Frailty among Older Adults and Its Distribution in England.

BACKGROUND: Information on the spatial distribution of the frail population is crucial to inform service planning in health and social care. OBJECTIVES: To estimate small-area frailty prevalence among older adults using survey data. To assess whether prevalence differs between urban, rural, coastal and inland areas of England. DESIGN: Using data from the English Longitudinal Study of Ageing (ELSA), ordinal logistic regression was used to predict the probability of frailty, according to age, sex and area deprivation. Probabilities were applied to demographic and economic information in 2020 population projections to estimate the district-level prevalence of frailty. RESULTS: The prevalence of frailty in adults aged 50+ (2020) in England was estimated to be 8.1 [95% CI 7.3-8.8]%. We found substantial geographic variation, with the prevalence of frailty varying by a factor of 4.0 [3.5-4.4] between the most and least frail areas. A higher prevalence of frailty was found for urban than rural areas, and coastal than inland areas. There are widespread geographic inequalities in healthy ageing in England, with older people in urban and coastal areas disproportionately frail relative to those in rural and inland areas. CONCLUSIONS: Interventions aimed at reducing inequalities in healthy ageing should be targeted at urban and coastal areas, where the greatest benefit may be achieved.

[Pilot study on pain response patterns in chronic low back pain. The influence of pain response patterns on quality of life, pain intensity and disability]. / Schmerzverarbeitungspattern bei chronischen Rückenschmerzen Pilotstudie. Der Einfluss von "Avoidance-Endurance"-Modell-Pattern auf die Lebensqualität, Schmerzintensität und Beeinträchtigung.

BACKGROUND: The variables pain intensity (SI), disability (DS) and quality of life (QoL) belong to a set of primary patient-based outcomes in chronic low back pain (CLBP). The avoidance-endurance model (AEM) assumes three maladaptive and one adaptive pain response pattern. The purpose of this study was to study the level and course of the outcomes with regard to the four AEM patterns. PATIENTS AND METHODS: A total of 52 CLBP inpatients were investigated at 2 points in time: during the first days after admission and 6 months after the acute exacerbation of pain. Differences between AEM patterns were analyzed with repeated measurement analyses of variance. RESULTS: Groups differences were found for SI (F((3, 48))=2.82, p<0.05), general (F((3, 48))=6.78, p<0.05) and health-related QoL (F((3, 48))=5.99, p <0.05). In contrast, for the variable disability only a significant time effect was found. CONCLUSION: The results show differences in the level and process of SI, DS and QoL between the subgroups. An AEM-based classification of subgroups is also reasonable for CLPB patients.

The ORNATE India Project: United Kingdom-India Research Collaboration to tackle visual impairment due to diabetic retinopathy.

INTRODUCTION: The ORNATE India project is funded by the UK Research and Innovation (UKRI) through the Global Challenges Research Fund. The aim is to build research capacity and capability in India and the UK to tackle global burden of diabetes-related visual impairment. As there are over 77 million people with diabetes in India, it is challenging to screen every person with diabetes annually for sight-threatening diabetic retinopathy (DR). Therefore, alternate safe approaches need to be developed so that those at-risk of visual impairment due to DR is identified promptly and treated. METHODS: The project team utilised diverse global health strategies and research methods to co-design work packages to build research capacity and capability to ensure effective, affordable and efficient DR services are made available for the population. The strategies and methods employed included health system strengthening; implementation science; establishing care pathways; co-designing collaborative studies on affordable technologies, developing quality standards and guidelines to decrease variations in care; economic analysis; risk modelling and stratification. Five integrated work packages have been developed to deal with all aspects of DR care. These included implementation of a DR screening programme in the public health system in a district in Kerala, evaluating regional prevalence of diabetes and DR and assessing ideal tests for holistic screening for diabetes and its complications in 20 areas in India, utilising artificial intelligence on retinal images to facilitate DR screening, exploring biomarker and biosensor research to detect people at risk of diabetes complications, estimating cost of blindness in India and risk modelling to develop risk-based screening models for diabetes and its complications. A large collaborative network will be formed to propagate research, promote shared learning and bilateral exchanges between high- and middle-income countries to tackle diabetes-related blindness.

Prostaglandin release from rat femurs after implantation of hydroxylapatite and aluminium oxide ceramics.

