Primary hemiarthroplasty in old patients with displaced femoral neck fracture: a 1-year follow-up of 103 patients aged 80 years or more

103 patients with displaced femoral neck fractures (Garden 3-4) treated with primary hemiarthroplasty in the Department of Orthopedics, Malm? University Hospital, Sweden 1998-1999 were followed in a prospective, consecutive study for 1 year. Inclusion criteria were age of at least 80 years, signs of mental changes and/or residence in an institution. The control group consisted of 69 patients with internal fixation (Hansson hook pins). The arthroplasty group required more blood transfusions, a longer operation and had more superficial infections. No differences were detected as regards other complications, length of hospital stay, in-hospital mortality or ability to return home. The 1-year mortality rates were similar in the arthroplasty (29/103) and control groups (28/69). Within 1 year, we found a lower failure rate in the arthroplasty group (6/103) than in the control group (18/69). In the arthroplasty group, 2/103 had dislocations. Of the surviving arthroplasty patients at 12 months, 31/74 could walk as well as before the fracture and 55/74 had no pain. We recommend primary hemiarthroplasty for demented and/or institutionalized patients over 80 years with displaced femoral neck fractures.     

Dimercapto-succinic acid scintigraphy instead of voiding cystourethrography for infants with urinary tract infection

PURPOSE: We study the ability of dimercapto-succinic acid (DMSA) scintigraphy to predict the presence of dilating vesicoureteral reflux (VUR) in infants with urinary tract infection (UTI) to simplify the evaluation protocol. MATERIALS AND METHODS: A retrospective analysis of the records of 303 children younger than 2 years with initial UTI investigated with DMSA scintigraphy and voiding cystourethrography (VCU) within 3 months after UTI was performed. RESULTS: In 156 of the 303 children (51%) DMSA scintigraphy showed renal lesions. VUR was found in 80 patients (26%) and VUR grade significantly correlated with the presence of renal lesions. A normal DMSA scintigraphy and dilating VUR (grade III) occurred in 7 infants. At followup after 1 to 2 years, 6 of these 7 patients had normal DMSA scans and 1 had a scarred duplex kidney. VUR resolved spontaneously in 5 and improved spontaneously to grade 1 in 2 patients. None of the 7 children had recurrent UTI. CONCLUSIONS: DMSA scintigraphy in infants with UTI may replace VCU as a first line investigation. A strategy to perform VCU in only patients with renal lesions is proposed. In this study 147 of 303 VCUs would have been unnecessary as only 1 child with a damaged kidney was missed.     

Truncal fat mass as a contributor to inflammation in end-stage renal disease

BACKGROUND: An activated inflammatory response is a common feature of end-stage renal disease (ESRD) and predicts outcome. Adipose tissue is an endocrine organ that may contribute to an inflammatory burden by secreting adipocytokines such as interleukin 6 (IL-6). OBJECTIVE: The objective was to relate plasma concentrations of IL-6 in ESRD patients to body composition, regional fat mass distribution, and blood lipid profiles. DESIGN: One hundred ninety-seven ESRD patients (123 men; +/- SE age: 52 +/- 1 y) were evaluated shortly before dialysis started. Lean body mass and truncal and nontruncal fat mass were estimated by dual-energy X-ray absorptiometry. Nutritional status was evaluated on the basis of subjective global assessment and handgrip strength. Inflammatory biomarker and blood lipid concentrations were also evaluated. RESULTS: Median IL-6 (8.5 compared with 4.5 pg/mL; P < 0.001) concentrations were significantly greater in malnourished than in well-nourished patients. Moreover, negative correlations were observed between IL-6 and serum creatinine (rho = -0.19, P < 0.01), handgrip strength (rho = -0.24, P < 0.001), and serum albumin (rho = -0.34, P < 0.001). A significantly higher truncal fat mass (12.8 +/- 0.7 compared with 10.5 +/- 0.4 kg; P < 0.005) was observed in ESRD patients with inflammation (C-reactive protein >/= 10 mg/L). Inverse correlations were observed between plasma IL-6 and HDL cholesterol (rho = -0.16, P < 0.05) and apolipoprotein A (rho = -0.23, P < 0.001). CONCLUSIONS: Plausible relations exist between inflammatory biomarkers, such as IL-6 and high-sensitivity C-reactive protein, and regional fat distribution in ESRD patients. Moreover, the strong inverse relations between HDL cholesterol and apolipoprotein A and biomarkers of inflammation suggest that the chronic inflammatory response observed in ESRD patients is an important contributor to the atherogenic lipoprotein profile in uremia.     

