Relatively low and moderate pre-fracture serum 25-hydroxyvitamin D levels associated with the highest survival in elderly hip fracture patients in Finland: a minimum 3-year follow-up.

The association between serum 25-hydroxyvitamin D level and post-fracture mortality indicates beneficial relatively high serum 25-hydroxyvitamin D concentrations. A 1-year cohort study on 245 hip fracture patients in Finland indicated the lowest 3-year mortality and highest survival among patients with serum 25-hydroxyvitamin D level of 50-74 nmol/L. PURPOSE: To explore pre-fracture serum 25-hydroxyvitamin D level as a factor associated with post-fracture survival among a cohort of hip fracture patients in Finland. METHODS: A prospectively collected cohort of hip fracture patients (n = 245, 70% women) from two hospitals was followed for 3.2 post-hip fracture years. Serum 25-hydroxyvitamin D was measured in admission to the hospital and classified: < 50, 50-74, 75-99, and ≥ 100 nmol/L. Survival was analyzed with a Bayesian multivariate model. Relative survival was explored with the life table method according to serum 25-hydroxyvitamin D. Mortality according to serum 25-hydroxyvitamin D level and to the hospital was calculated. RESULTS: Mortality in the patients with serum 25-hydroxyvitamin D level of 50-74 nmol/L was significantly lower than in all other patients together at every post-fracture year. The most important factors for survival were age under 85 years; living in an actual/private home; serum 25-hydroxyvitamin D level of 50-74 nmol/L, followed by 75-99 nmol/L; ASA classes 1-2 and 3; and female sex. The mean age of patients with serum 25-hydroxyvitamin D level of 50-99 nmol/L was significantly higher than in other levels. Relative survival was highest in men, women, and patients in hospital B with serum 25-hydroxyvitamin D level of 50-74 nmol. CONCLUSION: The highest 3-year survival and the lowest mortality in this cohort appeared in patients with pre-fracture serum 25-hydroxyvitamin D level of 50-74 nmol/L. This result differs from similar studies and is lower than the recommended level of 25-hydroxyvitamin D among hip fracture patients. The results should be examined in future research with larger data.

Evaluation of minimal fracture liaison service resource: costs and survival in secondary fracture prevention-a prospective one-year study in South-Finland.

BACKGROUND: Fracture liaison service (FLS) is a secondary prevention model for identification of patients at risk for fragility fractures. AIMS: This study was conducted to evaluate the number and costs of secondary prevention of low-energy fractures in the city of Kouvola in Finland. METHODS: Women aged ≥ 45 years and men ≥ 60 years treated in the emergency department with a low-energy fracture were identified. Laboratory testing, BMI, and DXA scans were performed. Fracture Risk Assessment Tool was used. The direct FLS costs were calculated. Survival was analyzed using univariate and multivariate analysis and the life-table method. RESULTS: 525 patients with 570 fractures were identified. The mean age of women was 73.8 years and of men 75.9 years. Most patients sustained wrist (31%), hip (21%) or proximal humerus (12%) fractures. 41.5% of the patients had osteoporosis according to DXA scans. 62% of patients used calcium and vitamin D daily and 38% started anti-osteoporotic medication. Protective factors for survival were: age < 80 years, female sex, and S-25OHD concentration of 50-119 nmol/L. Excess mortality was highest among patients with a fracture of the femur. The total annual direct costs of FLS were 1.3% of the costs of all fractures. DISCUSSION: Many low-energy fracture types were associated with excess mortality. The use of anti-osteoporotic medication was not optimal. CONCLUSIONS: FLS increased the catchment of low-energy fracture patients and was inexpensive. However, identification, evaluation and post-fracture assessment of patients should be expedited. Rehabilitation of hip fracture patients needs to be improved.

Statins influence epithelial expression of the anti-microbial peptide LL-37/hCAP-18 independently of the mevalonate pathway.