The bony reaction after implantation of uncemented ceramics is of special interest. Therefore porous and dense hydroxylapatite and aluminium oxide ceramics were implanted in rat femurs. One group received no surgical manipulation and another with a sham procedure where no ceramics were implanted served as controls. After 6 and 10 days the rat femurs were harvested and the release of PGE2 and 6-keto-PGF1 alpha was measured with specific radioimmunoassays. Decrease in the release of PGE2 from day 6 to day 10 was present in all three implants. In contrast, 6-keto-PGF1 alpha increased from day 6 to day 10. Comparing the ceramic types an increase in 6-keto-PGF1 alpha release was seen in the porous hydroxylapatite group. These prostaglandin (PG) release patterns after ceramic implantation are similar to those of fracture healing, but aluminium oxide seems to be inert, while hydroxylapatite, especially the porous type, stimulates 6-keto-PGF1 alpha release.

In vitro hyperextension injuries in the human cadaveric cervical spine.

To investigate the relationship between the type of hyperextension injuries and the conditions producing them, nine cervical specimens (occiput to T1) were loaded to failure in tension at a fixed extension angle of 30 degrees. Under these loading conditions, specimens failed at average tensile loads and extension moments of 499 +/- 148 (SD) N and 4.0 +/- 3.1 Nm, respectively. Failure occurred at an average tensile displacement of 18.8 +/- 7.7 mm. The anterior longitudinal ligament ruptured and the intervertebral disc failed in at least one level in all specimens. In four specimens, the disc failed at an additional level, leaving the anterior longitudinal ligament intact at that site. With one exception, all injuries occurred in the lower cervical spine (C5-C6 and C6-C7), the region most often injured in vivo. The location of the injuries was associated with the degree of degeneration of the facet joints and the discs. The discs of the lower cervical spine were significantly more degenerated than those at the C2-C3 level. In addition, the degree of disc degeneration in the noninjured discs was significantly less than in the injured discs. These data help quantify the threshold of injury and the patterns of tissue damage resulting from hypertension loading of the cervical spine.

Physical and mechanical properties of calf lumbosacral trabecular bone.

The physical and mechanical properties of calf lumbar and sacral trabecular bone were determined and compared with those of human trabecular bone. The mean tissue density (1.66 +/- 0.12 g cm-3), equivalent mineral density (169 +/- 36 mg cm-3), apparent density (453 +/- 89 mg cm-3), ash density (194 +/- 59 mg cm-3), ash content (0.6 +/- 0.05%), compressive strength (7.1 +/- 3.0 MPa) and compressive modulus (173 +/- 97 MPa) of calf trabecular bone are similar to those of young human. There were moderate, positive linear correlations between apparent density and equivalent mineral density, ash density, and compressive strength; and between compressive strength and equivalent mineral density (R2 ranging from 0.35 to 0.48, p less than 0.001). Apparent density, ash density, and equivalent mineral density did not differ significantly in different regions. In contrast to humans, the compressive strength increased from posterior, near the facet, to the anterior vertebral body. These comparisons of physical and mechanical properties, as well as anatomical comparisons by others, indicate that the calf spine is a good model of the young non-osteoporotic human spine and thus useful for the testing of spinal instrumentation.

Prostaglandin release from lumbar disc and facet joint tissue.

OBJECTIVES: The authors measured prostaglandin (PG) and leukotriene (LT) release from human disc and lumbar facet joint tissues. SUMMARY OF BACKGROUND DATA: High levels of phospholipase A2 (PLA2) have been measured in the human disc. PLA2 releases fatty acids from lipid membranes. These can be converted to PG and LT, which are potent inflammatory mediators and supposed to be involved in lumbar diseases. METHODS: The tissues were obtained during surgery and incubated in Tyrode's solution. PG and LT release was measured radioimmunologically from the supernatant. RESULTS: Disc (4 ng/g wet weight), cartilage (21 ng/g wet weight), and bone (14 ng/g wet weight) released PGs but no LTs. CONCLUSION: Because PG release from sequestrated disc is rather low, the inflammatory effect might be more because of immunologic reactions.

Flexibility and distraction after monosegmental and bisegmental lumbosacral fixation with angular stable fixators.

STUDY DESIGN: In human lumbosacral spines, the flexibility and intersegmental distraction allowed by four monosegmental and bisegmental intrapedicular devices during compression and flexion/compression loading were investigated. OBJECTIVES: To compare the flexibility and intersegmental distraction allowed by four monosegmental and bisegmental intrapedicular, lumbosacral fixation devices applied to destabilized cadaveric spines, and to determine the effect of each device on the flexibility and intersegmental distraction of the motion segment above each fused segment. SUMMARY OF BACKGROUND DATA: The lumbosacral segment is the most mobile region in the lumbar spine, exhibiting the highest range of motion in both flexion and extension. Therefore, the fixation of this and the adjacent segment is of special clinical interest. METHODS: L5-S1 facetectomy or L5 laminectomy procedures were performed on cadaveric human lumbosacral spines. Fixation devices then were applied across one or two levels, and intersegmental motion under flexion/compression or under pure compression loads was monitored. RESULTS: The flexibility and posterior strain allowed by the four implants did not differ significantly between implants. The strain across the stabilized site (monosegmental and bisegmental) was below 10% for all devices tested. The flexibility and distraction were reduced to levels below intact after the fixators were applied. The distraction across the segment above the fusion was not increased because of fixation with these four fixators. CONCLUSIONS: Angular stable fixation devices, such as those described here, provide adequate stabilization of the posteriorly destabilized spine.

