How well are we managing fragility hip fractures? A narrative report on the review with the attempt to setup a Fragility Fracture Registry in Hong Kong.

INTRODUCTION: In setting up a disease registry for fragility fractures in Hong Kong, we conducted a retrospective systematic study on the management of fragility hip fractures. Patient outcomes were compared with the standards from our orthopaedic working group and those from the British Orthopaedic Association that runs a mature fracture registry in the United Kingdom. METHODS: Clinical data on fragility hip fracture patients admitted to six acute major hospitals in Hong Kong in 2012 were captured. These included demographics, pre- and post-operative assessments, discharge details, complications, and 1-year follow-up information. Analysis was performed according to the local standards with reference to those from the British Orthopaedic Association. RESULTS: Overall, 91.0% of patients received orthopaedic care within 4 hours of admission and 60.5% received surgery within 48 hours. Preoperative geri-orthopaedic co-management was received by 3.5% of patients and was one of the reasons for the delayed surgery in 22% of patients. Only 22.9% were discharged with medication that would promote bone health. Institutionalisation on discharge significantly increased by 16.2% (P<0.001). Only 35.1% of patients attended out-patient follow-up 1 year following fracture, and mobility had deteriorated in 69.9% compared with the premorbid state. Death occurred in 17.3% of patients within a year of surgery compared with 1.6% mortality rate in a Hong Kong age-matched population. CONCLUSIONS: The efficiency and quality of acute care for fragility hip fracture patients was documented. Regular geri-orthopaedic co-management can enhance acute care. Much effort is needed to improve functional recovery, prescription of bone health medications, attendance for follow-up, and to decrease institutionalisation. A Fracture Liaison Service is vital to improve long-term care and prevent secondary fractures.

The DRD2 TaqI-B polymorphism and its relationship to smoking abstinence and withdrawal symptoms.

The dopamine receptor D2 (DRD2) gene has polymorphisms that have been linked to regulation of the dopamine system and to an increased prevalence of smoking. The present study examined the relationship of the DRD2 TaqI-A and -B polymorphisms with short-term clinical outcome (abstinence and withdrawal symptoms), collected from daily (14 pre-quit and 42 post-quit) diary data among smokers (n=116) treated with the nicotine patch plus either venlafaxine or placebo. The results showed that B1/B1 or B1/B2 smokers were slightly less likely to be abstinent on a given day than those homozygous for the TaqI-B2 allele. Significant DRD2 TaqI-B x time interactions were found for several of the withdrawal scales, indicating that those smokers with the B1/B1 or B1/B2 genotypes tended to report more symptoms over time compared to those with the B2/B2 genotype. No interactions or main effects were found for the DRD2 TaqI-A polymorphism. The findings demonstrate that smokers homozygous for the TaqI-B2 allele experience progressive improvement in self-reported withdrawal symptoms while smokers with the TaqI-B1 allele showing little change.

Effect of scheduled second therapeutic endoscopy on peptic ulcer rebleeding: a prospective randomised trial.

AIM: Recurrent bleeding after initial haemostasis is an important factor that directly relates to the outcome in the management of peptic ulcer bleeding. Conflicting reports have been published concerning the effectiveness of scheduled second therapeutic endoscopy on ulcer rebleeding. We investigate the use of scheduled second endoscopy with appropriate therapy on peptic ulcer rebleeding. METHODS: From August 1999 to January 2001, we prospectively randomised patients who had endoscopically confirmed bleeding peptic ulcer with stigmata of acute bleeding, visible vessel, or adherent clot into two groups. Endoscopic therapy was standardised to initial epinephrine injection and subsequent heater probe application. The study group (n = 100) received scheduled second endoscopy 16-24 hours after initial haemostasis, and further therapy was applied if endoscopic stigmata persisted, as above. The control group (n = 94) were observed closely. Those patients that developed rebleeding in either group underwent operation if further endoscopic therapy failed. Outcome measures included ulcer rebleeding, transfusion, duration of stay, and mortality. RESULTS: After initial endoscopic haemostasis, 194 eligible patients were randomised into two groups. Thirteen patients in the control group developed recurrent bleeding within 30 days while five patients in the study group sustained recurrent bleeding (p = 0.0314) (relative risks 0.33, 95% confidence interval 0.1-0.96). The number of patients that required surgery for recurrent bleeding was six in the control group and one in the study group (p = 0.05). There was no difference in duration of hospital stay, transfusion, or mortality between the two groups. CONCLUSIONS: A scheduled repeat endoscopy with appropriate therapy 16-24 hours after initial endoscopic haemostasis reduces the number of cases of recurrent bleeding.

Conservative approach is feasible in the management of acute diverticulitis of the right colon.

