Prediction of long-term quality of life after severe traumatic brain injury based on variables at hospital admission.

Objectives: Variables collected early after severe traumatic brain injury (sTBI) could predict health-related quality of life (HRQoL). Our aim was to determine the prevalence of patients with a low HRQoL 4 years after sTBI and to develop a prediction model including early variables.Methods: Adult patients with both sTBI [abbreviated injury score of the head region (HAIS) >3] and disease-specific HRQoL assessments using the 'Quality of Life after Brain Injury' (QOLIBRI) were included. The outcome was the total score (TS) of QOLIBRI; cutoff for low HRQoL: <60 points. A multivariate logistic regression model and prediction model were performed.Results: One hundred-sixteen patients [median age 50.8 years (IQR 25.9-62.8; 21.6% >65 years)] were included; 68 (58.6%) with HAIS = 4, 48 (41.4%) with HAIS = 5. Median Glasgow Coma Scale (GCS) was 13 (IQR 3-15). Median TS was 77 (IQR 60-88). Low HRQoL was observed in 28 patients (24.1%). Two variables were associated with low HRQoL: GCS <13, working situation other than employed or retired. The prediction model had an AUROC of 0.765; calibration was moderate (Hosmer Lemeshow Chi2 6.82, p = .556).Conclusion: One in four patients had a low HRQoL after 4 years. A lower GCS and working situations were associated with low HRQoL.

Comparison of two prehospital predictive models for mortality and impaired consciousness after severe traumatic brain injury.

BACKGROUND: The primary aim was to investigate the performance of a National Advisory Committee for Aeronautics based predictive model (NACA-BM) for mortality at 14 days and a reference model using motor GCS (GCS-RM). The secondary aim was to compare the models for impaired consciousness of survivors at 14 days (IC-14; GCS ≤ 13). METHODS: Patients ≥16 years having sustained TBI with an abbreviated injury scale score of head region (HAIS) of >3 were included. Multivariate logistic regression models were used to test models for death and IC-14. The discrimination was assessed using area under the receiver-operating curves (AUROCs); noninferiority margin was -5% between the AUROCs. Calibration was assessed using the Hosmer Lemeshow goodness-of-fit test. RESULTS: Six hundred and seventy seven patients were included. The median age was 54 (IQR 32-71). The mortality rate was 31.6%; 99 of 438 surviving patients (22.6%) had an IC-14. Discrimination of mortality was 0.835 (95%CI 0.803-0.867) for the NACA-BM and 0.839 (0.807-0.872) for the GCS-RM; the difference of the discriminative ability was -0.4% (-2.3% to +1.7%). Calibration was appropriate for the NACA-BM (χ2 8.42; P = 0. 393) and for the GCS-RM (χ2 3.90; P = 0. 866). Discrimination of IC-14 was 0.757 (0.706-0.808) for the NACA-BM and 0.784 (0.734-0.835) for the GCS-RM; the difference of the discriminative ability was -2.5% (-7.8% to +2.6%). Calibration was appropriate for the NACA-BM (χ2 10.61; P = 0.225) and for the GCS-RM (χ2 6.26; P = 0.618). CONCLUSIONS: Prehospital prediction of mortality after TBI was good with both models, and the NACA-BM was not inferior to the GCS-RM. Prediction of IC-14 was moderate in both models.

Recovery of Bone Mineral Mass After Upper Limb Fractures in Children and Teenagers.