Five-year results from chemonucleolysis with chymopapain or collagenase: a prospective randomized study.

STUDY DESIGN: A 5-year clinical follow-up assessment of a prospective randomized study of chemonucleolysis using chymopapain (4000 IU) or collagenase (400 ABC units) was performed. SUMMARY OF BACKGROUND DATA: Intradiscal therapy can be performed for patients with contained discs by chemonucleolysis, percutaneous discectomy, or laser ablation. The oldest intradiscal therapy is chemonucleolysis with chymopapain. OBJECTIVE: The purpose of this study was to compare prospectively the efficacy of chymopapain and collagenase for intradiscal injection. METHODS: In this study, 100 patients with indication for intradiscal therapy were prospectively randomized to treatment with either chymopapain or collagenase. All the injections were performed by the double-needle technique with the patient under general anesthesia. The mean age of the patients was 35.5 years in the chymopapain group and 38 years in the collagenase group. An equal number of injections was performed at L4-L5 and L5-S1. RESULTS: After 5 years, good and excellent results were observed in 72% of the chymopapain group and 52% of the collagenase group when the surgically treated and lost patients were graded as poor. Using a scale of 0 (no pain) to 10 (intractable pain), the pain level dropped from 8.5 to 0.7 in the chymopapain group and from 8.6 to 0.9 in the collagenase group. Microdiscectomy at the injected level was required for 23 patients (14 in the collagenase group and 9 in the chymopapain group). CONCLUSIONS: After 5 years, no deterioration had occurred, as compared with the 1-year follow-up assessment. Chymopapain has proved to be safe, with one minor anaphylactic reaction, and effective even over the long term. Collagenase may need further study and cannot be recommended at this time.

Load-sharing characteristics of stabilized lumbar spine segments.

STUDY DESIGN: Load sharing in stabilized spinal segments was evaluated using sequential injury and stabilization with a posterior instrumentation system under an in vitro flexibility protocol. OBJECTIVE: To analyze the partitioning of applied loads between anatomic and implanted structures of lumbar functional spinal units stabilized with a posterior instrumentation system. To identify surgical indications for which the risk of fixator breakage in vivo is high. SUMMARY OF BACKGROUND DATA: Relatively few groups have experimentally measured the in vitro and in vivo forces and/or moments supported by posterior instrumentation systems, and no analysis, of the load sharing in these systems has been performed. This information will provide novel insight into implant fatigue life, and the degree to which the spinal anatomy is shielded from the applied load and will allow the verification of mathematical models for new injury scenarios. METHODS: Specimen kinematics were determined using an optoelectronic tracking system. Intradiscal pressure and the forces and moments supported by the implants were measured using, respectively, a needle-mounted pressure sensor and strain gauges mounted on the spinal implants. RESULTS: A large majority of the applied moments were supported by an equal and opposite force pair between the intervertebral disc and fixator rods in flexion and extension and an equal and opposite force pair between the left and right fixator rods in lateral bending. Torsional moments were shared approximately equally between the posterior elements, intervertebral disc, an equal and opposite shear force pair in the transverse plane between the right and left fixators and internal fixator moments. CONCLUSIONS: When posterior instrumentation devices are used to stabilize severe anterior column injuries, they are at risk of fracture secondary to reversed bending moments.

Compressive strength of autologous and allogenous bone grafts for thoracolumbar and cervical spine fusion.

The selection of the bone graft type for stabilization of spinal fusion depends on availability, the clinical situation, and the desired mechanical stability. The authors determined the potential immediate postoperative compressive strength of various types of bone grafts under axial compression on a material testing machine. The fibular strut graft (5,070 +/- 3,250 N, mean +/- standard deviation [SD]) was significantly stronger (P less than 0.05) than the anterior (1,150 +/- 487 N) and posterior (667 +/- 311 N) iliac crest grafts, and the rib grafts (452 +/- 192 N). Hydroxyapatite grafts with a pore size of 200 mu were significantly stronger (P less than 0.05) than those with a pore size of 500 mu (1,420 +/- 480 N versus 338 +/- 78 N). Ethylenoxide sterilization had no significant effect on the immediate compressive strength. Bicortical and tricortical Bailey-Badgley and Cloward bone grafts also were compared. Results showed that all cervical graft types may be sufficiently strong to support sizable loads.

