Fracture Risk After Bariatric Surgery: Roux‐en‐Y Gastric Bypass Versus Adjustable Gastric Banding

The long‐term consequences of bariatric surgery on fracture risk are unclear but are likely to vary by procedure type. In physiologic studies, Roux‐en‐Y gastric bypass (RYGB) and adjustable gastric banding (AGB) have differential effects on rates of bone loss. Therefore, our objective was to compare fracture risk in obese adults after RYGB and AGB procedures. Using claims data from a US commercial health plan, we analyzed rates of nonvertebral fractures within a propensity score–matched cohort (n = 15,032) of morbidly obese adults who received either RYGB or AGB surgery between 2005 and 2013. A total of 281 nonvertebral fractures occurred during a mean follow‐up time of 2.3 ± 1.9 years. RYGB patients had an increased risk of nonvertebral fracture (hazard ratio [HR] = 1.43, 95% confidence interval [CI] 1.13–1.81) compared with AGB patients. In fracture site–specific analyses, RYGB patients had increased risk of fracture at the hip (HR = 1.54, 95% CI 1.03–2.30) and wrist (HR = 1.45, 95% CI 1.01–2.07). Nonvertebral fracture risk associated with RYGB manifested >2 years after surgery and increased in subsequent years, with the highest risk in the fifth year after surgery (HR = 3.91, 95% CI 1.58–9.64). In summary, RYGB is associated with a 43% increased risk of nonvertebral fracture compared with AGB, with risk increasing >2 years after surgery. Fracture risk should be considered in risk/benefit discussions of bariatric surgery, particularly among patients with high baseline risk of osteoporosis who are deciding between RYGB and AGB procedures. © 2017 American Society for Bone and Mineral Research.     

Bridging the Gap between Clinical Practice and Research Part I: Findings of a Pilot Study on Daniel Stern's ‘Moments of Meeting’ from the UKCP's Practitioner Research Network

Psychotherapists continue to be wary of researchers who enter the clinical domain and their methodologies, which can seem opaque and alien to clinical practice. The following is a report on a pilot project, supported and enabled through the Practice Research Network of the UK Council for Psychotherapy (UKCP), to explore whether adopting the role of researcher on the therapy process, using their own clients, could help to dissipate this discomfort. Findings were anticipated concerning two groups of issues. First, we sought to examine whether, and how, a ‘moment of meeting’ (MoM) might impact on the therapy, and its outcomes. Second, whether, and how, undertaking the role of researcher with one's own clients might affect clinical practice, and how systematic reflection on observations from clinical practice might provide rich evidence in the development of the MoM concept. We report on two broad issues arising from the project. First, using the data collected by the research team in a mixed method study of their own cases, we examine the relationship of the process variable MoM to clinical outcome. Relationships between other process variables were also investigated, using both established measures and a new, post-therapy interview developed by the team during the project. Second we explore the experience of the participant clinicians undertaking research on their own, and their colleagues’, clinical practice. Finally we consider the learning taken from this pilot project, making recommendations for taking our experience of clinician–research collaboration further.     

Total Hip Bone Mineral Density as an Indicator of Fracture Risk in Bisphosphonate-Treated Patients in a Real-World Setting

Bone mineral density (BMD) is an established measure used to diagnose patients with osteoporosis. In clinical trials, change in BMD has been shown to provide a reliable estimate of fracture risk reduction, and achieved BMD T-score has been shown to reflect the near-term risk of fracture. We aimed to test the association between BMD T-score and fracture risk in patients treated for osteoporosis in a real-world setting. This retrospective, observational cohort study included Swedish females aged ≥55 years who had a total hip BMD measurement at one of three participating clinics. Patients were separated into two cohorts: bisphosphonate-treated and bisphosphonate-naïve prior to BMD measurement, stratified by age and prior nonvertebral fracture status. The primary outcome was cumulative incidence of clinical fractures within 24 months of BMD measurement, with other fracture types included as secondary outcomes. Associations between T-score and fracture risk were estimated using proportional hazards regression and restricted cubic splines. A total of 15,395 patients were analyzed: 11,973 bisphosphonate-naïve and 3422 bisphosphonate-treated. In the 24 months following BMD measurement, 6.3% (95% confidence interval [CI], 5.9–6.7) of bisphosphonate-naïve and 8.4% (95% CI, 7.5–9.4) of bisphosphonate-treated patients experienced a clinical fracture. Strong inverse relationships between BMD T-score and fracture incidence were observed in both cohorts. Among bisphosphonate-naïve patients, this relationship appeared to plateau around T-score −1.5, indicating smaller marginal reductions in fracture risk above this value; bisphosphonate-treated patients showed a more consistent marginal change in fracture risk across the evaluated T-scores (−3.0 to –0.5). Trends remained robust regardless of age and prior fracture status. This real-world demonstration of a BMD–fracture risk association in both bisphosphonate-naïve and bisphosphonate-treated patients extends evidence from clinical trials and recent meta-regressions supporting the suitability of total hip BMD as a meaningful outcome for the clinical management of patients with osteoporosis. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).     

