems than those with tetraplegia. Because dry mouth and smoking were significantly associated with these problems, patient education from both dental and medical providers should emphasize awareness of the side effects of xerostomia-causing medications, dry mouth management, and smoking cessation. Findings also indicate unmet needs for low-cost preventive and treatment dental services for this vulnerable population.     

Primary Anticoagulation With Bivalirudin for Patients With Implantable Ventricular Assist Devices

Bivalirudin is a direct thrombin inhibitor that is increasingly used in patients undergoing mechanical circulatory support as it presents many advantages compared with unfractionated heparin. The aim of this study was to describe our experience with bivalirudin as primary anticoagulant in patients undergoing ventricular assist device (VAD) implantation. An observational study was performed on 12 consecutive patients undergoing VAD implantation at our institution. Patients received a continuous infusion of bivalirudin, with a starting dose of 0.025 mg/kg/h; the target activated partial thromboplastin time (aPTT) was between 45 and 60 s. Patients never received heparin during hospitalization nor had a prior diagnosis of heparin‐induced thrombocytopenia (HIT). All patients received a continuous flow pump except one. Preoperative platelets count was 134 000 ± 64 000 platelets/mm³. Mean bivalirudin dose was 0.040 ± 0.026 mg/kg/h over the course of therapy (5–12 days). Lowest platelets count during treatment was 73 000 ± 23 000 platelets/mm³. No thromboembolic complications occurred. Two episodes of minor bleeding from chest tubes that subsided after reduction or temporary suspension of bivalirudin infusion were observed. Intensive care unit stay was 8 (7–17) days, and hospital stay was 25 (21–33) days. Bivalirudin is a valuable option for anticoagulation in patients with a VAD and can be easily monitored with aPTT. The use of a bivalirudin‐based anticoagulation strategy in the early postoperative period may overcome many limitations of heparin and, above all, the risk of HIT, which is higher in patients undergoing VAD implantation. Bivalirudin should no longer be regarded as a second‐line therapy for anticoagulation in patients with VAD. [Correction added on 6 December 2013, after first online publication: The dose of bivalirudin in the Abstract to 0.025 mg/kg/h].     

Breast Cancer With Chest Wall Progression: Treatment With Photodynamic Therapy

Background: Chest wall progression of breast carcinoma affects up to 5% of breast cancer patients and is a major source of their pain. Treatment options are limited or may not be offered to these patients. Low-dose Photofrin-induced photodynamic therapy (PDT) offers an excellent clinical response with minimal morbidity. We report our continued experience with PDT in this setting.Methods: Fourteen patients with more than 500 truncal metastases were treated with PDT. All received off-label Photofrin (.8 mg/kg) IV and light treatment at 630 nm from a diode laser with a microlens at a fluence of 1800 mW and a total light dose of 150 to 200 J/cm² at 48 hours. One patient required re-treatment because of extensive disease.Results: Follow-up was at least 6 months, and several extended to >24 months. All patients demonstrated tumor necrosis, with 9 of 14 complete responses, including with lesions >2 cm in thickness. Disease progression occurred outside of the treatment field. Several patients had initial regression of untreated lesions. Wound care, especially with disease in the deep tissues, was an issue.Conclusions: Low-dose Photofrin-induced PDT offers patients with chest wall progression a treatment option with an excellent clinical response. To date, the response is prolonged and offers good local control. Surgical oncologists have an active role in this treatment option.