BACKGROUND: Loss of bone mineral mass and muscle atrophy are predictable consequences of cast-mediated immobilization following wrist and forearm fractures. This study aimed to prospectively determine whether previously reported lower bone mineral mass following immobilization for wrist and forearm fractures in children and teenagers had recovered at 6- and 18-month follow-up. METHODS: We recruited 50 children and teenagers who underwent a cast-mediated immobilization for a forearm or wrist fracture. Dual-energy x-ray absorptiometry scans of different skeletal sites were performed at the time of fracture, at cast removal, at 6 and at 18-month follow-up. Injured patients were paired with healthy controls according to sex and age. Dual-energy x-ray absorptiometry values were compared between groups and the injured and uninjured forearms of the patients. RESULTS: At the time of fracture, injured and healthy subjects showed no differences between their bone mineral density (BMD) and bone mineral content (BMC) z-scores at the lumbar spine, or between their BMDs at the peripheral wrist. At cast removal, upper limb bone mineral variables were significantly lower in the injured group (except for the ultradistal radius) than in the uninjured group, with differences ranging from 3.8% to 10.2%. No residual decrease in bone mineral variables was observed at any upper limb site at 6- and 18-month follow-up (28 injured patients). Significant residual increases in the BMDs and BMCs were observed for the injured group's ultradistal radius and whole wrists (+4.8% to +5.2%). CONCLUSIONS: A rapid bone mass reversal occurs by resumption of mobilization, with full bone recovery 6 months after a forearm or wrist fracture. Finally, healing bone callus could introduce a bias into the interpretation of BMD and BMC data at the fracture site, not only at cast removal but also 18 months after the fracture.

Trajectory of disability and quality-of-life in non-geriatric and geriatric survivors after severe traumatic brain injury.

OBJECTIVE: The objective was to investigate disability and health-related quality-of-life (HRQoL) 3, 6 and 12 months after traumatic brain injury (TBI) in non-geriatric (≤ 65 years) and geriatric patients (> 65 years). METHODS: Patients ≥ 16 years who sustained a severe TBI (Abbreviated Injury Scale of the head region > 3) were included in this prospective, multi-centre study. Outcome measures were Glasgow Outcome Scale Extended (GOSE; disability), SF-12 (HRQoL). Mixed linear model analyses were performed. RESULTS: Three hundred and fifty-one patients (median age = 50 years; interquartile range (IQR) = 27-67) were included; 73.2% were male and 27.6% were geriatric patients. Median GOSE at 3, 6 and 12 months was 5 (IQR = 3-7), 6 (IQR = 4-8) and 7 (IQR = 5-8); this increase (slopetime = 0.22, p < 0.0001) was age dependent (slopeage*time = -0.06, p = 0.003). Median SF-12 physical component scale score at 3, 6 and 12 months was 42.1 (IQR = 33.6-50.7), 46.6 (IQR = 37.4-53.9) and 50.4 (IQR = 39.2-55.1); this increase (slopetime = 1.52, p < 0.0001) was not age dependent (slopeage*time = -0.30, p = 0.083). SF-12 mental component scale scores were unchanged. CONCLUSIONS: Disability decreased and HRQoL improved after TBI between 3-12 months. In geriatric patients this improvement was relevant for HRQoL only.

Predictors of inpatient (neuro)rehabilitation after acute care of severe traumatic brain injury: An epidemiological study.

OBJECTIVE: To describe the discharge destination of patients with severe traumatic brain injury (sTBI) after acute care. To identify predictors associated with inpatient rehabilitation (vs discharge home) and to identify predictors associated with neurorehabilitation (vs general rehabilitation). METHODS: A national, multi-centre, prospective study with adult survivors after sTBI (abbreviated injury scale head score > 3). Univariate and multivariate logistic regression models included patient characteristics, pre-injury conditions, initial neuro-physiological assessment, trauma mechanisms, severity of TBI and pre-hospital conditions to find predictors of discharge destination. RESULTS: Out of the 566 included patients, 341 (60%) were referred to inpatient rehabilitation, thereof 249 (73%) to neurorehabilitation; 225 (40%) were discharged home or to a nursing home. Lower scores on the Glasgow Coma Scale at admission/at 14 days, higher injury severity scores and older age were predictors for inpatient rehabilitation. Younger age and male gender were predictors for neurorehabilitation. CONCLUSIONS: Patients' pathways after acute care are not only determined by the severity of their brain injury, but also by their overall injury severity and socio-biological factors. More than half of the patients after sTBI are not discharged to specialized inpatient neurorehabilitation and, therefore, efforts should be taken to optimize post-acute care.

