Compound risk of high mortality following osteoporotic fracture and refracture in elderly women and men

After fracture there is increased risk of refracture and premature mortality. These outcomes, particularly premature mortality following refracture, have not previously been studied together to understand overall mortality risk. This study examined the long‐term cumulative incidence of subsequent fracture and total mortality with mortality calculated as a compound risk and separated according to initial and refracture. Community‐dwelling participants aged 60+ years from Dubbo Osteoporosis Epidemiology Study with incident fractures, followed prospectively for further fractures and deaths from 1989 to 2010. Subsequent fracture and mortality ascertained using cumulative incidence competing risk models allowing four possible outcomes: death without refracture; death following refracture; refracture but alive, and event‐free. There were 952 women and 343 men with incident fracture. Within 5 years following initial fracture, 24% women and 20% men refractured; and 26% women and 37% men died without refracture. Of those who refractured, a further 50% of women and 75% of men died, so that total 5‐year mortality was 39% in women and 51% in men. Excess mortality was 24% in women and 27% in men. Although mortality following refracture occurred predominantly in the first 5 years post–initial fracture, total mortality (post‐initial and refracture) was elevated for 10 years. Most of the 5‐year to 10‐year excess mortality was associated with refracture. The long‐term (>10 years) refracture rate was reduced, particularly in the elderly as a result of their high mortality rate. The 30% alive beyond 10 years postfracture were at low risk of further adverse outcomes. Refractures contribute substantially to overall mortality associated with fracture. The majority of the mortality and refractures occurred in the first 5 years following the initial fracture. However, excess mortality was observed for up to 10 years postfracture, predominantly related to that after refracture. © 2013 American Society for Bone and Mineral Research.     

Influence of Oral Vitamin E Therapy on Micro-Inflammation and Cardiovascular Disease Markers in Chronic Hemodialysis Patients

Background. The aim of this study was to evaluate the influence of oral vitamin E therapy on serum concentrations of several markers of micro-inflammation and cardiovascular disease in chronic hemodialysis (HD) patients. Methods. 29 HD patients were randomized into two groups: 15 patients were treated orally with 400mg of vitamin E daily for a period of five weeks, and 14 patients received no antioxidant supplementation. Before and after vitamin E therapy, serum concentrations of vitamin E (high-performance liquid chromatography), pregnancy-associated plasma protein-A (immunochemical – TRACE assay), C-reactive protein (nephelometry), intercellular adhesion molecule-1 (ELISA), and E-selectin (ELISA) were measured. HD patients were compared with 16 healthy controls. Results. Baseline serum concentrations of PAPP-A and CRP were significantly higher in HD patients than in healthy controls (PAPP-A: 26.23±11.94 vs. 11.41±1.94 mIU/L, p<0.001; CRP: 5.20±3.50 vs. 3.40±3.80 mg/L, p<0.05). After five weeks of oral vitamin E intake, serum PAPP-A, CRP, ICAM-1, and E-selectin concentrations remained unchanged in both groups of HD patients. Conclusion. Chronic micro-inflammation in HD patients is documented by the elevation of CRP and PAPP-A. A daily oral dose of 400 mg of vitamin E does not seem to be able to reduce enhanced oxidative stress and micro-inflammation in chronic HD patients.     

A Collision of Diseases: Chronic Lymphocytic Leukemia Discovered During Lymph Node Biopsy for Melanoma

Background

In the United States in 2012, there were 16,060 new cases of chronic lymphocytic leukemia (CLL). Often CLL is clinically occult and first detected during pathologic evaluation of the sentinel lymph node biopsy (SLNB). We reviewed our experience of patients with the coexisting diagnosis of melanoma and CLL.

Methods

An institutional review board-approved review was performed on patients with CLL and melanoma treated from 1995 to 2009 at Moffitt Cancer Center and compared with the incidence of melanoma and CLL in our tumor registry patients with breast, prostate, lung, and colon cancer.

Results

Fifty-two patients (44 males; median age, 71 years [range, 46–88]) were identified with concurrent diagnoses of melanoma and CLL. Twenty-two patients (42 %) had CLL on SLNB for their melanoma. Thirty-two patients (62 %) were diagnosed with melanoma before CLL. Concomitant or prior cancer diagnoses included nonmelanoma skin cancers (N = 29), prostate (N = 6), colorectal (N = 2), and Merkel cell carcinoma (N = 2). Five of 20 patients (25 %) had metastatic melanoma found at the time of SLNB. Patients with melanoma had a tenfold increase of CLL diagnosis compared with colorectal cancer patients, an eightfold increase compared to prostate cancer patients, and a fourfold increase compared with breast cancer patients.

