Implementing a fracture liaison service open model of care utilizing a cloud-based tool.

PURPOSE: Although half of women and one-quarter of men aged 50 and older will sustain an acute low-trauma fracture, less than a quarter receive appropriate secondary fracture prevention. The goal of this quality improvement demonstration project was to implement a Fracture Liaison Service (FLS) focused on secondary prevention of an osteoporotic fracture in three open health care systems aided by a cloud-based tool. METHODS: The pre-post study design examined the proportion of men and women over age 50 who received appropriate assessment (bone mineral density, vitamin D levels) and treatment (calcium/vitamin D, pharmacologic therapy) in the six months following a recently diagnosed fracture. The pre-study (Pre FLS) included a retrospective chart review for baseline data (N = 344 patients) within each health care system. In the post-evaluation (Post FLS, N = 148 patients), the FLS coordinator from each health care system examined these parameters following enrollment and for 6 months following the recently diagnosed fracture. Data were managed in the cloud-based FLS application tool. RESULTS: Ninety-three participants completed the program. The FLS program increased the percentage of patients receiving bone mineral density testing from 21% at baseline to 93% (p < 0.001) Post FLS implementation. Assessments of vitamin D levels increased from 25 to 84% (p < 0.001). Patients prescribed calcium/vitamin D increased from 36% at baseline to 93% (p < 0.001) and those prescribed pharmacologic treatment for osteoporosis increased on average from 20 to 54% (p < 0.001) Post FLS. CONCLUSIONS: We conclude that the FLS model of care in an open health care system, assisted by a cloud-based tool, significantly improved assessment and/or treatment of patients with a recently diagnosed osteoporotic fracture. Future studies are necessary to determine if this model of care is scalable and if such programs result in prevention of fractures. Mini-Abstract: The goal was to implement a Fracture Liaison Service (FLS) focused on secondary prevention of an osteoporotic fracture in open health care systems aided by a cloud-based tool. This model significantly improved assessment and/or treatment of patients with a recently diagnosed fracture.

Selective method for identification and quantification of Bifidobacterium animalis subspecies lactis BB-12 (BB-12) from the gastrointestinal tract of healthy volunteers ingesting a combination probiotic of BB-12 and Lactobacillus rhamnosus GG.

AIM: To develop a novel validated method for the isolation of Bifidobacterium animalis ssp. lactis BB-12 (BB-12) from faecal specimens and apply it to studies of BB-12 and Lactobacillus rhamnosus GG (LGG) recovered from the healthy human gastrointestinal (GI) tract. METHODS AND RESULTS: A novel method for isolating and enumerating BB-12 was developed based on its morphologic features of growth on tetracycline-containing agar. The method identified BB-12 correctly from spiked stool close to 100% of the time as validated by PCR confirmation of identity, and resulted in 97-104% recovery of BB-12. The method was then applied in a study of the recovery of BB-12 and LGG from the GI tract of healthy humans consuming ProNutrients® Probiotic powder sachet containing BB-12 and LGG. Viable BB-12 and LGG were recovered from stool after 21 days of probiotic ingestion compared to baseline. In contrast, no organisms were recovered 21 days after baseline in the nonsupplemented control group. CONCLUSIONS: We demonstrated recovery of viable BB-12, using a validated novel method specific for the isolation of BB-12, and LGG from the GI tract of healthy humans who consumed the probiotic supplement. SIGNIFICANCE AND IMPACT OF THE STUDY: This method will enable more detailed and specific studies of BB-12 in probiotic supplements, including when in combination with LGG.

Real-world practices to prevent venous thromboembolism with pharmacological prophylaxis in US orthopedic surgery patients: an analysis of an integrated healthcare database.

