A synergistic impact of body mass index and gamma gap on heart failure and mortality rate among older patients with coronary artery disease: a prospective study with 10-year follow-up.

PURPOSE: This prospective study with 10-year follow-up aimed to analyze potential impact of body mass index (BMI) and gamma gap on heart failure and mortality rate in older patients with coronary artery disease (CAD). METHODS: There were 987 consecutive older patients with CAD included and divided into four groups according to BMI and gamma gap levels. RESULTS: Median age was 86 years. The highest proportion of heart failure (46.2%) and the highest mortality rate (84.4%) was observed in patients with low BMI and high gamma gap, whereas the lowest proportion of heart failure (18.9%) and the lowest mortality rate (62.9%) was observed in those with high BMI and low gamma gap. After full adjustment in multivariate Logistic regression analysis, heart failure was most common in patients with low BMI and high gamma gap compared with those with high BMI and low gamma gap (hazard ratio [HR]: 2.82, 95% confidence interval [CI]: 1.79-4.48, P < 0.05). Meanwhile, multivariate Cox regression analysis showed that mortality rate was the highest in those with low BMI and high gamma gap compared with patients with high BMI and low gamma gap (HR: 1.65, 95% CI: 1.32-2.07, P < 0.05). CONCLUSION: The combination of low BMI and high gamma gap could further promote heart failure and increase mortality rate in older patients with CAD. Future studies should explore the underlying mechanisms linking low BMI, high gamma gap, and mortality rate, as well as the potential benefits of nutritional and immunological interventions to improve health prognosis in older patients with CAD.

A novel machine-learning algorithm for predicting mortality risk after hip fracture surgery.

INTRODUCTION: Although several risk stratification models have been developed to predict hip fracture mortality, efforts are still being placed in this area. Our aim is to (1) construct a risk prediction model for long-term mortality after hip fracture utilizing the RSF method and (2) to evaluate the changing effects over time of individual pre- and post-treatment variables on predicting mortality. METHODS: 1330 hip fracture surgical patients were included. Forty-five admission and in-hospital variables were analyzed as potential predictors of all-cause mortality. A random survival forest (RSF) algorithm was applied in predictors identification. Cox regression models were then constructed. Sensitivity analyses and internal validation were performed to assess the performance of each model. C statistics were calculated and model calibrations were further assessed. RESULTS: Our machine-learning RSF algorithm achieved a c statistic of 0.83 for 30-day prediction and 0.75 for 1-year mortality. Additionally, a COX model was also constructed by using the variables selected by RSF, c statistics were shown as 0.75 and 0.72 when applying in 2-year and 4-year mortality prediction. The presence of post-operative complications remained as the strongest risk factor for both short- and long-term mortality. Variables including fracture location, high serum creatinine, age, hypertension, anemia, ASA, hypoproteinemia, abnormal BUN, and RDW became more important as the length of follow-up increased. CONCLUSION: The RSF machine-learning algorithm represents a novel approach to identify important risk factors and a risk stratification models for patients undergoing hip fracture surgery is built through this approach to identify those at high risk of long-term mortality.

Quantitative proteomics and reverse engineer analysis identified plasma exosome derived protein markers related to osteoporosis.

Alongside an aging population, osteoporosis has become increasingly common, representing a major public health problem. Human blood provides the predominant matrix for pathological targets underlining disease mechanisms. In the present study, the protein profiles of blood plasma exosomes from patients with osteoporosis, osteopenia, and those with normal bone mass were compared. The aim of the study was to search for potential novel diagnostic/therapeutic targets for further investigation in osteoporosis. A total of 60 participants were included from the PLAGH Hip Fracture Database. Quantitative proteomics was carried out to profile the plasma exosome derived proteins from patients diagnosed with osteoporosis, osteopenia, and normal bone mass, respectively. A Parallel reaction monitoring (PRM) analysis was further carried out to validate the identified proteins. Bio-informatics analyses including GO annotation and reverse engineering of gene regulatory networks analysis were applied in annotating the biological relevance of the identified proteins. Forty-five differentially expressed proteins were identified in the discovery dataset and four of them, PSMB9, AARS, PCBP2, and VSIR were further verified in a validation set. Based on the results, an exosomal-proteins index was constructed to classify individuals with osteoporosis from those without, an AUC of 0.805 (95% CI 0.620-0.926, p < 0.001) was achieved in classification performance assessment. Additionally, a reverse engineer of the regulatory network analysis identified and predicted the proteins which may interact with the four target proteins identified, providing references for further investigations into the pathological mechanisms of osteoporosis.