Conclusions

We have confirmed an increased association of CLL and melanoma. This may be related to an underlying immunologic defect; however, there has been scant investigation into this phenomenon. Surgeons and pathologists should understand this occurrence and recognize that not all grossly enlarged or abnormal sentinel lymph nodes in melanoma patients represent melanoma.     

Fertility of Spinal Cord Injured Males: Effect of Genitourinary Infection and Bladder Management on Results of Electroejaculation

ABSTRACT

Thirty-eight men undergoing electroejaculation (EEJ) procedures for anejaculatory infertility were examined for the presence or absence of infection in urine and semen. In 29 spinal cord injury patients, a high incidence of infected urine and infected semen (41% and 56%, respectively) was seen, in contrast to patients with normal bladder function (0% and 11 %).

Urinary infection was associated with slightly lower sperm quality and lower pregnancy rates (10% vs 30% in the presence of sterile urine). Semen infection had no effect on sperm counts or pregnancy rates. If intermittent self-catheterization (ISC) was used to empty the neurogenic bladder, slightly better sperm quality was seen, the total failure rate was less, and much better pregnancy rates (44%) resulted than for patients using an alternative bladder management (7%).

Antibiotics did not reduce the incidence of urine or semen infection, but did improve sperm counts slightly. Continuous prophylaxis was associated with bacterial resistance to many oral antibiotics and had no advantage over a short course of antibiotics prior to the procedure.

Despite the above associations, the sperm quality in our patient population was never normal compared with that of men who ejaculate normally. We conclude that the low sperm quality seen in electroejaculation specimens from spinal cord injured males is not due entirely to infection or to the type of bladder management. Short courses of antibiotics, instead of continuous antibiotic prophylaxis, may be beneficial. Intermittent catheterization is superior to other methods of neurogenic bladder management in maintaining the fertility of spinal cord injured men.     

Leg Strength,Preferred Walking Speed,and Daily Step Activity in Adults With Incomplete Spinal Cord Injuries

Background:

The reduction in physical activity that accompanies spinal cord injury (SCI) contributes to the development of secondary health concerns. Research has explored potential strategies to enhance the recovery of walking and lessen the impact of physical disability following SCI, but further work is needed to identify determinants of community walking activity in this population.

Objectives:

To quantify relationships among lower extremity strength (LES), preferred walking speed (PWS), and daily step activity (DSA) in adults with incomplete SCI (iSCI) and determine the extent to which LES and PWS predict DSA in persons with iSCI.

Methods:

Participants were 21 adults (age range, 21 to 62 years; AIS levels C and D) with iSCI. Maximal values of hip abduction, flexion, and extension, knee flexion and extension, and ankle dorsiflexion and plantar flexion were measured using handheld dynamometry and were summed to determine LES. PWS was calculated using a photoelectric cell-based timing system, and participants were fitted with activity monitors to measure DSA in a natural setting.

Results:

Statistically significant (P <; .05) correlations of moderate to high magnitude (.74 to .87) were observed among LES, PWS, and DSA. Multiple regression analysis revealed that LES and PWS accounted for 83% (adjusted R2) of the variation in DSA (P <; .001).

Conclusion:

A significant proportion of the explained variance in DSA can be predicted from knowledge of LES and PWS in adults with iSCI. These findings suggest that future efforts to improve community walking behavior following SCI should be directed toward increasing LES and PWS.Key words: daily step activity, incomplete spinal cord injury, lower extremity strength, walking, walking speedIn designing rehabilitative strategies to lessen the decline in physical function observed in persons with incomplete spinal cord injury (iSCI), it is critical to identify key factors that promote effective ambulation in community settings. In this regard, 2 potential variables of interest are lower extremity strength and preferred walking speed, both of which decline following SCI.¹ If walking bouts require greater leg strength than can be generated, or if a walking task cannot be completed in a reasonable time period, more efficient forms of mobility (eg, wheelchairs, motorized scooters) are often used to compensate for limitations in walking status. Although these compensatory strategies enable individuals with iSCI to become more functionally mobile, they also paradoxically contribute to a reduction in walking behavior.²Increases in leg strength and walking speed have been associated with recovery of walking and fewer secondary health consequences in persons with SCI.³ However, the impact of lower extremity strength and speed deficits on locomotor function in this population has primarily been documented using measures such as the FIM-Locomotor subsection (FIM-L), the Walking Index for Spinal Cord Injury (WISCI-II), walking speed for 50 feet, and distance covered in a 6-minute walk test.⁴ Although these assessments provide valid clinical measures of walking capability, their ecological validity is limited because they do not reflect walking performance in real-life settings. In addition, use of the lower extremity motor score (LEMS), which features a graded strength assessment of lower limb muscle groups,^5,6 may limit the ability to detect small but clinically meaningful differences in muscle strength between individuals with iSCI or reveal subtle changes in muscle force generation resulting from therapeutic interventions.Consequently, the primary aim of this study was to quantify relationships among lower extremity strength, preferred walking speed, and community-based step activity in adults with iSCI. A secondary focus of this investigation was to document the extent to which lower extremity strength and preferred walking speed predict daily step activity in persons with iSCI. We hypothesized that significant associations would exist among lower extremity strength, preferred walking speed, and daily step activity in adults with iSCI and that knowledge of lower extremity strength and preferred walking speed would account for a large proportion of explained variance in the number of steps taken under free-living conditions.     

