Does post acute care reduce the mortality of octogenarian and nonagenarian patients undergoing hip fracture surgery?

BACKGROUND: With the increasing number of elderly individuals worldwide, a greater number of people aged 80 years and older sustain fragility fracture due to osteopenia and osteoporosis. METHODS: This retrospective study included 158 older adults, with a median age of 85 (range: 80-99) years, who sustained hip fragility fracture and who underwent surgery. The patients were divided into two groups, one including patients who joined the post-acute care (PAC) program after surgery and another comprising patients who did not. The mortality, complication, comorbidity, re-fracture, secondary fracture, and readmission rates and functional status (based on the Barthel index score, numerical rating scale score, and Harris Hip Scale score) between the two groups were compared. RESULTS: The patients who presented with fragility hip fracture and who joined the PAC rehabilitation program after the surgery had a lower rate of mortality, readmission rate, fracture (re-fracture and secondary fracture), and complications associated with fragility fracture, such as urinary tract infection, cerebrovascular accident, and pneumonia (acute coronary syndrome, out-of-hospital cardiac arrest, or in-hospital cardiac arrest. CONCLUSIONS: PAC is associated with a lower rate of mortality and complications such as urinary tract infection, bed sore, and pneumonia in octogenarian and nonagenarian patients with hip fragility fracture.

Betulin Accelerated the Functional Recovery of Injured Muscle in a Mouse Model of Muscle Contusion.

Muscle contusion is an injury to muscle fibers and connective tissues. It commonly happens in impact events, and could result in pain, swelling, and limited range of motion. Diclofenac is one of commonly used nonsteroidal anti-inflammatory drugs to alleviate pain and inflammation after injury. However, it can potentially cause some side effects including gastrointestinal complications and allergy. Betulin is a lupine-type pentacyclic triterpenoid. It is showed to have valuable pharmacological effects, but the physiological effect of betulin on muscle contusion has not been reported. This study aimed to explore the therapeutic effects of betulin on muscle contusion that produced by the drop-mass method in mice. C57BL/6 mice were randomly assigned to control (no injury), only drop-mass injury (Injury), diclofenac treatment (Injury+diclofenac), and betulin treatment (Injury+betulin) groups. Injury was executed on the gastrocnemius of the right hind limb, and then phosphate-buffered saline (PBS), diclofenac, or betulin were oral gavage administrated respectively for 7 days. Results revealed that betulin significantly restored motor functions based on locomotor activity assessments, rota-rod test, and footprints analysis. Betulin also attenuated serum creatine kinase (CK) and lactate dehydrogenase (LDH) levels after muscle injury. Neutrophil infiltration was alleviated and desmin levels were increased after betulin treatment. Our data demonstrated that betulin attenuated muscle damage, alleviated inflammatory response, improved muscle regeneration, and restored motor functions after muscle contusion. Altogether, betulin may be a potential compound to accelerate the repair of injured muscle.

Attenuation of Endoplasmic Reticulum Stress Enhances Carvacrol-Induced Apoptosis in Osteosarcoma Cell Lines.

Carvacrol is a monoterpenoid phenol that has excellent antimicrobial, antiviral, and anti-inflammatory activities. It can also improve wound healing. However, few studies have explored its antitumor effect on osteosarcoma. In this report, we tried to determine the potential efficacy of carvacrol against osteosarcoma cell lines. Our data revealed that carvacrol exposure inhibited the proliferation of osteosarcoma HOS and U-2 OS cells. In addition, carvacrol exposure enhanced the levels of cleaved PARP and caspase 3 and increased annexin V-positive cells, indicating that carvacrol exposure triggers apoptosis in osteosarcoma cell lines. Furthermore, the levels of reactive oxygen species (ROS) were enhanced after carvacrol exposure and cotreatment with NAC, the ROS scavenger, decreased the levels of cleaved PARP and caspase 3, suggesting the involvement of ROS in carvacrol-induced apoptosis. Importantly, we found that carvacrol exposure triggered several protein expressions related to endoplasmic reticulum (ER) stress, including GRP78/Bip, IRE1a, PERK, and CHOP, in HOS and U-2 OS cells, indicating that carvacrol exposure could result in ER stress in these cell lines. Cotreatment with the ER stress inhibitor 4-PBA increased the levels of cleaved PARP and caspase 3 and further suppressed cellular proliferation in carvacrol-exposed osteosarcoma cell lines. Overall, the results indicate that induced ER stress can protect cells from apoptosis, but increased ROS contributes to apoptosis in carvacrol-treated cells. In this report, we first demonstrate the role of ER stress in carvacrol-induced apoptosis and suggest that ER stress could be targeted to enhance the antitumor activity of carvacrol in osteosarcoma cell lines.