Multidirectional percutaneous drilling and autologous bone marrow injection for the treatment of femoral diaphyseal nonunions: a prospective interventional study.

BACKGROUND: To examine the outcomes of multidirectional percutaneous drilling and autologous concentrated bone marrow (BM) transplantation for atrophic femoral diaphyseal nonunion characterized by intact hardware and mechanical stability at the nonunion site. METHODS: Fourteen patients (22-63 years of age) were admitted to our hospital with atrophic femoral diaphyseal nonunion. All patients were treated with a combination of multidirectional percutaneous drilling and autologous concentrated BM transplantation. Radiographic evaluation was conducted every month after transplantation until bone healing was achieved. RESULTS: Bony union was achieved in 13 of the 14 patients (92.9%) after an average of 3.9 months (range: 2.5-6 months). The average radiographic union scale in tibial (RUST) scale score improved significantly from the preoperative period (6.15±1.21) to follow-up (11.23±0.73; P<0.05). The mean follow-up after transplantation was 31.4±9.5 months (range: 18-50 months). At the final follow-up, the quality of function had improved significantly, allowing a return to normal activities. CONCLUSION: Combined multidirectional percutaneous drilling and autologous concentrated BM transplantation is an easy, safe, inexpensive, and efficacious method to treat atrophic femoral diaphyseal nonunion characterized by intact hardware and mechanical stability at the nonunion site.Trial registration number: ISRCTN29808592.

Differences in Bone Mineral Density and Hip Geometry in Trochanteric and Cervical Hip Fractures in Elderly Chinese Patients.

OBJECTIVE: To assess the differences in bone mineral density (BMD) and hip geometry in trochanteric and cervical hip fractures in elderly Chinese patients. METHODS: A consecutive series of 196 hip fracture patients aged over 50 years was recruited from November 2013 to October 2015, including 109 cases of cervical fractures (36 males and 73 females) and 87 cases of trochanteric fractures (34 males and 53 females). All patients were evaluated through dual-energy X-ray absorptiometry, and baseline characteristics, BMD and structural parameters were collected and reviewed. RESULTS: There were statistically significant differences in age, height, and body mass index between patients with each type of fracture, and patients with trochanteric fractures were older than those with cervical fractures, especially in women. The BMD in trochanteric fractures was markedly lower than in cervical fractures in all five sites of the hip by an approximate reduction of 10%, in both men and women. The cross-sectional area, cross-sectional moment of inertia, and the cortical thickness in the cervical fracture group were significantly higher than in the trochanteric fracture group. However, the buckling ratio of both the femoral neck and trochanteric region were significantly lower in the cervical fracture group. Age (/10 years), cross-sectional moment of inertia in femoral neck and buckling ratio in trochanteric region were significant risk factors for trochanteric fractures compared with cervical fractures. CONCLUSIONS: Compared with cervical hip fractures, patients with trochanteric fractures were older, had a lower BMD, and had less bone mechanical strength, especially in female patients. Age, femoral neck cross-sectional moment of inertia (FNCSMI), and trochanteric region buckling ratio (ITBR) were stronger risk factors for trochanteric hip fractures than for cervical fractures.

Bone-Derived Extracellular Vesicles: Novel Players of Interorgan Crosstalk.

An increasing number of studies have shown that bone plays an active role in regulating glucose metabolism, affects renal, and cardiovascular diseases and even influences the development of offspring. These novel findings have indicated that bone plays a much more important role in the human body than only providing physical support. However, further investigations of the mechanisms underlying the effects of bone are needed. Recently, extracellular vesicles (EVs) have received increased attention because they can transfer functional proteins, mRNAs, and miRNAs between cells/organs. After reviewing the existing evidence, we hypothesized that bone may be involved in interorgan communication via EVs. Further research exploring bone-derived EVs may facilitate the understanding of bone as a multifunctional organ.

