Time to surgery and 30-day morbidity and mortality of periprosthetic hip fractures

Background and aim

The management of femoral periprosthetic fractures following hip replacement surgery is a complex and challenging situation. Whilst the early complications for both primary hip arthroplasty and proximal femoral fracture surgery have been widely documented, there is a paucity of published data regarding early outcomes following periprosthetic fracture surgery.Delay to surgery for native proximal femoral fractures has been clearly documented as a predictor towards adverse outcome. This study therefore aims to correlate the timing of operative intervention with the complication rate following periprosthetic fracture surgery. In addition, the study aims to identify further factors in the perioperative period that positively predict a poor postoperative outcome.

Methods

Sixty patients who were operatively managed for a femoral implant periprosthetic fracture were identified and each case assessed retrospectively.

Results and conclusion

There was an overall complication rate of 45% including a 30-day mortality of 10%. An abbreviated mental test score of 8 out of 10 or less and a delay to surgery of >72 h were found to be significant risk factors for adverse outcome. Both the patient cohort in this study and the predictors for poor postoperative outcome were comparable to those for native proximal femoral fractures.     

An international matched cohort study of the contribution of metabolic impairments to subclinical atherosclerosis in United Kingdom and Jamaican African-Caribbeans

Caucasian carriers of the T allele at R46L in the proprotein convertase subtilisin/kexin type 9 (PCSK9) locus have been reported to have 15% lower low-density lipoprotein (LDL) cholesterol (C) levels and 47% lower coronary heart disease (CHD) risk. Our objective was to examine two PCSK9 single nucleotide polymorphisms (SNPs), R46L and E670G, in 5783 elderly participants in Prospective Study of Pravastatin in the Elderly at Risk (PROSPER), of whom 43% had a history of vascular disease at baseline, and who were randomized to pravastatin or placebo with followup. In this population 3.5% were carriers of the T allele at R46L, and these subjects had significantly (p < 0.001) lower levels of LDL C (mean, −10%), no difference in LDL C lowering response to pravastatin, and a non-significant 19% unadjusted and 9% adjusted decreased risk of vascular disease at baseline, with no on trial effect. Moreover, 6.0% were carriers of the G allele at E670G with no significant relationships with baseline LDL C, response to pravastatin, or vascular disease risk being observed. Our data support the concept that the rare allele of the R46L SNP at the PCSK9 locus significantly lowers LDL C, but does not greatly reduce CHD risk in an elderly population with a high prevalence of cardiovascular disease.     

Homocysteine and cardiovascular disease

Research over the past decade has shown that elevated levels of homocysteine have a strong association with all forms of atherothrombotic disease and venous thromboembolism. This association is particularly strong for coronary disease and newer data indicate that screening for homocysteine levels may be warranted in those with unexplained thrombotic tendencies and in young patients who develop coronary events or disease without the usual predisposing factors such as hypertension, smoking, hypercholesterolemia, or diabetes. Although the link between hyperhomocysteinemia and cardiac disease has not been conclusively shown to be causal as yet, data are emerging that lowering homocysteine levels may be beneficial in patients at high risk. Such lowering can be done safely and inexpensively with increased intake of fruits and vegetables and in those patients who are particularly at high risk using supplementation with folic acid and the B vitamins. Preliminary studies have shown that lowering homocysteine levels in this manner may slow the progression of atherosclerosis in coronary and carotid vessels. No mortality data exist yet showing that reducing homocysteine reduces cardiac or total mortality, although it is likely that ongoing and planned trials that are underway will shed light on these important questions soon.     

Alterations in daily rhythms of testosterone and progesterone in old male rats

Studies were undertaken to characterize the daily patterns of secretion of testosterone (T), progesterone (P) and dihydrotestosterone (DHT) in young (3-4 months old) and old (19-20 months old) male Sprague-Dawley rats. In young rats, plasma T concentrations show dramatic daily variations with peak and nadir levels at 1130 and 2330 h, respectively. In old male rats, no such rhythmic pattern in plasma T was observed. Plasma P concentrations varied significantly in both young and old male rats, with peak levels occuring 8 h (1930 h) after the plasma T peak in young rats. Additionally, in old male rats, the daily increase in plasma P was significantly larger and was sustained for a longer period than in young rats. Plasma DHT concentrations were similar and changed little during the day in both young and old animals. In view of the known P influence on gonadal secretion, the possible significance of these age-related changes in daily patterns in plasma P and T are discussed.     