Anti-microbial resistance increases among bacterial pathogens and new therapeutic avenues needs to be explored. Boosting innate immune mechanisms could be one attractive alternative in the defence against infectious diseases. The cholesterol-lowering drugs, statins, have been demonstrated to also affect the immune system. Here we investigate the effect of statins on the expression of the human cathelicidin anti-microbial peptide (CAMP) LL-37/hCAP-18 [encoded by the CAMP gene] and explore the underlying mechanisms in four epithelial cell lines of different origin. Simvastatin induced CAMP expression in bladder epithelial cells telomerase-immortalized uroepithelial cells (TERT-NHUCs), intestinal cells HT-29 and keratinocytes HEKa, but not in airway epithelial cells A549. Gene induction in HEKa cells was reversible by mevalonate, while this effect was independent of the cholesterol biosynthesis pathway in TERT-NHUCs. Instead, inhibition of histone deacetylases by simvastatin seems to be involved. For HT-29 cells, both mechanisms may contribute. In addition, simvastatin increased transcription of the vitamin D-activating enzyme CYP27B1 which, in turn, may activate LL-37/hCAP-18 production. Taken together, simvastatin is able to promote the expression of LL-37/hCAP-18, but cell line-specific differences in efficacy and the involved signalling pathways exist.

Association between vitamin D, antimicrobial peptides and urinary tract infection in infants and young children.

AIM: Vitamin D stimulates production of the endogenous antimicrobial peptides cathelicidin and ß-defensin-2, which are expressed in the urinary tract. We investigated vitamin D status and levels of cathelicidin and ß-defensin-2 and their association with urinary tract infection (UTI). METHODS: The study included 120 children under three years of age: 76 children with UTIs and 44 otherwise healthy children with congenital hydronephrosis. Serum 25-hydroxycholecalciferol levels were measured by direct competitive electro-chemiluminescence immunoassay, and plasma cathelicidin and ß-defensin-2 concentrations were analysed by enzyme-linked immunosorbent assay. RESULTS: We found that vitamin D insufficiency and deficiency are prevalent in young children (21%). Serum vitamin D levels negatively correlated with age and were significantly lower in girls. Levels of vitamin D positively correlated with levels of cathelicidin but not with ß-defensin-2. Low concentrations of vitamin D were associated with UTIs in girls, but we did not see any correlation with the recurrence of infection at one-year follow-up. CONCLUSION: Vitamin D deficiency is common and may prove to be a risk factor for UTIs especially in girls. We hypothesise that adequate supplementation with vitamin D may become a way to prevent first-time UTIs.

Correction to: Remarkable improvement in serum 25-hydroxyvitamin levels among hip fracture patients over a 12-year period: a prospective study in South-eastern Finland.

The presentation of Table 4 was unclear in the original publication. The article has now been corrected in this respect.

Remarkable improvement in serum 25-hydroxyvitamin levels among hip fracture patients over a 12-year period: a prospective study in South-eastern Finland.

Hypovitaminosis D is a problem among hip fracture patients. In a 1-year cohort study comprising 245 hip fracture patients (mean age of females 81 years and males 78 years) from south-eastern Finland, the mean 25-hydroxyvitamin D [S-25(OH)D] concentration was 73(SD 31) nmol/L. Vitamin D supplementation has been integrated into our current practice. INTRODUCTION: The objectives of this study are to verify vitamin D levels among hip fracture patients and to compare the results with a similar study conducted in the same two hospitals covering the same geographic area 12 years ago. METHODS: A prospective cohort comprising 245 Caucasian hip fracture patients was enrolled in the study in two acute hospitals in south-eastern Finland (61° N) over a 12-month period in 2015-2016. The S-25(OH)D was measured using 25-hydroxyvitamin D electrochemiluminescence binding assay. The S-25(OH)D concentrations were compared with the corresponding concentrations of a similar cohort analyzed in the same two hospitals 12 years ago. RESULTS: Of the 245 patients, 70% were women with a mean age of 81 (SD 10) years, while the men had a mean age of 78 (SD 12) years (p < 0.01). The total mean S-25(OH)D concentration was 73 (SD 31.3) nmol/L. Regional differences were found: 15% in hospital A and 36% in hospital B had a S-25(OH(D level < 50 nmol/L, and the mean S-25(OH)D level was 79.2 (SD 31.7) nmol/L in hospital A and 62.4 (SD 27.5) nmol/L in hospital B (p < 0.001). No differences were found in S-25(OH)D concentrations by either the place of residence or the time of year. Overall, the percentage of patients with a sufficient vitamin D level (> 50 nmol/L) was remarkably higher in 2015-2016 (77%) than in 2003-2004 (22%). CONCLUSION: Our results indicate that vitamin D supplementation has been widely integrated into our current practice. However, regional differences were found in the S-25(OH)D concentrations for which the reasons are unknown.