Acute generation of reactive oxygen species that induced by doxycycline pretreatment results in rapid cell death in polyphyllin G-treated osteosarcoma cell lines.

Polyphyllin G, a pennogenyl saponin extracted from Paris polyphylla, has been shown to possess antitumor effects. In this study, we demonstrated that doxycycline, an antibiotic medicine, could significantly enhance the sensitivities of osteosarcoma cell lines to polyphyllin G. As the cells were pretreated with doxycycline at non-toxic concentrations and then co-exposed to polyphyllin G, this combination could induce a rapid cell death distinct from apoptosis. The non-apoptotic cell death was characterized by a loss of integrity of plasma membrane without externalization of phosphatidyl serine. Furthermore, this combined treatment resulted in suppression of cell viability and colony-forming ability, and increased the level of γ-H2A.X, a critical marker for DNA damage, in osteosarcoma cell lines. When examining the underlying mechanism, it was revealed combination of polyphyllin G and doxycycline triggered an enhanced generation of reactive oxygen species (ROS), and up-regulated mitochondrial oxidative stress within 0.5 h. Co-administration of the ROS inhibitor NAC reversed the suppressed cell viability and colony-forming ability, and abolished the increased level of γ-H2A.X in the cells with the combined treatment, indicating that the enhanced ROS was involved in the anti-proliferative effect of the combined treatment. Overall, the results demonstrated that doxycycline may function as chemosensitizers by inducing an acute and lethal ROS production to enhance cytotoxic of polyphyllin G in osteosarcoma cell lines, and the combined use of drugs may provide an alternative thinking for the development of new therapeutic agents.

Does nail size or difference between canal and nail diameter influence likelihood of union or time to union of femoral shaft fractures treated with intramedullary nailing? A retrospective cohort study.

BACKGROUND: This study aims to determine whether nail size or the difference between canal and nail diameter (CN difference) affects the union rate and time of femoral shaft fracture treated with an interlocking intramedullary nail (IMN). METHODS: This was a retrospective review of 257 patients with femoral shaft fractures treated with IMN at a tertiary trauma medical center. All the IMN inserted were the same (Stryker T2 Femoral Nail). The patients were divided into groups based on nail size (10-, 11-, 12-, or 13-mm) and CN difference (< 1, 1-2, or > 2 mm), and union rate and time to union were compared. RESULTS: The 10-, 11-, 12-, and 13-mm groups based on nail size had 113, 74, 54, and 16 patients, respectively. The overall union rate was 97% (257/265). No significant differences in union rate or time to union were observed among these 4 groups. The groups based on CN differences of < 1-, 1 to 2, and > 2 mm comprised 143, 79, and 35 patients, respectively. Again, no significant differences were noted in union rate or mean time to union among the groups. CONCLUSIONS: Similar union rate and time to union were observed, regardless of nail size or CN difference. This finding indicates that most simple femoral shaft fractures can be treated with a standard, reamed 10-mm IMN. A larger nail insertion is unnecessary and presents more risks; comparatively, the use of a small nail with less reaming is simpler, requires shorter operative times, results in less blood loss, and is less expensive.

Different Cell Responses to Hinokitiol Treatment Result in Senescence or Apoptosis in Human Osteosarcoma Cell Lines.