Increased risk for cardiovascular mortality in psoriasis inpatients but not in outpatients

We have conducted a historical cohort study to assess cardiovascular mortality among psoriasis patients. Using the Swedish Inpatient Registry, we selected 8991 patients hospitalized for psoriasis at dermatological wards. To represent an outpatient cohort, 19,757 members of the Swedish Psoriasis Association were selected. Mortality from cardiovascular diseases was compared with the general population. We found no increased cardiovascular mortality among outpatients with psoriasis (standardized mortality ratio, SMR 0.94; 95% confidence interval, CI: 0.89-0.99). The overall risk among inpatients admitted at least once was increased by 50% (SMR 1.52; 95% CI: 1.44-1.60). The excess risk increased with increasing number of hospital admissions (p for trend <0.001). Cardiovascular mortality was higher among those admitted at younger ages (p for trend <0.001; SMR 2.62, 95% CI: 1.91-3.49, for patients aged 20 to 39 years at first admission). Young age at first admission appeared to further increase the risk among those who were repeatedly admitted. We conclude that a diagnosis of psoriasis per se does not appear to increase the risk for cardiovascular mortality. Severe psoriasis, however, here measured as repeated admissions, and early age at first admission, is associated with increased risk for cardiovascular death.     

Cost effectiveness of alendronate for the treatment of male osteoporosis in Sweden

Background: One third of all the hip fractures occur in men. The risk for mortality following hip fracture is higher for men compared to women. The Fracture Intervention Trial (FIT) showed that the bisphosphonate alendronate reduces the risk of fractures and increases bone mineral density (BMD) in osteoporotic women. Similar effects of alendronate were observed in men in some other trials. There are also results demonstrating alendronate to be cost-effective in the treatment of osteoporosis in women. Objective: To investigate the cost effectiveness of alendronate for male osteoporosis in Sweden by assuming the same relative risk reduction of fractures in men as for women, based on the FIT trial. Design: A Markov model earlier used to analyze cost effectiveness of alendronate in treatment of postmenopausal osteoporosis in Sweden was adapted to fit a cohort of Swedish men. Cost effectiveness of alendronate vs. no treatment was assessed by transitioning men in the model over time between different health states. Time horizon: The patients were followed from start of intervention until 100 years of age or death. In the base-case alendronate was assumed to have a fracture-risk-reducing effect for 10 years; a treatment duration period of 5 years followed by a 5-year period where the effect declined linearly to zero. Results: Taking a societal perspective treating a 71-year-old man (mean age in the FIT) with low BMD and prior vertebral fracture (VFA) with alendronate was found to be associated with a cost of €14,843 per quality adjusted life year (QALY) gained. Conclusions: The results in this study indicate that treating osteoporotic men with alendronate was projected to be cost-effective, under the assumption of the same fracture-risk-reducing effect of alendronate for men as for women.     

The place of inhaled corticosteroids in chronic obstructive pulmonary disease

The role of systemic corticosteroids in the treatment of exacerbations of chronic obstructive pulmonary disease (COPD) is well established. However, despite being frequently prescribed for the treatment of COPD, the clinical utility of inhaled corticosteroids (ICS) is less clearly defined. This review article seeks to clarify the role of ICS in the clinical management of COPD through a review of key pivotal short-, medium- and long-term studies in this field. Studies for inclusion in this review were identified by means of a computerised search of several databases (including MEDLINE, BIOSIS and EMBASE) from 1980 to 2003. While individual clinical and epidemiological studies have yielded conflicting results, meta-analysis of available data suggests that ICS may reduce the frequency and severity of exacerbations, the number of hospitalisations and the mortality rate, as well as yielding improvements in lung function and health-related quality of life (HRQL) in some subgroups of COPD patients. More recently, clinical trials evaluating the effect of combination therapy with ICS and long-acting beta2-agonists (LABA) have shown significant effects on the prevention of exacerbations and HRQL. Emerging data are expected to clarify the role of ICS in the management of patients with COPD of different severities as well as the place of treatment with ICS/LABA combinations in the management of this chronic and disabling disorder.     