Pretreatment of Cr(VI)-Amended Soil With Chromate-Reducing Rhizobacteria Decreases Plant Toxicity and Increases the Yield of Pisum sativum

Pot culture experiments were performed under controlled greenhouse conditions to investigate whether four Cr(VI)-reducing bacterial strains (SUCR44, SUCR140, SUCR186, and SUCR188) were able to decrease Cr toxicity to Pisum sativum plants in artificially Cr(VI)-contaminated soil. The effect of pretreatment of soil with chromate-reducing bacteria on plant growth, chromate uptake, bioaccumulation, nodulation, and population of Rhizobium was found to be directly influenced by the time interval between bacterial treatment and seed sowing. Pretreatment of soil with SUCR140 (Microbacterium sp.) 15 days before sowing (T+15) showed a maximum increase in growth and biomass in terms of root length (93 %), plant height (94 %), dry root biomass (99 %), and dry shoot biomass (99 %). Coinoculation of Rhizobium with SUCR140 further improved the aforementioned parameter. Compared with the control, coinoculation of SUCR140+R showed a 117, 116, 136, and 128 % increase, respectively, in root length, plant height, dry root biomass, and dry shoot biomass. The bioavailability of Cr(VI) decreased significantly in soil (61 %) and in uptake (36 %) in SUCR140-treated plants; the effects of Rhizobium, however, either alone or in the presence of SUCR140, were not significant. The populations of Rhizobium (126 %) in soil and nodulation (146 %) in P. sativum improved in the presence of SUCR140 resulting in greater nitrogen (54 %) concentration in the plants. This study shows the usefulness of efficient Cr(VI)-reducing bacterial strain SUCR140 in improving yields probably through decreased Cr toxicity and improved symbiotic relationship of the plants with Rhizobium. Further decrease in the translocation of Cr(VI) through improved nodulation by Rhizobium in the presence of efficient Cr-reducing bacterial strains could also decrease the accumulation of Cr in shoots.     

Electronic health records: new opportunities for clinical research

Clinical research is on the threshold of a new era in which electronic health records (EHRs) are gaining an important novel supporting role. Whilst EHRs used for routine clinical care have some limitations at present, as discussed in this review, new improved systems and emerging research infrastructures are being developed to ensure that EHRs can be used for secondary purposes such as clinical research, including the design and execution of clinical trials for new medicines. EHR systems should be able to exchange information through the use of recently published international standards for their interoperability and clinically validated information structures (such as archetypes and international health terminologies), to ensure consistent and more complete recording and sharing of data for various patient groups. Such systems will counteract the obstacles of differing clinical languages and styles of documentation as well as the recognized incompleteness of routine records. Here, we discuss some of the legal and ethical concerns of clinical research data reuse and technical security measures that can enable such research while protecting privacy. In the emerging research landscape, cooperation infrastructures are being built where research projects can utilize the availability of patient data from federated EHR systems from many different sites, as well as in international multilingual settings. Amongst several initiatives described, the EHR4CR project offers a promising method for clinical research. One of the first achievements of this project was the development of a protocol feasibility prototype which is used for finding patients eligible for clinical trials from multiple sources.     

Secular trends in the management of hypertension and atrial fibrillation in patients presenting with stroke

We studied changes in stroke prevention in 2000 ischaemic stroke patients using prospectively collected data from an incident stroke register over 3 years. Patients were divided into those with risk factors but no previous history of a vascular event (asymptomatic vascular disease) and those with risk factors and a previous history of stroke or TIAs, ischaemic heart disease, angina, myocardial infarction or peripheral vascular disease (symptomatic vascular disease). Time trends were analysed for the use of aspirin, management of hypertension and atrial fibrillation prior to the presenting episode. Median age of those with known risk factors included in the study was 75 years (range 44-99 years); 60% were women. Year-by-year analysis showed no differences in demography, stroke characteristics or vascular risk profile. The use of aspirin for symptomatic vascular disease increased with time (28% to 72%) (p<0.001), but did not increase for asymptomatic vascular disease, despite risk factors being present. The proportion of patients receiving antihypertensive treatment for symptomatic vascular disease was unchanged with time (66% to 64%) but there was a significant increase in the number of patients receiving antihypertensive treatment for asymptomatic vascular disease (28% to 44%) (p<0.05). The proportion of patients with atrial fibrillation receiving antithrombotic treatment did not increase for asymptomatic vascular disease (23% to 21%) (p=0.54) but did increase for symptomatic vascular disease (19.5% to 37%) (p<0.01) over 3 years. The use of warfarin in atrial fibrillation increased both in the case of asymptomatic (4.5% to 42%) (p<0.01) and symptomatic vascular disease (12.5% to 33.0%) (p<0.01).