Effect of low-intensity pulsed ultrasound on distraction osteogenesis: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Low-intensity pulsed ultrasound (LIPUS) is a common adjunct used to promote bone healing for fresh fractures and non-unions, but its efficacy for bone distraction osteogenesis remains uncertain. This study aims to determine whether LIPUS can effectively and safely reduce the associated treatment time for patients undergoing distraction osteogenesis. METHODS: MEDLINE, EMBASE, and the Cochrane Library were searched until May 1, 2018, without language restriction. Studies should be randomized controlled trials (RCTs) or quasi-RCTs of LIPUS compared with sham devices or no devices in patients who undergo distraction osteogenesis. The primary outcome was the treatment time. The secondary outcome was the risk of complications. Treatment effects were assessed using mean differences, standardized mean differences, or risk ratios using a random-effects model. The Cochrane risk-of-bias tool was used to assess the risk of bias. The I2 statistic was used to assess the heterogeneity. The GRADE system was used to evaluate the evidence quality. RESULTS: A total of 7 trials with 172 patients were included. The pooled results suggested that during the process of distraction osteogenesis, LIPUS therapy did not show a statistically significant reduction in the treatment time (mean difference, - 8.75 days/cm; 95% CI, - 20.68 to 3.18 days/cm; P = 0.15; I2 = 72%) or in the risk of complications (risk ratio, 0.90 in favor of LIPUS; 95% CI, 0.65 to 1.24; I2 = 0%). Also, LIPUS therapy did not show a significant effect on the radiological gap fill area (standardized mean difference, 0.48 in favor of control; 95%CI, - 1.49 to 0.52; I2 = 0%), the histological gap fill length (standardized mean difference, 0.76 in favor of control; 95%CI, - 1.78 to 0.27; I2 = 0%), or the bone density increase (standardized mean difference, 0.43 in favor of LIPUS; 95%CI, - 0.02 to 0.88; I2 = 0%). CONCLUSIONS: Among patients undergoing distraction osteogenesis, neither the treatment time nor the risk of complications could be reduced by LIPUS therapy. The currently available evidence is insufficient to support the routine use of this intervention in clinical practice. TRIAL REGISTRATION: CRD 42017073596.

A meta-analysis and systematic review evaluating the use of erythropoietin in total hip and knee arthroplasty.

PURPOSE: The debate is still ongoing on the effectiveness and safety of erythropoietin (EPO) treatment in orthopedic surgeries. Specifically, previous studies have not compared the dynamic change of hemoglobin (Hb) levels between different transfusion methods. Besides, complications or side effects of this alternative have not been quantitatively analyzed. We conducted a meta-analysis and systemic review to evaluate the efficacy of EPO on Hb levels observed during the whole perioperative period as well as the volume of allogeneic blood transfusion (ABT), the risk of venous thromboembolism, and application frequency of ABT in hip and knee surgery. MATERIALS AND METHODS: PubMed, Embase, Web of Science, and the Cochrane library were systematically searched from inception to November 2017. The data from randomized controlled trials were extracted and the risk of bias assessed using Cochrane's Collaboration's tool. RESULTS: Twenty-five randomized controlled trials involving 4,159 patients were included in this meta-analysis. EPO could reduce exposure to allogeneic blood transfused (odds ratio [OR] =0.42, P=0.001) and reduce the average volume of allogeneic blood transfused (OR = -0.28, P=0.002). When EPO and preoperative autologous blood donation (PABD) were compared, the use of EPO was associated with lower exposure to ABT (OR =0.48, P=0.03), but no significant decrease in the average volume of allogeneic blood transfused (OR = -0.23, P=0.32). The use of EPO was associated with a higher level of Hb with or without use of PABD at all the 4 time points (preoperation, 24-48 hours postoperation, 3-5 days postoperation, discharge of last observation) (P<0.0001), which means EPO could increase the level of Hb significantly during the perioperative period. The results also indicated EPO does not increase the risk of a venous thromboembolism event. CONCLUSION: Preoperative administration of EPO was shown to generally increase Hb levels during the whole perioperative period; however, the extent of the positive effects varies with time points. Additionally, EPO minimizes the need for transfusion significantly in patients undergoing hip or knee surgery without increasing the chance of developing thrombotic complications. Therefore, EPO offers an alternative blood management strategy in total hip arthroplasty and total knee arthroplasty.

