One Week of Hospitalization Following Elective Hip Surgery Induces Substantial Muscle Atrophy in Older Patients

Objectives

Short successive periods of skeletal muscle disuse have been suggested to substantially contribute to the observed loss of skeletal muscle mass over the life span. Hospitalization of older individuals due to acute illness, injury, or major surgery generally results in a mean hospital stay of 5 to 7 days, during which the level of physical activity is strongly reduced. We hypothesized that hospitalization following elective total hip arthroplasty is accompanied by substantial leg muscle atrophy in older men and women.

Haematologic parameters as risk factors for cardiac infarction, in an occupational health care setting

It is still controversial, whether moderately high haematocrit (Ht) and haemoglobin (Hb) values are risk factors for coronary heart disease. Using the computerized data-system of the Periodical Medical Examination (PME) of Phillips' International Electrical Company, a case-control study was carried out. Cases were male workers (n = 104, from 50 to 60 years of age) who had suffered a first, non-fatal myocardial infarction, and who had had a PME prior (on the average 16 months) to the occurrence of infarction. For each case two age-matched healthy controls were selected from the PME-attendancy list (= 208). For each subject information was abstracted from the PME-records about haematologic parameters and covariates (smoking, cholesterol, blood pressure, pulse-rate, weight, height, FEV5, consumption of antihypertensive agents). After dichotomizing the haematocrit and haemoglobin values at their whole sample means (0.46 l/l and 9.7 mmol/l respectively) in "low" (lower than or equal to the mean) and "high" (greater than the mean), crude odds-ratio's of 2.7 (95% CI: 1.6-4.6) and 2.1 (95% CI: 1.2-3.6) were found for Ht and Hb respectively, when comparing "high" with "low" levels. The associations between Ht and Hb, and the occurrence of myocardial infarction were still present after controlling for covariates using multiple logistic regression models, entering the continuous variables with their exact values. After adjustment, mean corpuscular volume (MCV) also appeared to be correlated with infarction. Our results confirm the hypothesis that moderately high haematocrit and--to a lesser extent--haemoglobin and MCV-values are risk factors for the occurrence of myocardial infarction.     

The value of objective measurements to select patients who are malnourished

Several studies have attempted to define nutritional parameters that can be used to select malnourished hospitalised patients for nutritional support. A combination of objective nutritional parameters was evaluated in a group of 50 patients selected for total parenteral nutrition on clinical grounds only and compared with a control group. This control group consisted of 38 patients who were admitted for elective minor surgical procedures such as varicectomy and hernia repair. On a subset of 18 objective nutritional measurements, discriminant analysis was performed. In the evaluation it was shown that a combination of albumin (ALB), prealbumin (PALB), total lymphocyte count (TLC) and the percentage of ideal weight (PIW) was the most useful combination of nutritional tests in discriminating a chosen malnourished (M) group and a control group who were declared not malnourished (NM). With this combination the patients were correctly classified in 93% with a sensitivity of 93% and a specificity of 94%.     

How Are Indeterminate Pulmonary Nodules at Diagnosis Associated with Survival in Patients with High-Grade Osteosarcoma?

BackgroundPulmonary metastases are a poor prognostic factor in patients with osteosarcoma; however, the clinical significance of subcentimeter lung nodules and whether they represent a tumor is not fully known. Because the clinician is faced with decisions regarding biopsy, resection, or observation of lung nodules and the potential impact they have on decisions about resection of the primary tumor, this remains an area of uncertainty in patient treatment. Surgical management of the primary tumor is tailored to prognosis, and it is unclear how aggressively patients with indeterminate pulmonary nodules (IPNs), defined as nodules smaller than 1 cm at presentation, should be treated. There is a clear need to better understand the clinical importance of these nodules.Questions/purposes(1) What percentage of patients with high-grade osteosarcoma and spindle cell sarcoma of bone have IPNs at diagnosis? (2) Are IPNs at diagnosis associated with worse metastasis-free and overall survival? (3) Are there any clinical or radiologic factors associated with worse overall survival in patients with IPN?MethodsBetween 2008 and 2016, 484 patients with a first presentation of osteosarcoma or spindle cell sarcoma of bone were retrospectively identified from an institutional database. Patients with the following were excluded: treatment at another institution (6%, 27 of 484), death related to complications of neoadjuvant chemotherapy (1%, 3 of 484), Grade 1 or 2 on final pathology (4%, 21 of 484) and lack of staging chest CT available for review (0.4%, 2 of 484). All patients with abnormalities on their staging chest CT underwent imaging re-review by a senior radiology consultant and were divided into three groups for comparison: no metastases (70%, 302 of 431), IPN (16%, 68 of 431), and metastases (14%, 61 of 431) at the time of diagnosis. A random subset of CT scans was reviewed by a senior radiology registrar and there was very good agreement between the two reviewers (κ = 0.88). Demographic and oncologic variables as well as treatment details and clinical course were gleaned from a longitudinally maintained institutional database. The three groups did not differ with regard to age, gender, subtype, presence of pathological fracture, tumor site, or chemotherapy-induced necrosis. They differed according to local control strategy and tumor size, with a larger proportion of patients in the metastases group presenting with larger tumor size and undergoing nonoperative treatment. There was no differential loss to follow-up among the three groups. Two percent (6 of 302) of patients with no metastases, no patients with IPN, and 2% (1 of 61) of patients with metastases were lost to follow-up at 1 year postdiagnosis but were not known to have died. Individual treatment decisions were determined as part of a multidisciplinary conference, but in general, patients without obvious metastases received (neo)adjuvant chemotherapy and surgical resection for local control. Patients in the no metastases and IPN groups did not differ in local control strategy. For patients in the IPN group, staging CT images were inspected for IPN characteristics including number, distribution, size, location, presence of mineralization, and shape. Subsequent chest CT images were examined by the same radiologist to reevaluate known nodules for interval change in size and to identify the presence of new nodules. A random subset of chest CT scans were re-reviewed by a senior radiology resident (κ = 0.62). The association of demographic and oncologic variables with metastasis-free and overall survival was first explored using the Kaplan-Meier method (log-rank test) in univariable analyses. All variables that were statistically significant (p < 0.05) in univariable analyses were entered into Cox regression multivariable analyses.ResultsFollowing re-review of staging chest CTs, IPNs were found in 16% (68 of 431) of patients, while an additional 14% (61 of 431) of patients had lung metastases (parenchymal nodules 10 mm or larger). After controlling for potential confounding variables like local control strategy, tumor size, and chemotherapy-induced necrosis, we found that the presence of an IPN was associated with worse overall survival and a higher incidence of metastases (hazard ratio 1.9 [95% CI 1.3 to 2.8]; p = 0.001 and HR 3.6 [95% CI 2.5 to 5.2]; p < 0.001, respectively). Two-year overall survival for patients with no metastases, IPN, or metastases was 83% [95% CI 78 to 87], 65% [95% CI 52 to 75] and 45% [95% CI 32 to 57], respectively (p = 0.001). In 74% (50 of 68) of patients with IPNs, it became apparent that they were true metastatic lesions at a median of 5.3 months. Eighty-six percent (43 of 50) of these patients had disease progression by 2 years after diagnosis. In multivariable analysis, local control strategy and tumor subtype correlated with overall survival for patients with IPNs. Patients who were treated nonoperatively and who had a secondary sarcoma had worse outcomes (HR 3.6 [95% CI 1.5 to 8.3]; p = 0.003 and HR 3.4 [95% CI 1.1 to 10.0]; p = 0.03). The presence of nodule mineralization was associated with improved overall survival in the univariable analysis (87% [95% CI 39 to 98] versus 57% [95% CI 43 to 69]; p = 0.008), however, because we could not control for other factors in a multivariable analysis, the relationship between mineralization and survival could not be determined. We were unable to detect an association between any other nodule radiologic features and survival.ConclusionThe findings show that the presence of IPNs at diagnosis is associated with poorer survival of affected patients compared with those with normal staging chest CTs. IPNs noted at presentation in patients with high-grade osteosarcoma and spindle cell sarcoma of bone should be discussed with the patient and be considered when making treatment decisions. Further work is required to elucidate how the nodules should be managed.Level of EvidenceLevel III, prognostic study.     