Importance of bone mineral density in instrumented spine fusions.

The effect of equivalent mineral density on pedicular screw fixation strength was investigated. The equivalent mineral density of human vertebral bodies was correlated highly with the pullout force of Kluger screws (r2 = 0.61, P less than 0.02). A moderate to high correlation existed between density and vertical force (r2 = 0.42 for Kluger screws, r2 = 0.55 for Steffee screws, P less than 0.02). In calf vertebral bodies of higher density (146 +/- 14 mg/cc), the forces were significantly higher than in the human vertebral bodies (P less than 0.05). Human lumbosacral spines were instrumented with three different fixators: Steffee plates, AO fixateur interne, and Kluger fixateur interne. Of five specimens with a mean density of 88 +/- 11 mg/cc, one screw loosened. More than one screw loosened in six specimens with a mean density of 63 +/- 12 mg/cc, and no screw loosened in four specimens with a mean density of 114 +/- 38 mg/cc. Measurement of equivalent mineral density correlates with the fixation strength of the intrapedicular screws in vitro and should be considered in patients with signs of osteopenia before using pedicular screws for spinal fusions. It is also concluded that calf spines are a good model for testing implants because they tend to focus failure processes in the implant rather than in the implant-bone interface.

A biomechanical study of the fatigue characteristics of thoracolumbar fixation implants in a calf spine model.

Clinical failures of internal fixation implants for the treatment of the thoracolumbar spine are generally attributed to fatigue. Few studies, however, have characterized changes in fixation rigidity with time or subjected spine-implant fixation constructs to fatigue loading until failure. Fatigue characteristics of five dorsally applied spinal fixation implants were determined using lumbosacral calf spines, with an L3 vertebrectomy, loaded cyclically in combined compression (maximum 605 N) and flexion (maximum 16 Nm) for up to 100,000 cycles. Displacement transducers monitored motion at the site of instability and at the segment above the implants. Flexibility and strain at these segments were then calculated. A one-way analysis of variance showed that there were no significant differences in flexibility of the five fixation constructs (P greater than .05). A multiple Bonferroni test revealed that the AO and Kluger fixateur interne and Steffee plates, with fixation at L2 and L4, allowed significantly more strain (P less than .01) across the site of instability than did Harrington rods and Luque plates with fixation at L1, L2, L4, and L5. There were no significant differences between fixation constructs in initial strain above the implants. After 10,000 cycles, however, there were significant increases in strain across the segment above the Luque and Harrington implants (P less than .05). Failure of the AO Schanz screw occurred in three of six constructs at a mean of 73,300 cycles. The Steffee screws failed in four of five constructs at a mean of 20,800 cycles. The rods of the Kluger fixateur interne broke in four of five constructs at a mean of 47,800 cycles, and one screw slipped at 11,000 cycles. There were no metal failures in the Harrington or Luque implants.(ABSTRACT TRUNCATED AT 250 WORDS)

[Ultrasonic velocity measurements at weight-bearing and non-weight-bearing sites of the peripheral skeleton. The effect of physical activity in soccer players]. / Ultraschallgeschwindigkeitsmessungen an belastungstragenden und nicht-belastungstragenden Stellen des peripheren Skeletts. Der Einfluss körperlicher Aktivität bei Fussballspielern.

Ultrasound transmission velocity at the appendicular skeleton is determined by elastic properties of the bone as mass density. We evaluated ultrasound transmission velocity at the os calcis of both feet and at the proximal phalanges of DII and DIII of both hands in 51 male subjects. 28 of them were professional soccer players of the 1st German division, 11 subjects performed non-professional exercise in various athletic organisations regularly and 12 did not exercise at all. A significant difference in the speed of sound could be seen at os calcis, where the soccer players had higher velocities than the other groups. The differences between the groups at the upper and lower extremities suggest that changes in ultrasound transmission velocity are not only affected by structural changes in the aging skeleton, as it might be suggested by age differences, but by exercise. Physical exercise can change the properties (structure and/or density) of weightbearing bone and this can be detected by measuring ultrasound velocity.

Heterotopic ossification after spinal cord injury. Epidemiology and risk factors.

