Tai Chi: improving functional balance and predicting subsequent falls in older persons

PURPOSE: To determine whether improved functional balance through a Tai Chi intervention is related to subsequent reductions in falls among elderly persons. METHODS: Two hundred fifty-six healthy, physically inactive older adults aged 70-92 (mean age +/- SD = 77.48 +/- 4.95), recruited from a local health system in Portland, OR, participated in a 6-month randomized controlled trial, with allocation to Tai Chi or exercise stretching control, followed by a 6-month postintervention follow-up. Functional balance measures included Berg balance scale, dynamic gait index, and functional reach, assessed during the 6-month intervention period (baseline, 3-month, and 6-month intervention endpoint) and again at the 6-month postintervention follow-up. Fall counts were recorded during the 6-month postintervention follow-up period. Data were analyzed through intention-to-treat analysis of variance and logistic regression procedures. RESULTS: Tai Chi participants who showed improvements in measures of functional balance at the intervention endpoint significantly reduced their risk of falls during the 6-month postintervention period, compared with those in the control condition (odds ratio (OR), 0.27, 95% confidence interval (CI), 0.07-0.96 for Berg balance scale; OR, 0.27, 95% CI, 0.09-0.87 for dynamic gait index; OR, 0.20, 95% CI, 0.05-0.82 for functional reach). CONCLUSIONS: Improved functional balance through Tai Chi training is associated with subsequent reductions in fall frequency in older persons.     

Wear, debris, and biologic activity of cross-linked polyethylene in the knee: benefits and potential concerns

Cross-linked polyethylene currently is being introduced in knee prostheses. The wear rates, wear debris, and biologic reactivity of non cross-linked, moderately cross-linked, and highly cross-linked polyethylene have been compared in multidirectional wear tests and knee simulators. Multidirectional pin-on-plate wear studies of noncross-linked, moderately cross-linked (5 Mrad), and highly cross-linked (10 Mrad) polyethylene showed a 75% reduction in wear with the highly cross-linked material under kinematics found in the hip, but only a 33% reduction under wear in kinematics representative of the knee. In knee simulator studies, with the fixed-bearing press-fit, condylar Sigma cruciate-retaining knee under high kinematic input conditions, the wear of 5 Mrad moderately cross-linked polyethylene was 13 +/- 4 mm per 1 million cycles, which was lower (p < 0.05) than the wear of clinically used, gamma vacuum foil GUR 1020 polyethylene (23 +/- 6 mm/1 million cycles). For the low-contact stress mobile-bearing knee, the wear of moderately cross-linked polyethylene was 2 +/- 1 mm per 1 million cycles, which was lower (p < 0.05) than GVF GUR 1020 polyethylene (5 +/- 2 mm/1 million cycles). The wear debris isolated from the fixed-bearing knees showed the moderately cross-linked material had a larger percentage volume of particles smaller than 1 mum in size, compared with GVF GUR 1020 polyethylene. Direct cell culture studies of wear debris generated in sterile wear simulators using multidirectional motion showed a increase (p < 0.05) in tumor necrosis factor-alpha levels and reactivity for GUR 1050 cross-linked polyethylene debris compared with an equivalent volume of noncross-linked GUR 1050 polyethylene. The use of cross-linked polyethylene in the knee reduces the volumetric wear rate. However, the clinical significance of reduced fracture toughness, elevated wear in abrasive conditions, and the elevated tumor necrosis factor-alpha release from smaller more reactive particles warrant further investigation.     

Neonatal brachial plexus palsy. Outcome of absent biceps function at three months of age

BACKGROUND: An important prognostic factor in neonatal brachial plexus palsy is the time interval to biceps muscle recovery. Although the natural history is not clear, biceps muscle recovery after more than three months of age has been used to predict poor long-term shoulder function. The absence of biceps muscle function at three months of age has been adopted as an indication for early brachial plexus microsurgery, in an attempt to improve recovery. To provide a benchmark for outcome comparison, the long-term outcome of patients with absent biceps muscle function at three months of age was studied. METHODS: Between 1980 and 1992, 170 patients with neonatal brachial plexus palsy were entered into a prospective study in which details of the birth and serial clinical examinations were recorded. Patients were grouped according to the level of injury and the time interval to biceps muscle recovery. Twenty-nine patients were observed to have absent biceps muscle function at three months of age. Twenty-eight of those patients were available for long-term followup at a mean age of eleven years and one month. At the time of follow-up, patients answered a questionnaire and underwent manual muscle strength testing, sensory evaluation, and grading of their shoulder function according to Gilbert's modification of the Mallet score, in which the function was graded as II, III, or IV with class I (no function) and V (normal) eliminated. The level of injury and the time that biceps muscle function returned were compared with the final outcomes. RESULTS: The level of injury was C5-C6 in thirteen (46%) of our twenty-eight patients with absent biceps muscle function at three months of age, C5-C7 in five (18%), and pan-plexus (C5-T1) in ten (36%). Biceps contraction was observed by six months of age in twenty patients (71%), including all thirteen patients with a C5-C6 level of injury. Twenty-two patients did not have surgery on the brachial plexus, but nine of those patients had subsequent orthopaedic procedures. At the time of follow-up, twenty-seven of the twenty-eight patients had at least antigravity biceps muscle function. Patients who regained biceps muscle function between three and six months of age had better scores for abduction (p = 0.04) and for hand-to-neck (p = 0.05) and hand-to-back (p < 0.001) function than did patients who regained biceps muscle function after six months of age. Patients with a C5-C6 lesion had better scores for external rotation (p = 0.04) and for hand-to-neck (p = 0.05), hand-to-mouth (p < 0.01), and hand-to-back (p < 0.001) function than did patients with a pan-plexus lesion. Twelve (55%) of the twenty-two patients who did not have brachial plexus surgery had a class-IV shoulder (good function) according to the modified Mallet score. Of the twelve patients with a C5-C6 level of injury who did not have brachial plexus surgery, eight had a class-IV shoulder. CONCLUSIONS: This study indicated associations between prolonged neurological recovery and a more extensive level of injury and worse long-term shoulder function. Patients with a C5-C6 injury and absent biceps muscle function at three months of age often have good long-term shoulder function without brachial plexus surgery.     

