Ortho-geriatric service--a literature review comparing different models.

In the fast-growing geriatric population, we are confronted with both osteoporosis, which makes fixation of fractures more and more challenging, and several comorbidities, which are most likely to cause postoperative complications. Several models of shared care for these patients are described, and the goal of our systematic literature research was to point out the differences of the individual models. A systematic electronic database search was performed, identifying articles that evaluate in a multidisciplinary approach the elderly hip fracture patients, including at least a geriatrician and an orthopedic surgeon focused on in-hospital treatment. The different investigations were categorized into four groups defined by the type of intervention. The main outcome parameters were pooled across the studies and weighted by sample size. Out of 656 potentially relevant citations, 21 could be extracted and categorized into four groups. Regarding the main outcome parameters, the group with integrated care could show the lowest in-hospital mortality rate (1.14%), the lowest length of stay (7.39 days), and the lowest mean time to surgery (1.43 days). No clear statement could be found for the medical complication rates and the activities of daily living due to their inhomogeneity when comparing the models. The review of these investigations cannot tell us the best model, but there is a trend toward more recent models using an integrated approach. Integrated care summarizes all the positive features reported in the various investigations like integration of a Geriatrician in the trauma unit, having a multidisciplinary team, prioritizing the geriatric fracture patients, and developing guidelines for the patients' treatment. Each hospital implementing a special model for geriatric hip fracture patients should collect detailed data about the patients, process of care, and outcomes to be able to participate in audit processes and avoid peerlessness.

The use of prolotherapy in the sacroiliac joint.

OBJECTIVE: In this study the effectiveness of prolotherapy in the treatment of deficient load transfer of the sacroiliac joint (SIJ) was determined. DESIGN: A prospective descriptive study. SETTING: Authors' private practice. PARTICIPANTS: 25 patients who consented to treatment and attended for at least one follow-up visit and assessment. STUDY PERIOD: From April 2004 to July 2007. INTERVENTION: Three injections of hypertonic dextrose solution into the dorsal interosseous ligament of the affected SIJ, under CT control, 6 weeks apart. MAIN OUTCOME MEASURES: Quebec Back Pain Disability Scale, Roland-Morris 24, Roland-Morris 24 Multiform questionnaires and clinical examination by two authors independently. RESULTS: All patients included in this study attended at least one follow-up visit at 3, 12 or 24 months.. The number of patients at follow-up decreased at 12 and 24 months. Functional questionnaires demonstrated significant improvements for those followed-up at 3, 12 and 24 months (p<0.05). Clinical scores showed significant improvement from commencement to 3, 12 and 24 months (p<0.001). CONCLUSIONS: This descriptive study of prolotherapy in private practice has shown positive clinical outcomes for the 76% of patients who attended the 3-month follow-up visit (76% at 12 months and 32% at 24 months). Similar results were found in the questionnaires (Quebec Back Pain Disability Scale, Roland-Morris 24 and Roland-Morris 24 Multiform questionnaires) at 3, 12 and 24 months.

Development of a medical nutrition therapy protocol for female collegiate athletes.

Nutrition intervention can improve athletic performance and reduce the risk of nutrition related problems in women athletes. The current healthcare environment demands that dietitians document the outcomes of the medical nutrition therapy (MNT) they provide. This requires the development and validation of MNT protocols so that outcomes can be documented and compared in similar populations across multiple settings. The purpose of this project was to develop a sports nutrition management MNT protocol for collegiate women athletes. A registered dietitian currently working with collegiate women athletes collaborated with four dietitians from the community to develop an MNT protocol. Further testing and validation using this MNT protocol will help dietitians document the outcomes of their interventions in this population.

Consensus for the pharmacological management of insomnia in the new millennium.

Insomnia, a common symptom throughout the world, is characterised by difficulty initiating or maintaining sleep or non-restorative sleep and is associated with significant morbidity. A comprehensive medical and sleep history and physical examination are necessary before treating patients with insomnia; the presence of co-morbidities, including medical and psychiatric disorders, or the possible use of substances that may contribute to sleeplessness should be thoroughly investigated. Non-pharmacological approaches include correction of sleep hygiene as well as behavioural treatments. Pharmacotherapy includes benzodiazepine-receptor agonists, which are the drugs of choice for this disorder. They can be subdivided into classic benzodiazepines and non-benzodiazepines. Although many agents in these classes have been prescribed, potential shortcomings include residual sedation, rebound insomnia, and psychomotor and memory impairment. Novel pharmacological strategies that address limitations of the traditional treatment approach, combined with proven modes of behavioural therapy, offer the most successful results in the management of insomnia. These advances provide the opportunity to establish these current recommendations for the optimal management of insomnia. This report from the XXII Collegium Internationale Neuro-Psychopharmacologicum Consensus Workshop outlines recommendations to serve as the foundation for developing a therapeutic plan for each patient.