Markers of innate immune activity in patients with type 1 and type 2 diabetes mellitus and the effect of the anti-oxidant coenzyme Q10 on inflammatory activity.

Major long-term complications in patients with diabetes are related to oxidative stress, caused by the hyperglycaemia characteristic for diabetes mellitus. The anti-oxidant coenzyme Q10 (CoQ10) has therefore been proposed as a beneficial supplement to diabetes treatment. Apart from its anti-oxidative function, CoQ10 appears to modulate immune functions by largely unknown mechanisms. The aim of this study was therefore to investigate the effect of CoQ10 on antimicrobial peptides and natural killer (NK) cells, both innate immune components implicated in the pathogenesis of diabetes and diabetes-associated long-term complications such as cardiovascular disease. We determined serum levels of antimicrobial peptides and the phenotype of NK cells isolated from peripheral blood of patients with type 1 (T1DM) or type 2 diabetes mellitus (T2DM) and from healthy controls. In addition, the same parameters were determined in diabetic patients after a 12-week period of CoQ10 supplementation. Two antimicrobial peptides, the human cathelicidin antimicrobial peptide (CAMP) and the human beta defensin 1 (hBD1), were reduced in serum from patients with T1DM. This defect was not reversible by CoQ10 supplementation. In contrast, CoQ10 reduced the levels of circulating hBD2 in these patients and induced changes in subset distribution and activation markers in peripheral NK cells. The results of the present study open up novel approaches in the prevention of long-term complications associated to T1DM, although further investigations are needed.

Cellulose and PapG are important for Escherichia coli causing recurrent urinary tract infection in women.

PURPOSE: To identify Escherichia coli factors associated with bacterial persistence in the human urogenital tract using well-defined clinical isolates from women with cystitis. METHODS: E. coli were isolated from women suffering from recurrent cystitis. For comparison, isolates from sporadically infected patients and healthy volunteers were included in the analysis. Samples were taken on three occasions from the urine, periurethra, and vagina. Isolates were typed by pulsed-field gel electrophoresis, and virulence factors were detected by PCR and morphotypic analysis. RESULTS: In all patients, the original E. coli strain was isolated repeatedly and from different regions. The presence of papG coding for a P fimbriae subtype linked to pyelonephritis was associated with strains isolated from patients with recurrent cystitis, including both among urinary and vaginal isolates. The biofilm component cellulose was detected at a higher frequency in urinary isolates from recurrent versus sporadic cystitis. CONCLUSION: The hypothesis of a periurethral/vaginal E. coli reservoir is supported by the results of this study. Our results also indicate an impact of cellulose on E. coli persistence in the human urogenital tract.

Use of benzodiazepines, z-hypnotics and antidepressants among hip fracture patients in Finland. Consistency between recorded and detected benzodiazepines.