Fractures of the radial head and neck treated with radial head excision

BACKGROUND: The reported long-term outcomes of the treatment of radial head and neck fractures with excision of the radial head have been mixed. The purpose of the present study was to evaluate the long-term outcomes of primary or delayed radial head excision for the treatment of these fractures. METHODS: Sixty-one individuals (mean age, forty-four years) with thirty-nine Mason type-II, ten Mason type-III, and twelve Mason type-IV fractures were evaluated subjectively, objectively, and radiographically at a mean of eighteen years (range, eleven to thirty-three years) after treatment. Forty-three fractures were treated with primary radial head excision, and the remaining eighteen were treated with delayed radial head excision at a median of five months (range, one to 238 months) after the injury. RESULTS: At the time of follow-up, twenty-eight individuals had no symptoms, twenty-seven had occasional elbow pain, and six had daily pain. Four individuals with daily pain had had a Mason type-IV fracture. The range of motion of the formerly injured upper extremities was slightly less than that of the uninjured upper extremities in terms of flexion (139 degrees +/- 11 degrees compared with 142 degrees +/- 8 degrees ), extension (-7 degrees +/- 12 degrees compared with -1 degrees +/- 6 degrees ), and supination (77 degrees +/- 20 degrees compared with 85 degrees +/- 10 degrees ) (all p < 0.01). A higher percentage of formerly injured elbows than uninjured elbows had cysts, sclerosis, and osteophytes (73% compared with 7%; p < 0.001), but none had a reduced joint space. No differences were found between the outcomes for individuals treated with a primary radial head excision and those for individuals treated with a delayed excision. CONCLUSIONS: Following a displaced radial head or neck fracture, excision of the radial head often leads to a good or fair result. We found no differences in outcome between primary and delayed radial head excisions following a Mason type-II, III, or IV fracture. The outcomes are associated with the type of fracture, with Mason type-IV fractures having the worst results, rather than with the timing of the radial head excision (primary or delayed).     

Excess mortality after hospitalisation for vertebral fracture

An excess mortality is well described after vertebral fracture. Deaths are in part related to co-morbidity, but could also be due to the fracture event itself, either directly or indirectly. The aim of this study was to examine the quantum and pattern of mortality following vertebral fracture. We identified 16,051 men and women aged 50 years or more with a vertebral fracture that required hospitalization in 28.8 million person years from the patient register of Sweden. Mortality after vertebral fracture was examined using Poisson models applied to fracture patients and compared to that of the general population. At all ages, the risk of death was markedly increased immediately after the event. After a short period of declining risk, the risk increased with age at a rate that was higher than that of the general population and comparable to that 1 year after hip fracture. The latter function was assumed to be due to deaths related to co-morbidity and the residuum assumed to be due to the vertebral fracture. Causally related deaths comprised 28% of all deaths associated with vertebral fracture (depending on age). We conclude that a minority of deaths following hospitalization for vertebral fracture are attributable to the fracture itself under the assumptions we used.     

Association between smoking and chronic renal failure in a nationwide population-based case-control study

For determining whether smoking is associated with an increased risk for chronic renal failure (CRF) overall and by type of renal disease, smoking data were analyzed from a nationwide population-based case-control study. Eligible as cases were native 18- to 74-yr-old Swedes whose serum creatinine for the first time and permanently exceeded 3.4 mg/dl (men) or 2.8 mg/dl (women). A total of 926 cases (78% of all eligible) and 998 control subjects (75% of 1330 randomly selected subjects from the source population), frequency matched to the cases by gender and age within 10 yr, were included. A face-to-face interview and a self-administered questionnaire provided information about smoking habits and other lifestyle factors. Logistic regression models estimated odds ratios (OR) as measures of relative risk for disease-specific types of CRF among smokers compared with never-smokers. Despite a modest and nonsignificant overall association, the risk increased with high daily doses (OR among smokers of >20 cigarettes/d, 1.51; 95% confidence interval [CI], 1.06 to 2.15), long duration (OR among smokers for >40 yr, 1.45; 95% CI, 1.00 to 2.09), and a high cumulative dose (OR among smokers with >30 pack-years, 1.52; 95% CI, 1.08 to 2.14). Smoking increased risk most strongly for CRF classified as nephrosclerosis (OR among smokers with >20 pack-years, 2.2; 95% CI, 1.3 to 3.8), but significant positive associations were also noted with glomerulonephritis. This study thus suggests that heavy cigarette smoking increases the risk of CRF for both men and women, at least CRF classified as nephrosclerosis and glomerulonephritis.