Major orthopedic surgery patients are at high risk of venous thromboembolism (VTE) in-hospital and post-discharge. This study assessed real-world inpatient and outpatient thromboprophylaxis practices following knee or hip arthroplasty. Patients from the Henry Ford Health System aged ≥18 years undergoing knee and hip arthroplasty (January 1997-June 2007) were identified using Current Procedural Terminology codes from administrative databases. Patients with <18 months of continuous enrollment in the system's health maintenance organization or with a current diagnosis of atrial fibrillation were excluded. Both inpatient and outpatient pharmacological prophylaxis was assessed. The analysis included 1393 (58.5%) patients following knee arthroplasty and 989 (41.5%) following hip arthroplasty. Average length of hospitalization was 4.9 days over the study period, although the median stay decreased from 5 days in 1997 to 3 days in 2007. Of patients included, 72.7% received pharmacological prophylaxis only in the inpatient setting following knee arthroplasty and 73.9% following hip arthroplasty. Both inpatient and outpatient pharmacological prophylaxis was received by 12.5% of knee and 12.3% of hip arthroplasty patients. Total length of pharmacological prophylaxis fluctuated between 2 to 4 days between 1997 and 2005, but increased to 11.5 ± 9.0 days in 2007. Although the duration of prophylaxis has recently increased, considerable numbers of hip and knee arthroplasty patients only receive prophylaxis for part of the time period recommended by guidelines. Further efforts are required to ensure the recommended duration of thromboprophylaxis is prescribed to all patients and continued outpatient VTE prophylaxis is provided.

[Usefulness of electromagnetic fields in the treatment of hip avascular necrosis: a prospective study of 30 cases]. / Utilidad de los campos electromagnéticos en el tratamiento de la necrosis avascular de cadera: estudio prospectivo de 30 casos.

A series is here reported of 30 hips from 21 patients with the diagnosis of avascular necrosis in different stages (Ficat 0 = 1, I = 4, II = 13, III = 10, IV = 2). Patients underwent external electro-stimulation by means of a electromagnetic field generator, and results were evaluated by NMR at three-month intervals. Lesions were categorized by NMR: < 25%, 25%-50%, and > 50% of involved head volume. The grading of lesions yielded the following distribution: grade 1 = 12, grade 2 = 10, and grade 3 = 7. Results were categorized in "clinical success", "NMR success" and "combined success" when symptoms decreased or disappeared, the lesion stabilized by NMR, or both, respectively. Overall, the corresponding figures were 80%, 76.6%, and 63.3%, and were remarkably influenced by the NMR grading of the lesion.

Phrenic nerve pacing in two young quadriplegic ventilator-dependent patients.

Patients who survive high cervical injury are usually dependent on mechanical ventilation and tracheostomy if the lesion above C3 is complete. We report our experience with phrenic nerve pacing (PNP) to achieve ventilator-independence in two young quadriplegic patients. A diaphragm conditioning programme, and combination of low frequency electrophrenic stimulation within each inspiratory burst and low breathing frequency enabled both patients initially to achieve continuous 24 hour ventilation independent of mechanical ventilation. One patient reverted to overnight mechanical ventilation (six hours) after three years. PNP should be considered in ventilator dependent patients with high cervical injury to achieve independence and improve quality of life.

Controlled clinical trial of cannabidiol in Huntington's disease.

Based on encouraging preliminary findings, cannabidiol (CBD), a major nonpsychotropic constituent of Cannabis, was evaluated for symptomatic efficacy and safety in 15 neuroleptic-free patients with Huntington's Disease (HD). The effects of oral CBD (10 mg/kg/day for 6 weeks) and placebo (sesame oil for 6 weeks) were ascertained weekly under a double-blind, randomized cross-over design. A comparison of the effects of CBD and placebo on chorea severity and other therapeutic outcome variables, and on a Cannabis side effect inventory, clinical lab tests and other safety outcome variables, indicated no significant (p greater than 0.05) or clinically important differences. Correspondingly, plasma levels of CBD were assayed by GC/MS, and the weekly levels (mean range of 5.9 to 11.2 ng/ml) did not differ significantly over the 6 weeks of CBD administration. In summary, CBD, at an average daily dose of about 700 mg/day for 6 weeks, was neither symptomatically effective nor toxic, relative to placebo, in neuroleptic-free patients with HD.

Functional electrical stimulation for upper limb strengthening in traumatic quadriplegia.