PURPOSE: We described the use of benzodiazepines (BZDs), z-hypnotics, and antidepressants; analyzed the consistency between recorded and detected BZDs among hip fracture patients admitted to two Finnish hospitals during one year; and compared the results with corresponding results from 12 years earlier. METHODS: Current use of medication was obtained from the National Prescription Register. Urine and blood samples used to detect BZD were taken during admission. The following Anatomical Therapeutic Chemical (ATC) classes were included: BZDs: N05BA, N05CD; z-hypnotics: N05CF; and antidepressants: N06A.The presence of BZDs in urine was analyzed using immunoassay. Positive BZDs were confirmed by gas chromatography mass spectrometry. BZDs in serum were analyzed using liquid chromatography. Concordance between recorded and detected BZDs was calculated with kappa (κ) and described using a Venn diagram. RESULTS: A total of 245 patients were enrolled in the study. BZD was detected in 18 %. Kappa was 0.39 (95 % CI 0.25-0.53). Overlap of detected and recorded BZDs was 59 %. According to the prescription register, 18 % used z-hypnotics, and according to both the detection of BZDs and register, 49 % used BZDs and/or z-hypnotics. 22 % used antidepressants and 15 % used combinations of the studied drugs concomitantly. CONCLUSION: Use rate of BZDs and/or z-hypnotics was similar to that 12 years ago. No difference in the consistency between our previous and present study was found either. All studied drugs and their concomitant use increase the risk for fractures. In the elderly, point prevalence of medication and appropriateness should be regularly assessed.

Modeling the length of the care episode after hip fracture: does the type of fracture matter?

BACKGROUND AND AIMS: Hip fractures are common events that require intensive operative hospital care and a lengthy rehabilitation. The effect of hip fracture type on successful rehabilitation is not well known. The aim of this study is to model and compare the length of the care episodes between intra- and extracapsular hip fractures in Finland. MATERIAL AND METHODS: 15544 hip fracture patients living at home in Finland 1998-2001 were followed using register-based data. Patient characteristics, outcomes, and length of stay (LOS) distributions were analyzed using a Bayesian nonparametric multilayer perceptron (MLP) network model. RESULTS: Mortality was similar in intra- and extracapsular hip fractures. Patients were more likely to need long-term care after extracapsular hip fracture. The average LOS at the surgical ward was similar for intra- and extracapsular fractures (1.7 weeks), but there was a considerable difference for the total inpatient LOS between the groups (5.2 weeks vs. 6.9 weeks). Intracapsular fractures had a simple unimodal LOS distribution, whereas the LOS distribution for the extracapsular fractures was multimodal with two clear peaks. Patients with more comorbidities required a longer LOS. CONCLUSIONS: The causes for differences in LOS between fracture types were most likely due to the different surgical methods and rehabilitation practices for the fracture types. As national guidelines suggest similar rehabilitation for all hip fracture patients, there is a need for early and aggressive rehabilitation of patients with extracapsular fractures, including full-weight bearing for all but selected patients.

A 10-Year Retrospective Study of 490 Hip Fracture Patients: Reoperations, Direct Medical Costs, and Survival.

BACKGROUND AND AIMS: Reoperations after operative treatment of hip fracture patients may be associated with higher costs and inferior survival. We examined the acute hospital costs, long-term reoperation rates, and survival of patients with a new hip fracture. MATERIALS AND METHODS: A total of 490 consecutive new hip fracture patients treated at a single center between 31 December 2004 and 6 December 2006 were analyzed retrospectively. Fractures were classified according to Garden and AO. All medical records were checked manually. The costs of reoperations were calculated using the diagnosis-related groups (DRG)-based prices. Survival analysis was performed using the life-table method. The follow-up time was 10 years. RESULTS: In all, 70/490 patients (14.3%) needed reoperations. Of all reoperations, 34.2% were performed during the first month and 72.9% within 1 year after the primary operation. The hemiarthroplasty dislocation rate was 8.5%, and mechanical failures of osteosynthesis occurred in 6.2%. Alcohol abuse was associated with a heightened risk of reoperation. The mean direct costs of primary fracture care were lower than the mean costs of reoperations (€7500 vs €9800). The mortality rate at 10 years was 79.8% among non-reoperated patients and 62.9% among reoperated patients. CONCLUSIONS: According to our hypothesis, the cost per patient of reoperation in acute care was 31% higher than the corresponding cost of a primary operation. Reoperations increased the overall immediate costs of index fractures by nearly 20%. One-third of all reoperations were performed during the first month and almost 75% within 1 year after the primary operation.