Simulation-based medical education training improves short and long-term competency in, and knowledge of central venous catheter insertion: A before and after intervention study.

BACKGROUND: Multimodal educational interventions have been shown to improve short-term competency in, and knowledge of central venous catheter (CVC) insertion. OBJECTIVE: To evaluate the effectiveness of simulation-based medical education training in improving short and long-term competency in, and knowledge of CVC insertion. DESIGN: Before and after intervention study. SETTING: University Geneva Hospital, Geneva, Switzerland, between May 2008 and January 2012. PARTICIPANTS: Residents in anaesthesiology aware of the Seldinger technique for vascular puncture. INTERVENTION: Participants attended a half-day course on CVC insertion. Learning objectives included work organization, aseptic technique and prevention of CVC complications. CVC insertion competency was tested pretraining, posttraining and then more than 2 years after training (sustainability phase). MAIN OUTCOME MEASURES: The primary study outcome was competency as measured by a global rating scale of technical skills, a hand hygiene compliance score and a checklist compliance score. Secondary outcome was knowledge as measured by a standardised pretraining and posttraining multiple-choice questionnaire. Statistical analyses were performed using paired Student's t test or Wilcoxon signed-rank test. RESULTS: Thirty-seven residents were included; 18 were tested in the sustainability phase (on average 34 months after training). The average global rating of skills was 23.4 points (±SD 4.08) before training, 32.2 (±4.51) after training (P < 0.001 for comparison with pretraining scores) and 26.5 (±5.34) in the sustainability phase (P = 0.040 for comparison with pretraining scores). The average hand hygiene compliance score was 2.8 (±1.0) points before training, 5.0 (±1.04) after training (P < 0.001 for comparison with pretraining scores) and 3.7 (±1.75) in the sustainability phase (P = 0.038 for comparison with pretraining scores). The average checklist compliance was 14.9 points (±2.3) before training, 19.9 (±1.06) after training (P < 0.001 for comparison with pretraining scores) and 17.4 (±1.41) (P = 0.002 for comparison with pretraining scores). The percentage of correct answers in the multiple-choice questionnaire increased from 76.0% (±7.9) before training to 87.7% (±4.4) after training (P < 0.001). CONCLUSION: Simulation-based medical education training was effective in improving short and long-term competency in, and knowledge of CVC insertion.

Switch to etravirine for HIV-positive patients receiving statin treatment: a prospective study.

BACKGROUND: Lifestyle changes and statins are the cornerstones in management of dyslipidaemia in patients with HIV infection. Replacement of an antiretroviral therapy (ART) component is a proposed therapeutic strategy to reduce cardiovascular risk. In dyslipidaemic patients with HIV infection, we assessed the efficacy of replacing boosted protease inhibitor (bPI) or efavirenz (EFV) by etravirine (ETR) as an alternative to statin therapy. MATERIALS AND METHODS: A prospective, open-label, multicentre, 12-week study of patients with HIV infection on ART including bPI or EFV, and statin treatment. Four weeks after statin interruption, bPI or EFV was switched to ETR (400 mg, 8 weeks) if serum low-density lipoprotein cholesterol (LDL-C) was ≥ 3 mM. The primary endpoint was the proportion of patients on ETR with no indication for statin treatment at study completion. Serum levels of HIV RNA, lipids and biomarkers of cardiovascular disease were also measured. (ClinicalTrials.gov: NCT01543035). RESULTS: The 31 included patients had a HIV-1 RNA < 50 copies/mL (median age, 52 years; median CD4, 709 cell/mL; median LDL-C, 2·89 mM), 68% were on EFV, and 32% were on bPI. At week 4, 27 patients switched to ETR. At study completion, 15 patients (56%) on ETR did not qualify for statin treatment. After the ETR switch, serum levels of the cardiovascular biomarkers sICAM and MCP1/CCL2 decreased by 11·2% and 18·9%, respectively, and those of CCL5/RANTES and tissue inhibitor of metalloproteinase-1 increased by 14·3% and 13·4%, respectively, indicating reduced cardiovascular risk. There were no notable treatment-related adverse events. CONCLUSIONS: Replacing bPI or EFV by ETR is a viable strategy to obviate primary prevention statin treatment.