Hinokitiol is a tropolone-related compound isolated from the heartwood of cupressaceous plants. It is known to exhibit various biological functions including antibacterial, antifungal, and antioxidant activities. In the study, we investigated the antitumor activities of hinokitiol against human osteosarcoma cells. The results revealed that hinokitiol treatment inhibited cell viability of human osteosarcoma U-2 OS and MG-63 cells in the MTT assay. Further study revealed that hinokitiol exposure caused cell cycle arrest at the S phase and a DNA damage response with the induction of γ-H2AX foci in both osteosarcoma cell lines. In U-2 OS cells with wild-type tumor suppressor p53, we found that hinokitiol exposure induced p53 expression and cellular senescence, and knockdown of p53 suppressed the senescence. However, in MG-63 cells with mutated p53, a high percentage of cells underwent apoptosis with cleaved-PARP expression and Annexin V staining after hinokitiol treatment. In addition, up-regulated autophagy was observed both in hinokitiol-exposed U-2 OS and MG-63 cells. As the autophagy was suppressed through the autophagy inhibitor chloroquine, hinokitiol-induced senescence in U-2 OS cells was significantly enhanced accompanying more abundant p53 expression. In MG-63 cells, co-treatment of chloroquine increased hinokitiol-induced apoptosis and decreased cell viability of the treated cells. Our data revealed that hinokitiol treatment could result in different cell responses, senescence or apoptosis in osteosarcoma cell lines, and suppression of autophagy could promote these effects. We hypothesize that the analysis of p53 status and co-administration of autophagy inhibitors might provide more precise and efficacious therapies in hinokitiol-related trials for treating osteosarcoma.

Exploring the Effectiveness of PAC Rehabilitation for Elders with Hip Surgery: A Retrospective Study.

BACKGROUND: Hip fractures are high risk and high-impact events in the elderly population; despite orthopedic hip surgery, the disability and mortality rate remains significant. The National Health Insurance Agency in Taiwan established a fragility fracture PAC rehabilitation program to provide functional recovery for these patients after the surgery. However, the current literature on PAC rehabilitation is outdated, and there is an urgent need for the re-evaluation of the program. METHODS: This is a retrospective cohort study that enrolled 159 patients in the PAC rehabilitation program, followed by hip repair surgery. Outcome measures were the differences in participants' pre- and post-PAC scores in 1) Barthel index, 2) Numerical Rating Scale (NRS), and 3) Harris Hip Scores (HHS) as surrogate indicators of the functional status, followed by the analysis of subgroups, including sex, age, site of the fracture, type of procedure, and the number of comorbidities. RESULTS: After completing PAC rehabilitation, 86.2% of the patients successfully returned to the community with either home or out-patient rehabilitation. The re-admission rate was 3.1% and 3.8% in 14-days and in 30-days follow up, respectively. The difference in pre- and post-Barthel index, NRS, and HHS showed significant improvement (p<0.001), without significant variations between the subgroups. Additionally, the Barthel index showed a positive correlation to HHS and a negative correlation to NRS. CONCLUSION: This study revealed that the current form of post-surgery fragility fracture PAC program effectively improves functional status, reduces the re-admission rate, and facilitates the patient transition back to the community. The results should improve patients' and physicians' confidence in such a program.

Butein induces cellular senescence through reactive oxygen species-mediated p53 activation in osteosarcoma U-2 OS cells.

Butein is a flavonoid isolated from various medicinal plants. It is known to have different biological activities including anti-inflammation, anti-adipogenesis, and anti-angiogenesis. In the study, we demonstrated the anti-proliferative effect of butein in human osteosarcoma U-2 OS cells. Our data showed that butein significantly suppressed the viability and colony formation ability of U-2 OS cells. Further experiments revealed butein exposure resulted in a cell cycle arrest at S and G2/M phase in U-2 OS cells. Importantly, we found that butein activated the tumor suppressor p53, and trigged a p53-dependent senescence in U-2 OS cells. Knockdown of p53 suppressed the senescence and rescued the viability in butein-treated U-2 OS cells. Furthermore, we observed that butein exposure significantly enhanced reactive oxygen species (ROS) levels in U-2 OS cells. Co-administration of the ROS inhibitor NAC largely abolished the up-regulated p53 protein level, and rescued the suppressed viability and colony formation ability in butein-exposed U-2 OS cells. Taken together, our data proposed the increased ROS by butein exposure activated p53, and the activated p53 was involved in the anti-proliferative effect of butein via inducing senescence in U-2 OS cells. This report suggests that butein is a promising candidate for cancer therapy against osteosarcoma.