Nonoperative management and delayed hemorrhage after pediatric liver injury: new issues to consider

The authors report the case of a grade 4 liver laceration caused by blunt abdominal trauma. The liver injury was managed nonoperatively, both initially and after an episode of delayed hemorrhage. The patient suffered 2 additional as yet unreported complications of pediatric liver injury: a right pleural effusion causing respiratory embarrassment followed by duodenal obstruction; the latter was caused by hypertrophy of the left lobe of the liver. Although numerous reports suggest that delayed hemorrhage after pediatric liver injury should be managed operatively, the mortality of such intervention remains high, reaffirming the dictum that one must treat the patient and not the injury.     

Immunological effects of granulocyte-macrophage colony-stimulating factor and autologous tumor vaccine in patients with renal cell carcinoma

PURPOSE: Biological therapy for renal cell carcinoma (RCC) uses agents that mobilize immune effector cells which are able to recognize and destroy cancer. We evaluated the effects of weekly then monthly autologous tumor vaccine combined with daily granulocyte macrophage-colony stimulating factor (GM-CSF) in patients with RCC as a method of stimulating antigen presenting cells. MATERIALS AND METHODS: Eligible patients with pathological stage II to IV RCC were entered into this pilot study. Autologous tumor vaccine (0.5 to 1 x 107 irradiated tumor cells) admixed with 250 microg GM-CSF per vaccine was given subcutaneously weekly for 4 weeks and then monthly for 4 months. GM-CSF (125 microg/m2) was given subcutaneously for 13 days after vaccine injection 1 and injections 4 to 8. Treatment related tumor specific CD4 and CD8 positive T cell precursors were assessed. RESULTS: A total of 22 patients were entered into this study. Patients were stratified by bulk of disease (group 1, 9 patients with micrometastatic disease, and group 2, 13 patients with macrometastatic disease). In general treatment was well tolerated. Of 9 patients in group 1 7 remained disease-free after nephrectomy. In group 2, 6 patients had stable (46.2%) and 7 patients had progressive disease (53.8%). Statistically significant treatment related increases in CD4 (p = 0.028) and CD8 (p = 0.018) positive tumor specific T cell precursors were observed for the entire group of patients. Changes in CD4 and CD8 positive precursors correlated significantly with each other (p = 0.0001). This correlation was seen in the 2 patient subpopulations as well (group 1 p = 0.003, group 2 p = 0.013). Patients with minimal disease, and with changes in CD4 and CD8 positive tumor specific T cell precursors greater than the median appeared to have an improved time to progression as well as a survival benefit. CONCLUSIONS: GM-CSF and autologous vaccine can be given safely in combination to patients with renal cell cancer. We observed treatment related changes in tumor specific circulating lymphocyte populations.     

DNR directives are established early in mechanically ventilated intensive care unit patients

Purpose

Setting treatment goals in the intensive care unit (ICU) often involves resuscitation decisions. Our objective was to study the rate of establishing do-not-resuscitate (DNR) directives, determinants, and outcomes of those directives for mechanically ventilated patients.

Methods

In a multicentre observational study, we included consecutive adults with no DNR directives within 24 hr of ICU admission who were mechanically ventilated for at least 48 hr. We identified the rate with which DNR directives were established, and factors associated with these directives.