Preoperative and early postoperative quality of life after major surgery - a prospective observational study.

BACKGROUND: Changes in health-related quality of life (HRQoL) several days after surgery have rarely been investigated. We aimed to estimate the perioperative change of HRQoL, to identify patients with clinically relevant decrease in postoperative HRQoL and to establish factors associated with this decrease in HRQoL at day 30 after major surgery. METHODS: Patients scheduled for major surgery at a university hospital were enrolled. Based on the HRQoL SF-12 questionnaire, the preoperative physical component summary (PCS) score, preoperative mental component summary (MCS) score, and postoperative PCS and MCS scores at day 30 were recorded. Minimal clinically important difference (MCID) was defined as those with a decrease of at least one half of the standard deviation (SD) of preoperative PCS or MCS scores. Differences between the groups with or without decreased HRQoL were investigated using univariate comparisons. A multiple logistic regression model was performed to evaluate the predictive value of potential perioperative variables. RESULTS: The mean ± SD preoperative PCS score was 38.5 ± 10.6, postoperative score was 35.1 ± 7.8 (p = .004) in 85 patients. Thirty-five patients (41.2%) had a clinically relevant decrease of the postoperative PCS score. A normal to high preoperative exercise metabolic capacity measured with metabolic equivalent of task (MET) (p = .01) was a predictor of the decrease in postoperative PCS. The mean preoperative MCS scores (p = .395) were 42.2 (SD 12.8) preoperative, and 43.45 (SD 12.4) postoperative, respectively. CONCLUSIONS: Major surgery decreases postoperative PCS scores of HRQoL at 30 days. A normal to high exercise capacity was a predictor of a clinically relevant decrease of postoperative PCS scores. TRIAL REGISTRATION: 07-107 (Ethical Committee NAC of Geneva University Hospitals).

Increased mortality after a first myocardial infarction in human immunodeficiency virus-infected patients; a nested cohort study.

AIMS: HIV infection may be associated with an increased recurrence rate of myocardial infarction. Our aim was to determine whether HIV infection is a risk factor for worse outcomes in patients with coronaray artery disease. METHODS: We compared data aggregated from two ongoing cohorts: (i) the Acute Myocardial Infarction in Switzerland (AMIS) registry, which includes patients with acute myocardial infarction (AMI), and (ii) the Swiss HIV Cohort Study (SHCS), a prospective registry of HIV-positive (HIV+) patients. We included all patients who survived an incident AMI occurring on or after 1st January 2005. Our primary outcome measure was all-cause mortality at one year; secondary outcomes included AMI recurrence and cardiovascular-related hospitalisations. Comparisons used Cox and logistic regression analyses, respectively. RESULTS: There were 133 HIV+, (SHCS) and 5,328 HIV-negative [HIV-] (AMIS) individuals with incident AMI. In the SHCS and AMIS registries, patients were predominantly male (72% and 85% male, respectively), with a median age of 51 years (interquartile range [IQR] 46-57) and 64 years (IQR 55-74), respectively. Nearly all (90%) of HIV+ individuals were on successful antiretroviral therapy. During the first year of follow-up, 5 (3.6%) HIV+ and 135 (2.5%) HIV- individuals died. At one year, HIV+ status after adjustment for age, sex, calendar year of AMI, smoking status, hypertension and diabetes was associated with a higher risk of death (HR 4.42, 95% CI 1.73-11.27). There were no significant differences in recurrent AMIs (4 [3.0%] HIV+ and 146 [3.0%] HIV- individuals, OR 1.16, 95% CI 0.41-3.27) or in hospitalization rates (OR 0.68 [95% CI 0.42-1.11]). CONCLUSIONS: HIV infection was associated with a significantly increased risk of all-cause mortality one year after incident AMI.