Cortical reafferentation following left subcortical hemorrhage: a serial functional MR study

A 48-year-old patient who had aphasia due to a left subcortical hemorrhage underwent three follow-up examinations to assess MR signal changes accompanying recovery. A word classification task was applied. During the 6-month follow-up period, we observed a dynamic change from negative toward positive blood oxygenation level-dependent MR signals, i.e., task-related reafferentation of eloquent cortices occurred. Clinical improvement from aphasia paralleled the MR signal changes.     

MIB-1 labelling index is an independent prognostic marker in primary breast cancer.

The proliferative activity of a tumour is considered to be an important prognostic factor in primary breast cancer. We have investigated the prognostic value of the MIB-1 labelling index in 341 patients with primary breast cancer and compared the results with the S-phase fraction in 220 patients of the same cohort. All patients were treated in one hospital and had a median follow-up of 128 months. No correlation between MIB-1 labelling and S-phase fraction could be demonstrated. MIB-1 had prognostic value for disease-free survival in the whole group of patients (P < 0.001) and in the node-negative subgroup (P < 0.001). In multivariate analysis, MIB-1 was an independent prognostic factor (P = 0.004) besides axillary lymph node status (P = 0.001). In univariate analysis high S-phase fraction was associated with decreased overall survival (P = 0.04); however, not in multivariate analysis. Moreover, S-phase fraction had a borderline prognostic significance for post-relapse survival in multivariate analysis (P= 0.08). Thus, in conclusion, the growth fraction of a tumour as determined by the MIB-1 labelling index is an important prognostic factor in patients with primary breast cancer.     

Preterm Infants 30–36 Weeks' Gestation in Victoria — Where Should They Be Delivered?

Summary: There is little doubt that very preterm infants <30 weeks' gestation should be born in level-3 perinatal centres. For preterm infants 30–36 weeks' gestation, however, the optimum place of birth is not so clear-cut. The aims of this study of livebirths 30–36 weeks' gestational age born in Victoria were to determine: 1) the proportions delivered outside level-3 centres, and 2) for infants born outside level-3 centres, the proportions transferred after birth to a level-3 nursery in the first days after birth. Data on the number of livebirths 30–36 weeks' gestational age in Victoria in the 3 years 1994–1996, inclusive, were supplied by the Victorian Perinatal Data Collection Unit. Data were obtained from the Newborn Emergency Transport Service (NETS) on all transfers within the first 3 days after birth to a level-3 centre for infants born outside level-3 centres. For the 3 years 1994–1996 there were 11,375 livebirths 30–36 weeks' gestational age in Victoria. The proportion born outside a level-3 perinatal unit was 57.9% overall, and rose with increasing gestational age, from 10.9% at 30 weeks to 69.0% at 36 weeks. Of the 6,587 livebirths outside a level-3 centre, 808 (12.3%) were transferred within the first 3 days after birth by NETS to a level-3 centre, the proportions falling with increasing maturity, being 73.7%, 48.5%, 28.4%, 26.9%, 18.8%, 11.8%, and 7.0% at 30, 31, 32, 33, 34, 35, and 36 weeks, respectively. These data may help medical practitioners when determining the place of delivery for infants 30–36 weeks' gestation.