Comparisons of the Nonlinear Relationship of Cerebral Blood Flow Response and Cerebral Vasomotor Reactivity to Carbon Dioxide under Hyperventilation between Postural Orthostatic Tachycardia Syndrome Patients and Healthy Subjects.

Postural orthostatic tachycardia syndrome (POTS) typically occurs in youths, and early accurate POTS diagnosis is challenging. A recent hypothesis suggests that upright cognitive impairment in POTS occurs because reduced cerebral blood flow velocity (CBFV) and cerebrovascular response to carbon dioxide (CO2) are nonlinear during transient changes in end-tidal CO2 (PETCO2). This novel study aimed to reveal the interaction between cerebral autoregulation and ventilatory control in POTS patients by using tilt table and hyperventilation to alter the CO2 tension between 10 and 30 mmHg. The cerebral blood flow velocity (CBFV), partial pressure of end-tidal carbon dioxide (PETCO2), and other cardiopulmonary signals were recorded for POTS patients and two healthy groups including those aged >45 years (Healthy-Elder) and aged <45 years (Healthy-Youth) throughout the experiment. Two nonlinear regression functions, Models I and II, were applied to evaluate their CBFV-PETCO2 relationship and cerebral vasomotor reactivity (CVMR). Among the estimated parameters, the curve-fitting Model I for CBFV and CVMR responses to CO2 for POTS patients demonstrated an observable dissimilarity in CBFVmax (p = 0.011), mid-PETCO2 (p = 0.013), and PETCO2 range (p = 0.023) compared with those of Healthy-Youth and in CBFVmax (p = 0.015) and CVMRmax compared with those of Healthy-Elder. With curve-fitting Model II for POTS patients, the fit parameters of curvilinear (p = 0.036) and PETCO2 level (p = 0.033) displayed significant difference in comparison with Healthy-Youth parameters; range of change (p = 0.042), PETCO2 level, and CBFVmax also displayed a significant difference in comparison with Healthy-Elder parameters. The results of this study contribute toward developing an early accurate diagnosis of impaired CBFV responses to CO2 for POTS patients.

Betulin inhibits mTOR and induces autophagy to promote apoptosis in human osteosarcoma cell lines.

Betulin is a lupane type pentacyclic triterpenoid, and commonly found in the bark of birch trees. It displays various pharmacological properties, such as antibacterial, anti-inflammation, antitumor, and antiviral. In this report, we attempted to investigate the anti-proliferative and pro-apoptotic effects of betulin on osteosarcoma cell lines. Our results revealed that betulin significantly decreased cell viability and colony formation in osteosarcoma cell lines. Dose-dependent induction of Annexin V positive cells, activated caspase 8, activated caspase 9, activated caspase 3, and the cleavage of poly (ADP-ribose) polymerase were observed after the treatment with betulin, indicating betulin induces apoptosis in osteosarcoma cell lines. mTOR has been identified as a key modulator of autophagy in response to different stresses. In this study, we found that the treatment with betulin suppressed the activation of mTOR, and increased the level of LC 3-II, the autophagy marker, in osteosarcoma cell lines. Co-administration of the autophagy inhibitor chloroquine significantly rescued the cell viability and the clonogenic activity in betulin-treated osteosarcoma cell lines. Our data showed that betulin induced autophagy, and the up-regulated autophagy positively contributed to the apoptosis. Taken together, our findings suggested that betulin may serve as a promising anti-proliferative agent for treating osteosarcoma.

Licochalcone A Suppresses the Proliferation of Osteosarcoma Cells through Autophagy and ATM-Chk2 Activation.