Recovery of physical activity levels in adolescents after lower limb fractures: a longitudinal, accelerometry-based activity monitor study.

BACKGROUND: In adolescents, loss of bone mineral mass usually occurs during phases of reduced physical activity (PA), such as when an injured extremity spends several weeks in a cast. We recorded the PA of adolescents with lower limb fractures during the cast immobilization, at 6 and at 18 months after the fracture, and we compared these values with those of healthy controls. METHODS: Fifty adolescents with a first episode of limb fracture and a control group of 50 healthy cases were recruited for the study through an advertisement placed at the University Children's Hospital of Geneva, Switzerland. PA was assessed during cast immobilization and at 6- and 18-month follow-up by accelerometer measurement (Actigraph(®) 7164, MTI, Fort Walton Beach, FL, USA). Patients and their healthy peers were matched for gender and age. Time spent in PA at each level of intensity was determined for each participant and expressed in minutes and as a percentage of total valid time. RESULTS: From the 50 initial teenagers with fractures, 44 sustained functional evaluations at 6 months follow-up, whereas only 38 patients were studied at 18 months. The total PA count (total number of counts/min) was lower in patients with lower limb fractures (-62.4%) compared with healthy controls (p<0.0001) during cast immobilization. Similarly, time spent in moderate-to-vigorous PA was lower by 76.6% (p<0.0001), and vigorous PA was reduced by 84.4% (p<0.0001) in patients with cast immobilization for lower limb injuries compared to healthy controls values. At 6 and 18 months after the fracture, the mean PA level of injured adolescents was comparable to those of healthy teenagers (-2.3%, and -1.8%, respectively).Importantly, we observed that time spent in vigorous PA, which reflects high-intensity forces beneficial to skeletal health, returned to similar values between both groups from the six month follow-up in adolescents who sustained a fracture. However, a definitive reduction in time spent in moderate PA was observed among patients with a lower limb fracture at 18 months, when comparing with healthy controls values (p = 0.0174). CONCLUSIONS: As cast immobilization and reduced PA are known to induce bone mineral loss, this study provides important information to quantify the decrease of skeletal loading in adolescents with limb fractures. The results of this study demonstrate that the amount of skeletal loading returns to normal values in adolescents with lower limb fractures after bone healing and is probably linked to an overall better pattern of functional recovery among this age group. When comparing both populations of adolescents, a definitive decrease in time spent in moderate-to-vigorous PA was observed among patients with a lower limb fracture at 18 months and may suggest a modification of lifestyle. The high rate of missing data (26.5%) due to above all non compliance with monitor wearing among teenagers complicates the data analysis, and requires a more cautious interpretation of the results. Future studies using accelerometer to monitor PA in adolescents should therefore include strategies for improving the rate of adherence and minimizing the ratio of missing data.

Bilateral and gender differences during single-legged vertical jump performance in healthy teenagers.

The determination of physiologic lower limb functional imbalance among healthy teenagers is important to follow the rehabilitation progress and return to normal activity of injured subjects. We investigated the differences in vertical jump capacity between both legs in a group of healthy boys and girls, considering the performances in the dominant vs. non-dominant, and in the most vs. least efficient leg. Strength and power performances were compared in 117 boys and 106 girls aged 10-16 years during a single-leg vertical countermovement jump (SLVCJ) test. When leg dominance was defined subjectively by the participant, no difference was noted between the 2 legs. Statistically significant differences were recorded between the most and less efficient leg in strength and power performances for both genders. Girls had significantly greater peak strength than did age-matched boys, but boys showed significant increases in maximal power outputs compared with that shown by age-matched girls. When the results were analyzed according to the percentage of participants falling within certain bands of limb asymmetry, approximately 20-30% showed a difference of >15% between the 2 limbs without any relation to gender. Subjective expression of leg dominance cannot be used as a predictor of SLVCJ performance. Differences of <15% in SLVCJ performance between both legs should be considered as the physiological norm in this age group. A greater appreciation of the potential diagnostic value of the SLVCJ test may be obtained if the results are interpreted in terms of the percentage of subjects falling within certain bands of limb asymmetry. Gender-based differences in the SLVCJ test vary and depend upon whether the results are interpreted in terms of strength or power output.