[Giant diverticula of the colon. Apropos of 2 cases]. / Les diverticules géants du côlon. A propos de deux cas.

Giant diverticulum of the colon is a rare complication of the colonic diverticulosis. It generally involves the sigmoid colon. In the chronic form, without symptoms or with only a few non-specific symptoms, an abdominal mass is frequently palpable. A plain abdominal radiogram, showing a gas-filled cyst, can suggest the diagnosis. If needed, an abdominal CT scan is appropriate and seems to be more accurate than a barium enema. The treatment of choice is a segmental resection of the colon involving the giant diverticulum, followed by a direct anastomosis. Despite the old age of these patients, both postoperative morbidity and mortality are low and justify such a radical approach. The acute clinical presentation (about 20%) is generally due to a peritonitis by perforation of the giant diverticulum and requires an emergency colectomy.

Heterologous in vitro fertilization and sperm capacitation in an endangered African antelope, the scimitar-horned oryx (Oryx dammah).

Scimitar-horned oryx sperm function was studied using protocols developed for domestic cattle. Objectives were to assess sperm 1) viability and motility in vitro over time, 2) capacitation in heparin- or calcium-supplemented medium, and 3) function in an in vitro fertilization system using heterologous (domestic cow) oocytes. Seminal aliquots were washed, and sperm were resuspended in 1) Talp with 5% fetal calf serum (TALP), 2) TALP + 10 microM heparin, 3) TALP + 20 microM heparin, and 4) TALP + 10 mM CaCl. At 0, 3, and 6 h, aliquots were evaluated for sperm motility, viability (using Hoechst 33258), and ability to acrosome-react when exposed to lysophosphatidylcholine (LC). Sperm function was assessed by evaluating fertilization and embryo development after coculture of in vitro-matured domestic cow oocytes with oryx sperm. Overall mean percentages of motile and viable sperm remained high at 6 h (> 60% and > 70%, respectively). Fewer (p < 0.05) sperm incubated in TALP + 10 microM heparin for 6 h contained intact acrosomes after exposure to LC, but there were no differences between LC and control samples after incubation in TALP without heparin. LC-treated sperm in TALP + 10 mM CaCl contained fewer (p < 0.05) intact acrosomes at 3 and 6 h (52.6% and 31.2%, respectively) than paired controls (83.6% and 70.0%, respectively). Oryx sperm from all males were capable of fertilizing cow oocytes (range 17 of 26 [65.4%] to 25 of 26 [96.2%]). Of the 55 2-cell embryos produced, 34 (61.8%) developed to > or = 8 cells. Of the 24 uncleaved oocytes, 7 (29.2%) were polyspermic. These data demonstrate that processed sperm from the endangered scimitar-horned oryx remain vigorous in vitro for at least 6 h. Capacitation can be induced using cattle sperm-processing techniques, with sperm appearing most responsive to elevated CaCl concentrations. Most interesting was the successful production and development of hybrid embryos after coincubation of oryx sperm with cow oocytes, suggesting that the two bovid species have similar fertilization mechanisms.

Snow leopard (Panthera uncia) spermatozoa are sensitive to alkaline pH, but motility in vitro is not influenced by protein or energy supplements.

To better understand the biology of snow leopard spermatozoa and to facilitate developing assisted reproduction, a series of studies was conducted to: 1) identify the component(s) of complex culture media responsible for the detrimental effect on sperm survival in vitro, 2) optimize medium for supporting sperm viability, and 3) evaluate sperm capacitation in vitro. Constituents of complex media were added systematically to phosphate-buffered saline (PBS) to isolate the factor(s) influencing snow leopard sperm motility in vitro. Sperm capacitation was also assessed following incubation in PBS with bovine serum albumin (BSA), fetal calf serum (FCS), or heparin. For maintaining sperm motility, there was no benefit (P > or = 0.05) to supplementing PBS with low (5%) or high (20%) concentrations of snow leopard serum (SLS) versus FCS or BSA. Likewise, adding supplemental energy substrates (pyruvate, glucose, lactate, or glutamine) did not enhance or hinder (P > or = 0.05) sperm motility. However, motility rapidly decreased (P < 0.05) with the addition of NaHCO3 to PBS or Ham's F10 nutrient mixture. Surprisingly, Ham's F10 with no buffering component or with both NaHCO3 and N-Z-hydroxyethylpiperazine-N'-2-ethanesulfonic acid (HEPES) maintained sperm motility at levels similar (P > or = 0.05) to PBS. Although sperm motility in all treatments decreased with time, there was a strong inverse relationship (P < 0.01; r = 0.90) between motility and sample pH at 6 hours. Spermatozoa incubated in PBS containing FCS, BSA, or heparin did not undergo the acrosome reaction when exposed to calcium ionophore. In summary, alkaline pH has a profound detrimental effect on snow leopard sperm motility, and capacitation does not occur under conditions that normally promote this event in other felid species. These results clearly demonstrate a high degree of interspecific variation among felids in fundamental sperm function, and they provide evidence for the necessity of basic research when developing assisted reproduction in little-studied nondomestic species.