Differences in gambling problem severity and gambling and health/functioning characteristics among Asian-American and Caucasian high-school students

Studies of Asian-American adults have found high estimates of problematic gambling. However, little is known about gambling behaviors and associated measures among Asian-American adolescents. This study examined gambling perceptions and behaviors and health/functioning characteristics stratified by problem-gambling severity and Asian-American and Caucasian race using cross-sectional survey data of 121 Asian-American and 1659 Caucasian high-school students. Asian-American and Caucasian adolescents significantly differed on problem-gambling severity, with Asian-American adolescents more often reporting not gambling (24.8% vs. 16.4%), but when they did report gambling, they showed higher levels of at-risk/problem gambling (30.6% vs. 26.4%). Parental approval or disapproval of adolescent gambling also significantly differed between races, with Asian-American adolescents more likely to perceive both parental disapproval (50.0% vs. 38.2%) and approval (19.3% vs. 9.6%) of gambling. Asian-American adolescents were also more likely to express concern about gambling among close family members (25.2% vs. 11.6%). Among Asian-American adolescents, stronger associations were observed between at-risk/problem gambling and smoking cigarettes (interaction odds ratio=12.6). In summary, differences in problem-gambling severity and gambling perceptions indicate possible cultural differences in familial attitudes towards gambling. Stronger links between cigarette smoking and risky/problematic gambling amongst Asian-American adolescents suggest that prevention and treatment efforts targeting youth addictions consider cultural differences.     

Minimally invasive lateral approach to the thoracolumbar junction for corpectomy

Diseases that affect the thoracolumbar junction present a unique challenge to the spine surgeon. Various techniques have been described to treat this clinical entity from the anterior, lateral, or posterior direction. These can be associated with significant morbidity due to extensive tissue dissection, blood loss, and postoperative pain leading to a lengthy recovery. The use of a tubular retractor allows the surgeon to minimize tissue dissection and potentially reduce approach-related morbidity while obviating the need for an approach surgeon for exposure. The surgical technique of a minimally invasive lateral approach to the thoracolumbar junction for corpectomy is described in detail and two illustrative patients are presented.     

Does Exposure to Stressors Predict Changes in Physiological Dysregulation?

Background

The allostatic load framework implies that cumulative exposure to stressors results in multi-system physiological dysregulation.

Purpose

The purpose of this study was to investigate the effect of stress burden on subsequent changes (2000–2006) in physiological dysregulation.

Methods

Data came from a population-based cohort study in Taiwan (n?=?521, aged 54+ in 2000, re-examined in 2006). Measures of stressful events and chronic strain were based on questions asked in 1996, 1999, and 2000. A measure of trauma was based on exposure to the 1999 earthquake. Dysregulation was based on 17 biomarkers (e.g., metabolic, inflammatory, neuroendocrine).

Results

There were some small effects among men: chronic strain was associated with subsequent increases in dysregulation (standardized β?=?0.08, 95 % CI?=?0.01 to 0.20), particularly inflammation; life events were also associated with increased inflammation (β?=?0.10, CI?=?0.01 to 0.26). There were no significant effects in women.

Conclusions

We found weak evidence that stress burden is associated with changes in dysregulation.     

Effects of Anger Awareness and Expression Training versus Relaxation Training on Headaches: A Randomized Trial

Background and Purpose

Stress contributes to headaches, and effective interventions for headaches routinely include relaxation training (RT) to directly reduce negative emotions and arousal. Yet, suppressing negative emotions, particularly anger, appears to augment pain, and experimental studies suggest that expressing anger may reduce pain. Therefore, we developed and tested anger awareness and expression training (AAET) on people with headaches.

Methods

Young adults with headaches (N?=?147) were randomized to AAET, RT, or a wait-list control. We assessed affect during sessions, and process and outcome variables at baseline and 4 weeks after treatment.

Results

On process measures, both interventions increased self-efficacy to manage headaches, but only AAET reduced alexithymia and increased emotional processing and assertiveness. Yet, both interventions were equally effective at improving headache outcomes relative to controls.

Conclusions

Enhancing anger awareness and expression may improve chronic headaches, although not more than RT. Researchers should study which patients are most likely to benefit from an emotional expression or emotional reduction approach to chronic pain.