Decrease of physical activity level in adolescents with limb fractures: an accelerometry-based activity monitor study.

BACKGROUND: Immobilization and associated periods of inactivity can cause osteopenia, the physiological response of the bone to disuse. Mechanical loading plays an essential role in maintaining bone integrity. Skeletal fractures represent one cause of reduction of the physical activity (PA) level in adolescents. The purpose of this study was to quantify the reduction of PA in adolescents with limb fractures during the cast immobilization period compared with healthy controls. METHODS: Two hundred twenty adolescents were divided into three groups: those with upper limb fractures (50 cases); lower limb fractures (50 cases); and healthy cases (120 cases). Patients and their healthy peers were matched for gender, age, and seasonal assessment of PA. PA level was assessed during cast immobilization by accelerometer. Time spent in PA in each of the different intensity levels - sedentary, light, moderate, and vigorous - was determined for each participant and expressed in minutes and as a percentage of total valid time. RESULTS: Reduction in PA during cast immobilization was statistically significant in patients with limb fractures compared to healthy controls. The total PA count (total number of counts/min) was significantly lower in those with upper and lower limb fractures (-30.1% and -62.4%, respectively) compared with healthy controls (p < 0.0001 and p = 0.0003, respectively). Time spent in moderate-to-vigorous PA by patients with upper and lower limb injuries decreased by 36.9% (p = 0.0003) and 76.6% (p < 0.0001), respectively, and vigorous PA was reduced by 41.4% (p = 0.0008) and 84.4% (p < 0.0001), respectively. CONCLUSIONS: PA measured by accelerometer is a useful and valid tool to assess the decrease of PA level in adolescents with limb fractures. As cast immobilization and reduced PA are known to induce bone mineral loss, this study provides important information to quantify the decrease of skeletal loading in this patient population. The observed reduction of high intensity skeletal loading due to the decrease in vigorous PA may explain osteopenia due to disuse, and these data should be kept in mind by trauma practitioners to avoid any unnecessary prolongation of the cast immobilization period.

Intravenous iron supplementation after liver surgery: Impact on anemia, iron, and hepcidin levels-a randomized controlled trial.

BACKGROUND: Anemia is a recognized risk factor for perioperative related morbidity and mortality and is frequently reported in liver surgeries with an estimated incidence of 32%. We aim to assess the impact of intravenous iron administration in the immediate postoperative period on anemia and iron status as well as to determine the kinetics of hepcidin after liver surgery. METHODS: The HepciFer trial, a randomized controlled trial, included 50 patients undergoing liver surgery. In accordance with the randomization process, patients received either ferric carboxymaltose (15 mg/kg, maximum 1 g) or placebo 4 hours after surgery. RESULTS: The mean hemoglobin level, 7 days after surgery, did not differ significantly between the intervention and control group (11.1 ± 1.8 g/dL and 10.4 ± 1.6 g/dL, respectively) with a mean difference of +0.7 g/dL ([95% confidence interval, -0.3 to +1.7], P = .173). Within patients receiving intravenous iron supplementation, none presented biological signs of functional iron deficiency. Hepcidin levels remained significantly higher during the observation period in the intervention group. Inflammatory biomarkers, red blood cells transfusion rate and hospital duration of stay were similar between groups. CONCLUSION: Intravenous ferric carboxymaltose administration did not result in a significant increase of hemoglobin levels 7 days after surgery. However, this study suggests that intravenous iron supplementation in the immediate postoperative settings prevents functional iron deficiency. Intravenous iron supplementation overcame the hepcidin-mediated blockade of iron absorption and should be considered as the preferred route of administration in the postoperative period.

Infrequent replication of parvovirus B19 and erythrovirus genotypes 2 and 3 among HIV-infected patients with chronic anemia.