Muscle Strength and Physical Performance Are Associated With Risk of Postfracture Mortality But Not Subsequent Fracture in Men

Muscle strength and physical performance are associated with incident fractures and mortality. However, their role in the risk of subsequent fracture and postfracture mortality is not clear. We assessed the association between muscle strength (grip strength) and performance (gait speed and chair stands time) and the risk of subsequent fracture and mortality in 830 men with low-trauma index fracture, who participated in the Osteoporotic Fractures in Men (MrOS) USA Study and had their index measurements assessed within 5 years prior to the index fracture. The annual decline in muscle strength and performance following index fracture, estimated using linear mixed-effects regression, was also examined in relation to mortality. The associations were assessed using Cox proportional hazards models adjusted for age, femoral neck bone mineral density (FN BMD), prior fractures, falls, body mass index (BMI), index fracture site, lifestyle factors, and comorbidities. Over a median follow-up of 3.7 (interquartile range [IQR], 1.3–8.1) years from index fracture to subsequent fracture, 201 (24%) men had a subsequent fracture and over 5.1 (IQR, 1.8–9.6) years to death, and 536 (65%) men died. Index measurements were not associated with subsequent fracture (hazard ratios [HRs] ranging from 0.97 to 1.07). However, they were associated with postfracture mortality. HR (95% confidence interval [CI]) per 1 standard deviation (1-SD) decrement in grip strength: HR 1.12 (95% CI, 1.01–1.25) and gait speed: HR 1.14 (95% CI, 1.02–1.27), and 1-SD increment in chair stands time: HR 1.08 (95% CI, 0.97–1.21). Greater annual declines in these measurements were associated with higher mortality risk, independent of the index values and other covariates. HR (95% CI) per 1-SD annual decrement in change in grip strength: HR 1.15 (95% CI, 1.01–1.33) and in gait speed: HR 1.38 (95% CI, 1.13–1.68), and 1-SD annual increment in chair stands time: HR 1.28 (95% CI, 1.07–1.54). Men who were unable to complete one or multiple tests had greater risk of postfracture mortality (24%–109%) compared to those performed all tests. It remains to be seen whether improvement in these modifiable factors can reduce postfracture mortality. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).     

Cost-effectiveness Analysis of Empagliflozin in Japan Based on Results From the Asian subpopulation in the EMPA-REG OUTCOME Trial

PurposeThe goal of this study was to assess the cost-effectiveness of empagliflozin in Japan based on the Asian subpopulation in the EMPA-REG OUTCOME trial.MethodsThe trial has shown a reduction in the risk for cardiovascular (CV) and renal events with empagliflozin in patients with type 2 diabetes mellitus and established CV disease. A cost-effectiveness analysis based on the overall population of the EMPA-REG OUTCOME trial was reported previously by using a lifetime discrete event simulation model. The same modeling frame was adapted to evaluate the cost-effectiveness of treatment with empagliflozin added to standard of care (SoC) compared with SoC alone in Japan. The time to relevant clinical events and the hazard ratios were derived from an Asian subpopulation in the EMPA-REG OUTCOME trial. The costs for each event were estimated from a Japanese medical claims database. Direct medical costs, life expectancy, and quality-adjusted life years (QALYs) were calculated from the public health care perspective.FindingsTreatment with empagliflozin was estimated to increase life expectancy by 6.2 years and 2.7 QALYs, whereas total cost increased by 1,115,475 yen compared with treatment with SoC alone. The incremental cost-effectiveness ratio was 415,849 yen/QALY. In the sensitivity analysis, there was no case that was in excess of the reference value of the incremental cost-effectiveness ratio in the pilot introduction for price revision in Japan (ie, 5 million yen/QALY).ImplicationsBased on the Asian subpopulation in the EMPA-REG OUTCOME trial, our results suggest that empagliflozin added to SoC is highly cost-effective compared with SoC alone in Japan.     

Glucose-Lowering Therapies for Cardiovascular Risk Reduction in Type 2 Diabetes Mellitus: State-of-the-Art Review

Type 2 diabetes mellitus (T2DM) is a major cardiovascular (CV) risk factor. Although antihyperglycemic therapies have typically focused on glycemic control, a paradigm shift for the treatment of T2DM has occurred, with an increased focus on CV risk reduction. Clinicians should base their clinical decisions on the beneficial effects of specific glucose-lowering agents on CV outcomes, while avoiding those therapeutic strategies with potential detrimental effects. Importantly, the presence of comorbidities (eg, established cardiovascular diseases, hypertension, obesity) should also guide the clinical decision toward therapies proven to reduce CV outcomes in that specific population. In this state-of-the-art review resulting from a comprehensive literature search (Pubmed, Google Scholar), we summarize the evidence related to the CV outcomes trials reported in the past several decades. Finally, we propose a therapeutic plan for patients with T2DM, suggesting the use of specific glucose-lowering agents based on the characteristics and presence of comorbidities of the individual patient.     