The increasing incidence and difference in sex distribution of Achilles tendon rupture in Finland in 1987-1999.

BACKGROUND AND AIMS: There have been reports about the increasing number of Achilles tendon ruptures. The most of the reports are based on records in a few hospitals only. We wanted to verify the increasing trend by investigating the epidemiology of Achilles tendon rupture in a very large population. MATERIAL AND METHODS: The retrospective data was collected from 1987 to 1999 in Finnish National Hospital Discharge Register. The study includes 7 375 tendon rupture patients. We recorded their age, gender, home district and the date of admission in a hospital. RESULTS: The incidence of operatively treated Achilles tendon rupture was 11.2/105. The number of the patients was increasing particularly in the old age-groups. The change during the study period was statistically significant (p = 0.015). The females with a tendon rupture were on average 2-3 years older than men (p < 0.01). The urban areas around the capital city had a higher occurrence of tendon ruptures than the rural areas (p < 0.05). CONCLUSION: The number of Achilles tendon ruptures is increasing, but the reasons for this remain unknown. The geographical variations in rupture rate might indicate the role of the urban life-style as a risk factor. One reason for the differences between the men and the women might be the different level of the sport activities, especially ball-games.

Comparing properties of audit data and routinely collected register data in case of performance assessment of hip fracture treatment in Finland.

OBJECTIVES: To compare prospective audit data and secondary administrative register data in the production of performance assessment information in the case of hip fracture treatment, and to cross-validate the quality of information. METHODS: First, a conceptual model for the performance assessment of hip fracture treatment was defined. This model was then utilized in comparisons between the prospective audit data concerning 106 consecutive hip fracture patients from the Kuusankoski Regional Hospital and corresponding register data from the Finnish Health Care Register and the Causes of Death Register. We examined the completeness of registration of patients and also the accuracy and degree of completeness of the registered data. Observed differences were checked against the medical records. RESULTS: Register data lack clinical detail, but outperform prospective data in the recording of inpatient care history. Completeness of the register data is very good. The accuracy of easily measurable variables in the register is at least 95%. The agreement between register and audit data was 86.3% for detailed hip fracture diagnosis. Polyserial correlation between the functional dependency variables was 0.68. CONCLUSIONS: Register and audit data have certain limitations and problems, but both seem to be suitable for the performance assessment of hip fracture treatment. To improve the feasibility of the administrative register data, the voluntary input of additional hip fracture event data to the register should be made possible. Standardized instructions that guide the use of available register classifications in a sensible way would improve the quality of data.

Non-union of the clavicle and delayed union of the proximal fifth metatarsal treated with low-intensity pulsed ultrasound in two soccer players.

Operative treatment has become the treatment of choice in athletes and active patients in non-union of the clavicle and delayed union of the proximal fifth metatarsal. The purpose of this study was to review the short- and long-term clinical results of low-intensity pulsed ultrasound treatment in a non-union of the clavicle and in a delayed union of the proximal fifth metatarsal in 2 elite soccer players. In both patients, the treatment sessions were performed with an ultrasound signal that was composed of a burst width of 200+/-10% mus containing 1.5+/-5% MHz sine waves, with a repeating rate of 1+/-10% kHz and a spatial average temporal intensity of 30+/-30% mW/cm2. The application of the ultrasound was performed by the patients at home for 20 min/day for 3 months. The healing of the non-union of the clavicle was followed by MR imaging and of the delayed union of the proximal fifth metatarsal by radiographs. In both of the cases the end-results were excellent and the players could continue playing at the highest level. The ultrasound method was successful and afforded players a quick return to sport activity.

Comparison of Injury Severity Between Moped and Motorcycle Crashes: A Finnish Two-Year Prospective Hospital-Based Study.