We investigated the role that erythroviruses (parvovirus B19 and erythrovirus genotypes 2 and 3) play in the lives of immunosuppressed HIV-infected patients with chronic anemia. We screened the serum samples of 428 patients by specific ultrasensitive real-time polymerase chain reaction assay. Sixteen patients had circulating DNA, with no apparent clinical impact. Erythrovirus-associated anemia is an extremely rare event in HIV-infected patients.

Assessment of muscular performance in teenagers after a lower extremity fracture.

BACKGROUND: Deleterious effects of lower limb immobilization in adults have been well described and suggest that altered muscle strength was not fully recoverable after rehabilitation. In this study, we hypothesized that the same significant differences in strength and power performances between the injured and noninjured leg are foreseeable 18 months after a lower limb fracture in teenagers, and between injured adolescents and healthy controls. METHODS: The effects of cast immobilization on the strength and power performance were evaluated 18 months after a lower limb fracture in 39 injured teenagers who were paired with healthy controls. Strength and power performance were assessed during a single-leg vertical jump test using a force platform. RESULTS: At 18 months, strength performance in injured teenagers was similar in both lower limbs. A significant difference was found between injured and noninjured legs for maximal muscular power measurement. However, the limb symmetry index was superior to 85% for maximal muscular power, which should be considered as normal. Limb asymmetries greater than 15% for muscular strength and power were more frequent in injured teenagers than in noninjured children and adolescents, but the difference was statistically significant only for the mean muscle power (P=0.0003). CONCLUSIONS: These findings show that the recovery of muscular strength and power is foreseeable after a lower limb fracture in the pediatric population, even if a greater percentage of injured teenagers was found to have limb asymmetries greater than 15% for mean muscular power 18 months after trauma compared with the healthy controls. LEVEL OF EVIDENCE: Level III, case-control study.

Low bone mineral density, renal dysfunction, and fracture risk in HIV infection: a cross-sectional study.

BACKGROUND: Reduced bone mineral density (BMD) is common in adults infected with human immunodeficiency virus (HIV). The role of proximal renal tubular dysfunction (PRTD) and alterations in bone metabolism in HIV-related low BMD are incompletely understood. METHODS: We quantified BMD (dual-energy x-ray absorptiometry), blood and urinary markers of bone metabolism and renal function, and risk factors for low BMD (hip or spine T score, -1 or less) in an ambulatory care setting. We determined factors associated with low BMD and calculated 10-year fracture risks using the World Health Organization FRAX equation. RESULTS: We studied 153 adults (98% men; median age, 48 years; median body mass index, 24.5; 67 [44%] were receiving tenofovir, 81 [53%] were receiving a boosted protease inhibitor [PI]). Sixty-five participants (42%) had low BMD, and 11 (7%) had PRTD. PI therapy was associated with low BMD in multivariable analysis (odds ratio, 2.69; 95% confidence interval, 1.09-6.63). Tenofovir use was associated with increased osteoblast and osteoclast activity (P< or = .002). The mean estimated 10-year risks were 1.2% for hip fracture and 5.4% for any major osteoporotic fracture. CONCLUSIONS: In this mostly male population, low BMD was significantly associated with PI therapy. Tenofovir recipients showed evidence of increased bone turnover. Measurement of BMD and estimation of fracture risk may be warranted in treated HIV-infected adults.

Effect of Pre-Hospital Intubation in Patients with Severe Traumatic Brain Injury on Outcome: A Prospective Cohort Study.