Licochalcone A, a flavonoid extracted from licorice root, has been shown to exhibit broad anti-inflammatory, anti-bacterial, anticancer, and antioxidative bioactivity. In this study, we investigated the antitumor activity of Licochalcone A against human osteosarcoma cell lines. The data showed that Licochalcone A significantly suppressed cell viability in MTT assay and colony formation assay in osteosarcoma cell lines. Exposure to Licochalcone A blocked cell cycle progression at the G2/M transition and induced extrinsic apoptotic pathway in osteosarcoma cell lines. Furthermore, we found the Licochalcone A exposure resulted in rapid ATM and Chk2 activation, and high levels of nuclear foci of phosphorylated Chk2 at Thr 68 site in osteosarcoma cell lines. In addition, Licochalcone A exposure significantly induced autophagy in osteosarcoma cell lines. When Licochalcone A-induced autophagy was blocked by the autophagy inhibitor chloroquine, the expression of activated caspase-3 and Annexin V positive cells were reduced, and cell viability was rescued in Licochalcone A-treated osteosarcoma cell lines. These data indicate that the activation of ATM-Chk2 checkpoint pathway and autophagy may contribute to Licochalcone A-induced anti-proliferating effect in osteosarcoma cell lines. Our findings display the possibility that Licochalcone A may serve as a potential therapeutic agent against osteosarcoma.

Augmentation Plate Fixation for Treating Subtrochanteric Fracture Nonunion.

BACKGROUND: The treatment of subtrochanteric fracture nonunion is challenging. Although revision with either an intramedullary or extramedullary device had been advocated with acceptable results, complications that require secondary procedures still arise. The use of an intramedullary device with augmentation plate fixation is a well-known approach for femoral or tibial diaphyseal nonunion. However, this approach has not previously been reported for subtrochanteric fracture nonunion. MATERIALS AND METHODS: A series of 21 cases of subtrochanteric fracture nonunion treated with an intramedullary device in combination with augmentation side plating were collected and retrospectively reviewed after an average of 18 months of followup. Fourteen patients with a prior well-fixed intramedullary device were treated with side plating and bone grafting. Seven patients underwent revision nailing in addition to side plating and bone grafting. RESULTS: All fractures united well without major complication. The average time to union was 7.1 months. CONCLUSION: The use of an intramedullary device with augmentation plate fixation is a reliable and decisive procedure for treating subtrochanteric fracture nonunion that produces satisfactory results with a low complication rate.

Hyperbaric oxygen-stimulated proliferation and growth of osteoblasts may be mediated through the FGF-2/MEK/ERK 1/2/NF-κB and PKC/JNK pathways.

We investigated whether the hyperbaric oxygen (O2) could promote the proliferation of growth-arrested osteoblasts in vitro and the mechanisms involved in this process. Osteoblasts were exposed to different combinations of saturation and pressure of O2 and evaluated at 3 and 7 days. Control cells were cultured under ambient O2 and normal pressure [1 atmosphere (ATA)]; high-pressure group cells were treated with high pressure (2.5 ATA) twice daily; high-O2 group cells were treated with a high concentration O2 (50% O2) twice daily; and high pressure plus high-O2 group cells were treated with high pressure (2.5 ATA) and a high concentration O2 (50% O2) twice daily. Hyperbaric O2 significantly promoted osteoblast proliferation and cell cycle progression after 3 days of treatment. Hyperbaric O2 treatment stimulated significantly increased mRNA expression of fibroblast growth factor (FGF)-2 as well as protein expression levels of Akt, p70(S6K), phosphorylated ERK, nuclear factor (NF)-κB, protein kinase C (PKC)α, and phosphorylated c-Jun N-terminal kinase (JNK). Our findings indicate that high pressure and high O2 saturation stimulates growth-arrested osteoblasts to proliferate. These findings suggest that the proliferative effects of hyperbaric O2 on osteoblasts may contribute to the recruitment of osteoblasts at the fracture site. The FGF-2/MEK/ERK 1/2/Akt/p70(S6K)/NF-κB and PKC/JNK pathways may be involved in mediating this process.