BACKGROUND: Acute diverticulitis of the caecum and ascending colon is uncommon. Controversies abound as regards the optimal surgical treatment, ranging from appendectomy, diverticulectomy to right hemicolectomy. The aim of the present paper was to review treatment strategy followed by a critical appraisal. METHODS: The case notes of 30 patients with acute diverticulitis of the right colon who were treated at the United Christian Hospital, Hong Kong from 1992 to 1998 were systematically reviewed. The data were subjected to statistical analysis. RESULTS: The median age was 34 years, with a male:female ratio of 1:1.15. All patients presented with acute right lower abdominal pain and localized rebound tenderness. All were diagnosed preoperatively as having appendicitis. The mean duration of symptoms was 2 days (range: 1-6 days). Two treatment groups were identified. Group A (n = 16; 53%) received appendicectomy alone, while group B (n = 14; 47%) underwent diverticulectomy in addition to appendicectomy, including one patient with perforated diverticulitis. Overall, there was no procedure-related morbidity or mortality. Both groups received a similar duration of broad-spectrum antibiotics. All the patients were interviewed by phone after operation to detect any recurrence of symptoms, with a median follow-up interval of 34 months (range: 11-78 months). There was no recurrence of symptoms in group A, which received appendicectomy and antibiotics. The only difference was operative time. CONCLUSION: For non-perforated diverticulitis of the right colon, appendicectomy and intravenous antibiotics without diverticulectomy is the preferred treatment strategy.

Sternomastoid-muscle transposition improves the cosmetic outcome of superficial parotidectomy.

A facial depressed deformity subsequent to superficial parotidectomy is unsightly. Although a facelift incision can improve the cosmetic outcome by concealing the scar, the hollow contour around the angle of the mandible remains conspicuous. We have attempted to mitigate this problem by transposition of the sternomastoid muscle. Transposition of the sternomastoid muscle to cover the parotid bed after superficial parotidectomy for benign tumour was performed in eight consecutive patients. The histopathology and postoperative results, including complications and patient satisfaction, were analysed. The depressed deformity was considerably alleviated in all eight patients. All patients except one, who had a wound infection, were satisfied with the cosmetic outcome postoperatively. The extra operative time required for sternomastoid-muscle transposition was only 10 min. There was no morbidity related to this additional procedure. By combining this simple method with a facelift incision, an appealing cosmetic outcome can be achieved after superficial parotidectomy.

Percutaneous intramedullary Kirschner wiring for displaced diaphyseal forearm fractures in children.

Displaced fractures of the forearm in children are often treated conservatively, but there is a relatively high incidence of redisplacement, malunion and consequent limitation of function. We have performed percutaneous Kirschner (K) wire fixation in 72 such children under the age of 14 years, of which 57 were reviewed for our study. Both the radius and ulna were fractured in 45 (79%), the radius only in eight and the ulna only in four. The mean initial angulation was 19 degrees in the lateral plane and 9 degrees in the anteroposterior plane for the radius and 15 degrees and 9 degrees, respectively, for the ulna. In 42 patients (74%) we performed closed reduction. In the remaining 15 (26%) closed reduction failed and an open reduction, through a minimal approach, was required before K wiring. At a mean follow-up of 20 months all patients had good functional results with an excellent range of movement. Only five had angulation of from 10 degrees to 15 degrees and none had nonunion, premature epiphyseal closure or deep infection. Percutaneous intramedullary K wiring for forearm diaphyseal fracture is a convenient, effective and safe operation, with minimal complications.

Intracellular ATP is required for actinomycin D-induced apoptotic cell death in HeLa cells.

In the present report, we demonstrate that reduction of cellular ATP content with antimycin A blocks actinomycin D-induced apoptotic cell death in HeLa cells. Compared to cells (approximately 80%) treated with actinomycin D (1 microgram/ml; 48 h) alone in glucose-containing medium, a much smaller percentage of cells (approximately 20%) treated with actinomycin D in the presence of antimycin A in glucose-free medium shows morphological characteristic of apoptosis. ATP-depleted cells with or without actinomycin D treatment, on the other hand, die necrotically. In cells under actinomycin D short exposure treatment (1 microgram/ml; 1 h), apoptosis occurs when cellular ATP content is rapidly recovered after the removal of antimycin A and resupplementation of glucose-containing medium. In the incubation of isolated Triton-permeabilized cells with ATP ( > 0.5 mM), apoptotic nuclei become abundant 4 h after ATP treatment. These results implicate the requirement of ATP for the induction of apoptosis.

Translocation of nucleophosmin from nucleoli to nucleoplasm requires ATP.

The movement of nucleophosmin from nucleoli to nucleoplasm in HeLa cells induced by cytotoxic drugs and detected by immunofluorescence is inhibited by concomitant treatment with antimycin A in glucose-free medium. Incubation of HeLa cells with antimycin A (300 nM; 30 min) and glucose-free medium resulted in an approximately 90% decrease in cellular ATP pools. To study the biochemical events involved in nucleophosmin translocation, we used an in vitro system consisting of Triton-permeabilized HeLA cells. Incubation of permeabilized cells with ATP (0.5 mM; 1 h) resulted in the translocation of nucleophosmin from nucleoli to nucleoplasm and cytoplasm. Similarly to drug-induced nucleophosmin translocation in whole cultured cells, there is no reduction (measured by e.l.i.s.a.) or degradation of nucleophosmin or change in the ratio of the high-molecular-mass form to the monomeric form (ascertained by Western blotting) during ATP treatment of permeabilized cells. Together, these results indicate a requirement for ATP for redistribution of nucleophosmin from nucleoli to nucleoplasm. Because this permeabilized cell model is simple and efficient and works effectively with exogenous factors, it should provide a powerful tool for investigating the biochemical features of nucleophosmin translocation from nucleoli to nucleoplasm.