Secondary injuries are associated with bad outcomes in the case of severe traumatic brain injury (sTBI). Patients with a Glasgow Coma Scale (GCS) < 9 should undergo pre-hospital intubation (PHI). There is controversy about whether PHI is beneficial. The aim of this study was to estimate the effect of PHI in patients after sTBI. A multicenter, prospective cohort study was performed in Switzerland, including 832 adults with sTBI. Outcomes were death and impaired consciousness at 14 days. Associations between risk factors and outcomes were assessed with univariate and multivariate Cox models for survival, and univariate and multivariate regression models for impaired consciousness. Potential risk factors were age, GCS on scene, pupil reaction, Injury Severity Score (ISS), PHI, oxygen administration, and type of admission to trauma center. Age, GCS on scene < 9, abnormal pupil reaction and ISS ≥ 25 were associated with mortality. GCS < 9 and ISS ≥ 25 were correlated with impaired consciousness. PHI was overall not associated with short-term mortality and consciousness. However, there was a significative interaction with PHI and major trauma. PHI improves outcome from patients with sTBI and an ISS ≥ 25.

Comparison of two simple models for prediction of short term mortality in patients after severe traumatic brain injury.

INTRODUCTION: The subscale motor score of Glasgow Coma Scale (msGCS) and the Abbreviated Injury Score of head region (HAIS) are validated prognostic factors in traumatic brain injury (TBI). The aim was to compare the prognostic performance of a HAIS-based prediction model including HAIS, pupil reactivity and age, and the reference prediction model including msGCS in emergency department (ED), pupil reactivity and age. METHODS: Secondary analysis of a prospective epidemiological study including patients after severe TBI (HAIS > 3) with follow-up from the time of accident until 14 days or earlier death was performed in Switzerland. Performance of prediction, based on accuracy of discrimination [area under the receiver-operating curve (AUROC)], calibration (Hosmer-Lemeshow test) and validity (bootstrapping with 2000 repetitions to correct) for optimism of the two prediction models were investigated. A non-inferiority approach was performed and an a priori threshold for important differences was established. RESULTS: The cohort included 808 patients [median age 56 {inter-quartile range (IQR) 33-71}, median motor part of GCS in ED 1 (1-6), abnormal pupil reactivity 29.0%] with a death rate of 29.7% at 14 days. The accuracy of discrimination was similar (AUROC HAIS-based prediction model: 0.839; AUROC msGCS-based prediction model: 0.826, difference of the 2 AUROC 0.013 (-0.007 to 0.037). A similar calibration was observed (Hosmer-Lemeshow X2 11.64, p = 0.168 vs. Hosmer-Lemeshow X2 8.66, p = 0.372). Internal validity of HAIS-based prediction model was high (optimism corrected AUROC: 0.837). CONCLUSIONS: Performance of prediction for short-term mortality after severe TBI with HAIS-based prediction model was non-inferior to reference prediction model using msGCS as predictor.

What is the real impact of upper limb cast immobilisation on activity-related energy expenditure in children?

BACKGROUND: Upper limb fractures and subsequent cast immobilisation constitute a potential cause of reduction in childhood levels of physical activity (PA), with subsequent decrease of energy consumption. The main objective of this study was thus to quantify the decrease of activity-related energy expenditure (AEE) due to upper limb cast immobilisation. METHODS: We conducted a longitudinal matched case-control study that included 35 children and teenagers with a first episode of upper limb fracture and 35 healthy cases. PA was assessed during cast immobilisation by accelerometer. AEE was the calculated using an equation based on the total counts per day measured by accelerometers. RESULTS: AEE in children and teenagers with upper limb fractures was estimated to be 7.4 % lower than healthy controls. The mean difference corresponded to 1.35 kcal/kg per mean valid recorded time (750 min), that is, the waking hours. When converted in kcal per mean subjects' weight, the difference in AEE amounted 63.5 kcal/day, which corresponds approximately to 26 min of walking at a speed of 4 km/hours. In comparison with the mean AEE in healthy controls (18.2 kcal/kg), the noted decrease (1.35 kcal/kg) represents only 7.4 % of AEE. CONCLUSION: Reduction of AEE in children and teenagers with upper limb fractures may lead to a slight positive energy balance, as there is usually no compensatory reduction of energy intake. An increase of light PA has to be counselled in this situation or patients should be advised to reduce their energy intake during the immobilisation period. LEVEL OF EVIDENCE: Level I: high-quality prospective study (all patients were enrolled at the same point in their disease with ≥80 % follow-up of enrolled patients).