Auditory awakening thresholds in sleepy and alert individuals.

Twenty-seven healthy men and women with regular sleep-wake habits (and no habitual napping) participated in a study to determine the relation between auditory awakening thresholds (AAT) and multiple sleep latency test (MSLT) scores. Subjects were free of any sleep complaints and were screened polysomnographically. Nine subjects had a screening MSLT of < or = 5 minutes (sleepy group), and 18 subjects had an MSLT of > or = 10 minutes. Subjects were assigned to three groups: a sleepy group, alert group and an alert sleep-deprived group. Subjects underwent 2 nights of AAT testing with at least 5 days in between each study night. AATs were determined at 0100, 0300, 0500 and 0730 hours. There were a total of 209 available AAT determinations, with a comparable number of trials across the groups. Because 68% of AAT determinations were done out of stage 2 non-rapid eye movement (NREM) sleep, the thrust of the analysis was based on the results of this stage of sleep. The AATs were averaged across the two experimental nights. Trials 1 and 2 (first half of the night) and 3 and 4 (second half of the night) were averaged for each subject. There was no main effect of group on AATs. However, there was a significant main effect of time and a significant group by time interaction. The former indicated an overall decline in AATs across the night. More importantly, the three groups had comparable AAT levels during the first half of the night:. Sleepy and alert-deprived subjects, however, failed to show a decline in AATs, whereas the alert group showed a significant decline in the second half of the night. This differential rate of decline in AATs is suggested to be related to the differences in sleep homeostasis among alert and sleepy individuals.

Experimental sleep fragmentation.

Thirty-six healthy young men and women (age range 21-35 years) were studied in an experimental model of sleep fragmentation. On 2 nights sleep was disrupted by presenting tones to produce brief electroencephalogram (EEG) arousals (without shortening sleep time) and daytime function was assessed the following day with the Multiple Sleep Latency Test and a divided attention performance test. The fragmentation of sleep produced significant disruption of nocturnal sleep and reduced daytime alertness. Adaptation in EEG-defined arousals occurred from the 1st to the 2nd night of fragmentation. Threshold (measured indirectly) characteristics of EEG-defined arousals were somewhat different than those of previous studies requiring behavioral awakening. The percent of tone series producing arousal, number of tones necessary for arousal and duration of the arousal all reflected heightened thresholds in stage 3/4 and rapid eye movement (REM) sleep compared to stage 1 and stage 2 sleep. In the last 3 hours of sleep versus the first 3 hours, arousals occurred less frequently, required more tones to produce, resulted in shorter durations and in fewer sleep stage changes, except for REM sleep where the converse was the case.

Effects of caffeine on alertness.

The alerting effects of caffeine were assessed using a standard physiological measure of daytime sleepiness/alertness, the Multiple Sleep Latency Test (MSLT). Healthy young men (n = 24) were randomly assigned to receive caffeine 250 mg or placebo administered double blind, at 0900 and 1300 hours on each of 2 days. On the 3rd day both groups received placebo to test for conditioning to the alerting effects of caffeine. Each day sleep latency was measured at 1000, 1200, 1400, and 1600 hours and performance (divided attention at 1030 hours and auditory vigilance at 1430 hours) was assessed. Caffeine increased sleep latency (i.e., improved alertness) and auditory vigilance performance compared to placebo. Tolerance to the effects of caffeine on sleep latency developed over the four administrations. On the conditioning test (day 3) the group receiving caffeine the previous two days was more alert and performed better than the placebo group.

Eligibility requirements in hypnotic trials.

Forty-eight patients complaining of insomnia were studied at two sleep laboratories using an identical protocol to evaluate hypnotic efficacy. All met the screening requirement of a mean sleep latency of 30 min or greater on 3 laboratory nights following an adaptation night. Of these patients 34 still complaining of insomnia were screened a second time 2 to 6 months later. Sixteen of the 34 failed the second screen. Sleep parameters for the 34 on screen 1 compared with screen 2 were the same except for sleep latency (the eligibility criteria), which was significantly shorter. There was no evidence of a systematic difference between laboratories, a change in procedure from screen 1 to 2, or a systematic loss of patients from screen 1 to 2. The data show that the statistical phenomenon of regression toward the mean must be considered in designing hypnotic efficacy studies.