From 1981 to 1986 we treated 413 patients for acute spinal-cord injuries. We reviewed 356 patients followed for a minimum of two years of whom 71 (20%) developed heterotopic ossification around one or more joints. Heterotopic ossification occurred more often in male patients (23%) than in female (10%), and was most frequent in the 20- to 30-year age group. It was also more common after injuries of the lower cervical or thoracic spine than after those of the lumbar spine. Patients with severe neurological deficits (Frankel grades A and B) showed significantly more heterotopic ossification but there was no correlation with the number or severity of associated head and limb injuries. Serum calcium levels did not change significantly in either group for 30 weeks after injury, but the erythrocyte sedimentation rate and the alkaline phosphatase level were significantly increased at six weeks in patients with heterotopic ossification.

Aspects of the creative process in music: a case report.

A gifted patient, hampered by his ambivalent strivings, began to write music during his analysis and became a professional composer. I have attempted to show a parallel between the analytic and the creative process. Both in his use of dreams and his particular style of free association, the original idea appeared in fully developed form, marked by key themes. As his ambivalent strivings were analyzed, his narcissistic libido was used less and less as a substitute for ego-strivings, but, instead, as countercathexis. With the freeing of ego functioning, the patient appeared to concentrate on working through, which parallels the development section in music and seems to contain one of the significant aspects of the creative process.

Stand-alone performance of a computer-assisted detection prototype for detection of acute pulmonary embolism: a multi-institutional comparison.

OBJECTIVE: To assess whether the performance of a computer-assisted detection (CAD) algorithm for acute pulmonary embolism (PE) differs in pulmonary CT angiographies acquired at various institutions. METHODS: In this retrospective study, we included 40 consecutive scans with and 40 without PE from 3 institutions (n = 240) using 64-slice scanners made by different manufacturers (General Electric; Philips; Siemens). CAD markers were classified as true or false positive (FP) using independent evaluation by two readers and consultation of a third chest radiologist in discordant cases. Image quality parameters were subjectively scored using 4/5-point scales. Image noise and vascular enhancement were measured. Statistical analysis was done to correlate image quality of the three institutions with CAD stand-alone performance. RESULTS: Patient groups were comparable with respect to age (p = 0.22), accompanying lung disease (p = 0.12) and inpatient/outpatient ratio (p = 0.67). The sensitivity was 100% (34/34), 97% (37/38) and 92% (33/36), and the specificity was 18% (8/44), 15% (6/41) and 13% (5/39). Neither significantly differed between the institutions (p = 0.21 and p = 0.820, respectively). The mean number of FP findings (4.5, 6.2 and 3.7) significantly varied (p = 0.02 and p = 0.03), but median numbers (2, 3 and 3) were comparable. Image quality parameters were significantly associated with the number of FP findings (p<0.05) but not with sensitivity. After correcting for noise and vascular enhancement, the number of FPs did not significantly differ between the three institutions (p = 0.43). CONCLUSIONS: CAD stand-alone performance is independent of scanner type but strongly related to image quality and thus scanning protocols.

Comparison of automated 4-chamber cardiac views versus axial views for measuring right ventricular enlargement in patients with suspected pulmonary embolism.

PURPOSE: Compare the right ventricle to left ventricle (RV/LV) diameter ratio obtained from axial pulmonary CT angiograms (CTPA) with those derived from automatically generated 4-chamber (4-CH) reformats in patients with suspected pulmonary embolism (PE). METHODS: In this institutional review board-approved study we included 120 consecutive non ECG-gated CTPA from 3 institutions (mean age 60 ± 16 years; 71 women). Twenty 64-slice CTPA with PE and 20 without PE were selected per institution. For each patient the RV/LV diameter ratio was obtained from both axial CTPA images and automatically generated 4-CH reformats. Measurements were performed twice in two separated sessions by 2 experienced radiologists and 2 residents. The differences between the measurements on both views were evaluated. RESULTS: The 4-CH view was successfully obtained in 113 patients. The mean axial and 4-CH diameter ratios were comparable for three of the four readers (p = 0.56, p = 0.13, p = 0.08). Although the mean diameters (1.0 and 1.03 respectively) for one resident were significantly different (p = 0.013), the difference of 0.03 seems negligible in clinical routine. Three readers achieved equally high intra-reader agreements with both measurements (ICCs of 0.94, 0.95 and 0.96), while one reader showed a different variability with ICCs of 0.96 for the axial view and 0.91 for the 4-CH view. The inter-reader agreement was equally high for both measurement types with ICCs of 0.95 and 0.94, respectively. CONCLUSION: In patients with suspected PE, RV/LV diameters ratio can be measured with the same reproducibility and accuracy using an automatically generated 4-CH view compared to the axial view.