Importance of Cadence in Bicycle Ergometer Training: A Review

Abstract

Reports concerning the evaluation of therapeutic ergometer training are scarce. Most articles deal with cyclists. The longer the duration of the exercise, the lower the cadence should be. Well-trained cyclists use higher cadences than others because of their skill and coordination. At higher cadences, it is more difficult to direct forces optimally; on the other hand, the peak force generated per pedal thrust decreases with increasing cadence. A higher cadence also means a higher heart rate, ventilation, oxygen uptake and blood lactate concentration. Lowest oxygen uptake and highest efficiency shift to higher frequencies with increasing work load. There are some differences in stress response (central hemodynamics) with regard to pedal speed in normal individuals and in patients suffering from cardiac disease. For non-cyclists, the subjective rating of perceived exertion is supposed to be minimal between 60 and 80 rpm. Patients with coronary heart disease usually rate the exertion higher than do normal individuals in relation to heart rate. The published literature regarding prescribed cadences for therapeutic ergometer training was reviewed, and an attempt was made to arrive at final conclusions in this regard.     

Dissimulation in Phallometric Testing of Rapists' Sexual Preferences

Sexual preferences of 38 rapists were assessedphallometrically with and without a semantic trackingtask in a counterbalanced design. Four categories ofaudiotaped vignettes describing neutral interactions, consenting sex, rape, and nonsexual violencewere employed as stimuli. In the semantic tracking task,participants were instructed to press one button whenviolent events were described in the vignette and another when sexual activities weredescribed. Phallometric assessment with the semantictask better discriminated between rapists andnon-sex-offender participants (from an earlier study)than the same assessment without the task. Among fourrapists who had previous experience with phallometrictesting, there was a very strong correlation betweendeviance scores and tracking accuracy. Results suggest that the semantic task may improve discriminantvalidity, particularly among sex offenders who have hadprevious experience with phallometricassessment.     

Four Cardinal Principles of Joint Mobilization and Joint Play Assessment

Abstract

The teaching and learning of fundamental principles that guide valid and effective assessment and intervention techniques in joint mobilization is a basic foundation to those health professions that make use of manual therapy. Such principles help establish the specificity of manual therapy techniques, the foremost quality of 'best practice.' However, authors of few textbooks or reference books devote space to establishing such fundamental principles for learners and practitioners of manual therapy techniques. The purpose of this paper is to present four cardinal principles that have impressed us, over our years as educators and clinicians, as the foundation for the teaching and practice of sound manual therapy techniques for either joint play assessment or joint mobilization. These principles are utilized in practice from entry-level to master clinicians, they can guide educators as to how to introduce and monitor effective manual therapy skills among students and colleagues, and they can also serve as a source of refreshment for experienced clinicians who desire continuing education for maintenance of their hands-on skills in manual therapy interventions and assessment.     

几丁糖对扩张后皮瓣纤维包膜中胶原含量的影响

BACKGROUND： Previous experiments have confirmed bone morphogenetic proteins （BMPs） upregulate cholinergic expression in neurons isolated from the embryonic rat hippocampus and cerebral cortex. Therefore, BMPs could be useful for treating Alzheimer＇s disease and other neurodegenerative diseases. OBJECTIVE： BMP-4 was infused into the hippocampal dentate gyrus of fomix-fimbria transected rats to test the effects of BMP-4 on cholinergic expression in dentate gyrus neurons, and to observe changes in spatial memory behavior. DESIGN： A randomized controlled animal experiment. SETTING： Department of Neurosurgery and Laboratory for Cell Biology, Institute of Geriatrics, General Hospital of Chinese PLA. MATERIALS： Twenty-seven healthy adult male Sprague Dawley （SD） rats, weighing 250-300 g, were provided by the Laboratory Animal Center of the General Hospital of Chinese PLA. Reagents： BMP-4 （B-2680, Sigma Company） and choline acetyl transferase （CHAT） antibody （AB5042, Chemicon Company） were used in this study. Equipments： a rat stereotaxic instrument （type： SN-2N, Narushige Group, Japan） and Image-prog-plus image analysis software （Media Cybernetics company, USA） were used in this study. The protocol was carried out in accordance with ethical guidelines for the use and care of animals. METHODS： This experiment was performed in the Institute of Geriatrics, General Hospital of Chinese PLA between July 2004 and March 2005. Rats were randomly divided into 4 groups： Alzheimer＇s disease group （n = 7）, normal control group （n = 5）, BMP-4-Alzheimer＇s disease group （n = 8）, and model group （n = 7）. In the Alzheimer＇s disease group, the left hippocampal fomix-fimbria of rats was transected to mimic Alzheimer＇s disease symptoms. In the BMP-4-Alzheimer＇s disease group, 1 μt L BMP-4 （10 mg/L） was perfused into the left dentate gyrus with a microinjector at 1 μ L/min. In the model group, 1 μ L saline was perfused into the same position by the same method