BACKGROUND AND AIMS: The coverage of the official statistics is poor in motorcycle and moped accidents. The aim of this study was to analyze the severity of motorcycle and moped crashes, and to define the degree of under-reporting in official statistics. MATERIAL AND METHODS: All first attendances due to an acute motorcyclist or moped driver injury registered in the emergency department between June 2004 and May 2006 were analyzed. The severity of the injuries was classified using the Abbreviated Injury Scale score and the New Injury Severity Score. The hospital injury data were compared to the traffic accident statistics reported by the police and compiled and maintained by Statistics Finland. RESULTS: A total of 49 motorcyclists and 61 moped drivers were involved in crashes, leading to a total of 94 and 109 injuries, respectively. There were slightly more vertebral and midfoot fractures among motorcyclists than among moped drivers (p = 0.038 and 0.016, respectively). No significant differences were found between the severity (maximum Abbreviated Injury Scale and median New Injury Severity Scores) of the motorcycle and moped crashes. There was no in-hospital mortality. The degree of agreement (overlap) between the hospital dataset and the official statistics was 32%. The rate of under-reporting was 68%. CONCLUSIONS: According to the maximum Abbreviated Injury Scale and New Injury Severity Scores, the injury severity was equal for motorcycle and moped crashes. The degree of agreement between the hospital dataset and the official statistics was 32%.

Recurrent macroscopic haematuria due to bladder blood vessels after exercise induced haematuria.

The case is reported of exercise induced asymptomatic macroscopic haematuria, which became recurrent haematuria no longer induced by exercise. The cause, diagnosis, and management are discussed. An overview of the potential causes of sport related haematuria is presented.

The incidence of hip fracture in Finland in the year 2000.

During 1985, 4,490 patients with a hip fracture were treated in Finland. From 1970 to 1985, the number almost doubled. The predicted annual number of patients with a hip fracture by the year 2000 will rise to 5,800 if the calculations are based on available demographic data, and to 7,100 if the trend observed during the period 1970 to 1985 continues.

Long-term results of proximal metatarsal osteotomy in hallux valgus.

The author presents the long-term results of a proximal metatarsal osteotomy in hallux valgus. The results are based on clinical findings and radiographs.

An 8-year follow-up study of 221 consecutive hip fracture patients in Finland: analysis of reoperations and their direct medical costs.

BACKGROUND: Some hip fracture patients need one or more reoperations because of complications following initial operative treatment. AIMS: The aim of this study was to identify all further surgical interventions in a cohort of patients with hip fractures over a period of 8 years after index fracture. Immediate direct costs of these reoperations were also calculated. MATERIAL AND METHODS: This retrospective study investigated 221 consecutive patients with hip fractures operated on at two different hospitals in southeastern Finland. The study period in hospital A was from 1 February 2003 to 31 January 2004, and in hospital B from 1 February 2003 to 30 April 2004. About 50% were femoral neck fractures, 41% trochanteric fractures, and 9% subtrochanteric fractures. Patients' medical records were checked from the hospital records and confirmed manually. Short- and long-term complications were recorded. Survival analysis was performed using a life-table method. The actual costs for reoperations and other further procedures for each patient were calculated using diagnosis-related groups-based costs for both hospitals in 2012. RESULTS: A total of 20 patients (9%) needed reoperations. Overall, 10 patients (8.9%) with a femoral neck fracture (n = 112), 8 patients (8.7%) with trochanteric fracture (n = 92), and 2 patients (10.5%) with subtrochanteric fracture (n = 19) were reoperated on. The median interval between the primary operation of the acute hip fracture (n = 20) and the first reoperation was about 300 days (range: 2 weeks to 82 months). Among the women reoperated on, the excess mortality was lower than among those undergoing a single operation. The median costs of treatment per patient with one or more reoperations were €13,422 in hospital A (range: €1616-€61,755), €11,076 in hospital B (range: €1540-€17,866), and €12,850 in the total study group (p = 0.43). In the case of infections (3 patients), the mean costs per patient were €28,751 (range: €11,076-€61,755). CONCLUSIONS: Almost 10% of hip fracture patients required reoperations, and these reoperations caused significant direct costs to health care. However, direct costs account for only approximately 25% of the first year's total costs. These costs should be taken into account when evaluating the economics of hip fractures and the burden of health care.