Results

Among 765 patients, DNR directives were established for 231 (30.2%) patients; 143 (62.1%) of these were established within the first week. Factors independently associated with a DNR directive were: patient age [> 75 yr (hazard ratio [HR] 2.3, 95% confidence interval 1.5–3.4], 65 to 74yr(HR 1.8, 1.2–2.7), 50 to 64 yr (HR 1.4, 1.0–2.2) relative to < 50 yr); medical rather than surgical diagnosis (HR 1.8, 1.3–2.5); multiple organ dysfunction score (HR 1.7 for each five-point increment, 1.4–2.0); physician prediction of ICU survival [< 10% (HR 15.0, 6.7–33.6)], 10 to 40% [(HR 5.0, 2.3–11.2), 41 to 60% (HR 4.0, 1.8–9.0) relative to > 90%]; and physician perception of patient preference to limit life support (no advanced life support [(HR 5.8, 3.6–9.4) or partial advanced life support (HR 3.2, 2.2–4.6) compared to full measures].

Conclusion

One third of mechanically ventilated patients had DNR directives established early during their ICU stay after the first 24 hr of admission. The strongest predictors of DNR directives were physician prediction of low probability of survival, physician perception of patient preference to limit life support, organ dysfunction, medical diagnosis and age.     

Four-year follow-up of a prospective randomized trial of mycophenolate mofetil with cyclosporine microemulsion or tacrolimus following liver transplantation

BACKGROUND: This is a 4-yr follow-up of a trial using mycophenolate mofetil (MMF) induction in orthotopic liver transplantation (OLT). The goal of this study was to evaluate a multidrug approach that would reduce both early and long-term morbidity related to immunosuppression while maintaining an acceptable freedom from rejection. METHODS: This was a prospective, randomized, intent to treat study designed to compare the primary endpoints of rejection and infection, and secondary endpoints of liver function, renal function, bone marrow function, cardiovascular risk factors, and the recurrence of hepatitis C. Ninety-nine consecutive patients with end stage liver disease who underwent OLT were randomized to receive either cyclosporine microemulsion (N) (50 patients) or tacrolimus (FK) (49 patients) starting on postoperative day 2, with MMF and an identical steroid taper begun preoperatively. RESULTS: Ninety of 99 patients (N 46, FK 44) completed the 4-yr follow-up. The overall 4-yr patient and graft survivals were 93 and 89%, respectively. There was no significant difference in 4-yr patient (N 96% vs. FK 90%, p = ns) or graft (N, 90% vs. FK, 88%, p = ns) survival between groups. The 4-yr rejection rate was not significantly different in either arm (N = 34%, FK = 24%; p = 0.28). There were no differences in infection rates in either arm. The patients with hepatitis C had no differences in the viral titers or Knodell biopsy scores between groups. However, in the hepatitis C subgroup (37 patients), the FK patients had a significantly lower rejection rate (p = 0.0097) and a significantly lower clinically recurrent hepatitis C rate (p = 0.05) than the N patients. No difference was seen in the percent of patients weaned off of steroids after 4 yr (N 51%, FK 49%). There were no differences in the incidences of diabetes mellitus and hypertension. When renal dysfunction was analyzed, a significant difference in the number of patients whose creatinine had increased twofold since transplant was seen (N 63%, FK 38%, p = 0.04). CONCLUSIONS: Use of MMF induction and maintenance following OLT in conjunction with either N or FK and an identical steroid taper, resulted in an acceptable long-term incidence of rejection and infection, without an increase in long-term graft or patient morbidity.     

Comparison of Recovery Time after Open and Laparoscopic Gastric Bypass and Laparoscopic Adjustable Banding

Background: Laparoscopy is believed to reduce recovery time and patient discomfort following bariatric surgical operations. This study tests that hypothesis. Methods: 60 randomly selected bariatric surgery patients, consisting of 20 open Roux-en-Y gastric bypass (RYGBP), 19 lap RYGBP, and 21 laparoscopic adjustable banding, were studied. Outcome measures including hospital length of stay (LOS), days to return to normal activity, days to surgical recovery, and pain medication usage were defined by the patients' subjective responses to a retrospective questionnaire. Overall differences among the three surgeries were first determined using the Kruskal-Wallis test, and then individual comparisons were made between each of the three pairs of operations using a Wilcoxon rank-sum test when a significant difference existed. Results: Patients reported an average LOS of 3.45 days following open RYGBP, 2.47 days following lap RYGBP, and 1.33 days following Lap-Band? surgery. There was little difference in return to normal activity, with open RYGBP patients reporting a 17.55 day delay in return to normal activity, and lap RYGBP reporting an 18.16 day delay. In contrast, Lap-Band? patients responded that the delay was only 7.24 days. Days to recovery were reported to be 29.05 for open RYGBP patients, 21.68 for lap RYGBP patients and 15.81 for Lap-Band? patients. Hospital days (P=0.0002), days to normal activity (P=0.0115), and days to recovery (P<0.0001) differed significantly among the surgery types. Lap and open RYGBP did not differ significantly regarding days to resumption of normal activities. Open RYGBP and banding differed significantly regarding days to recovery (P <0.001). Conclusions: Lap-Band? patients returned to normal activity levels earlier than gastric bypass patient's irrespective of approach. Lap-Band? patients also reported recovering from surgery significantly sooner than open RYGBP patients. Perceived differences in recovery time between open and laparoscopic RYGBP patients did not affect their time to resumption of normal activity.