The hypothesis of this study was that the functional electrical stimulation (FES)-assisted exercise of partially paralyzed arm muscles would result in significantly greater muscle strength in the arms of spinal cord injured quadriplegics than equal periods of conventional isotonic exercise. Single muscles were studied in seven subjects in a crossover design consisting of equal periods of FES-assisted exercise and conventional exercise. It was concluded that for these subjects using this exercise regime, neither FES-assisted exercise nor conventional exercise produced improvements in maximum voluntary force that were either statistically or functionally significant. The results, although disappointing, have helped these subjects to be more realistic about the potential therapeutic benefits of FES.

The management of hyperbilirubinemia.

When pre-established "safe" limits of serum bilirubin are exceeded, or when hyperbilirubinemia is present in association with other conditions such as prematurity with respiratory distress, asphyxia, or neonatal infections, the need to lessen the risk of bilirubin encephalopathy requires specific and effective interventions to lower the unconjugated or indirect-reacting bilirubin level in infants at risk. To this end the authors examine the criteria for intervention, the means of decreasing serum bilirubin levels, phototherapy, exchange transfusion, and the problem of jaundice in breast-fed infants.

Current advances in perinatal medicine.

The enhancement of pulmonary maturation with the resultant ability to prevent hyaline membrane disease has given rise to the use of a number of drugs experimentally including corticosteroids, thyroxine, aminophylline, heroin, and several suggested others for this purpose. In clinical use to date only the corticosteroids have been widely utilized in man but it is clear that these agents are capable of effecting an advancement in the maturation of the surfactant system of the lung and a subsequent reduction in the incidence of severity of hyaline membrane disease. However, all agents which act by the enhancement of maturation also carry with them a resultant arrest to replication of tissues and there have been demonstrable effects on both the lung and possibly the brain of the organisms to whom these agents have been administreted. In this connection it is, therefore, important to realize that the advantages gained from these agents may be counterbalanced by disadvantages from their usage and that a reasoned and careful approach in each individual case is mandatory when use of such agents is considered. Experimental and clinical studies suggest the possibility that Vitamin E acting as a free radical scavenger may be important in the prevention of oxygen toxicity both to the eye (retrolental fibroplasia) as well as ameliorating the oxygen component of the destructive effects of respirator lung disease (bronchopulmonary dysplasia). The action of Vitamin E under these circumstances is not dependent upon its actual quantitative level in the plasma of premature infants but in utilization to its excess. Although phototherapy has been universally and widely used since 1958, precise studies of its mechanism of action have not been revealing. Recent work has suggested that following exposure to photoirradiation, bilirubin in its unconjugated form can be seen to appear in the excretory bile ducts suggesting the transport of unconjugated bilirubin through the liver. More recent evidence has also suggested that this occurrence is the result of internal rotation following light exposure of one of the double bonded rings which effectively converts the molecule from a lipid soluble to a water soluble and thereby excretable form. These studies would not only account for an appropriate explanation of the quantitative reduction in bilirubin observed but carry with them the other important consideration that the amount of light exposure necessary to accomplish this is strikingly less than the previously considered photooxidation reaction. The clinical implications of these findings may suggest a reevaluation of the quanta of light which has been used for purposes of phototherapy to date.

Toxicity from tea ingestion in an infant: a computer simulation analysis.

A seven-week-old infant presented with tonic posturing and nervous irritability after concentrated tea ingestion. The tea was analyzed and found to contain caffeine, a methylxanthine central nervous system stimulant. With the aid of a computer, projected blood levels were calculated over a thirty-hour time period and comared to the infant's clinical status. It is recommended that beverages containing xanthines be given to infants and small children with caution.

The lack of effect of phototherapy on serum bilirubin-binding capacity in newborn infants.

Using a Sephadex G-25 separation technique, the total bilirubin-binding capacity was measured in 18 jaundiced infants before and after phototherapy. The initial total bilirubin-binding capacity obtained at 20 to 113 hours of age averaged 17.5 +/- 4.4 mg/dl (mean +/- SD) and was unchanged during phototherapy at 34 to 135 hours of age. In ten infants, the total bilirubin-binding capacity was measured before, during, and 24 hours after the cessation of phototherapy. Here too, phototherapy did not significantly influence the TBBC. These data indicate that in vivo, phototherapy does not alter the serum bilirubin binding capacity of newborn infants.