Exchange of genetic material: a new paradigm in bone cell communications.

An emerging concept in intercellular communication in mammals is that communication can be mediated by exchange of genetic material, mainly in the form of RNAs. In this review, we discuss recent studies that describe the trafficking of genetic material with a focus on bone cell communication. Three major carriers are discussed: gap junctions, protein-binding complexes, and genetic material exchange mediated by extracellular vesicles. While protein-level exchange has been well documented, no review has summarized the novel paradigm of cell-to-cell communication by genetic information exchange in bone tissues or its biological relevance in terms of bone homeostasis and bone-related diseases. The purpose of this review is to promote further understanding of this novel discovery regarding bone cell communication and provide references for further investigations.

Combination therapy of anabolic agents and bisphosphonates on bone mineral density in patients with osteoporosis: a meta-analysis of randomised controlled trials.

OBJECTIVE: We aimed to determine whether the concomitant combination therapy of anabolic agents and bisphosphonates produces more effects on bone mineral density (BMD) than anabolic agents alone in patients with osteoporosis. METHODS: We searched MEDLINE, EMBASE and the Cochrane Library for publications from 1 January 1980 to 1 August 2016 to identify all the randomised controlled trials (RCTs) and quasi-RCTs. The primary outcome was the mean per cent changes in BMD at the lumbar spine, the total hip and the femoral neck with an optimal period of treatment (6 to 12 months). The secondary outcome was the mean per cent changes in BMD at the same sites with the full period of recommendation (18 to 24 months). A random-effects model was used to estimate the standardised mean differences (SMDs) and the 95% CIs. RESULTS: Seven studies, with 747 patients, were included. With the optimal period, the concomitant combination therapy demonstrated a significant advantage over a monotherapy in BMD improvement at the total hip (SMD 0.42; 95% CI 0.26 to 0.58) and the femoral neck (SMD 0.30; 95% CI 0.14 to 0.46), but not for the spine BMD (SMD 0.13; 95% CI -0.17 to 0.43). With the full period, the concomitant combination therapy did not improve the BMD at the lumbar spine (SMD -0.06; 95% CI -0.71 to 0.59), the total hip (SMD 0.05; 95% CI -0.71 to 0.82) and the femoral neck (SMD -0.32; 95% CI -1.15 to 0.50). CONCLUSIONS: Compared with anabolic monotherapy, the concomitant combination therapy of anabolic agents and bisphosphonates significantly improved the BMD at the total hip and femoral neck with a shorter term (6 to 12 months) and produced similar benefits on BMD for the longer term (18 to 24 months). Also, the effect of concomitant combination therapy might be affected by the dose of anabolic agents. PROSPERO REGISTRATION NUMBER: CRD42016041335.

Parathyroid hormone analogues for fracture healing: protocol for a systematic review and meta-analysis of randomised controlled trials.

INTRODUCTION: Fracture healing is a complex physiological process. Impaired healing will increase the need for care and cause serious complications. Thus, identifying strategies to accelerate the rate of healing, preventing delayed unions and non-unions, is essential. Parathyroid hormone (PTH) is a key systemic regulator of calcium and phosphate metabolism. It has been determined that intermittent administration of PTH and its analogue can exert anabolic effect on bone, increase bone mass and reduce bone loss, leading to an increase in bone formation. Owing to their anabolic effect, there is an increasing interest in its potential in promoting the process of fracture healing. However, in clinical studies, the results are in conflict. This objective of this study is to determine the role of PTH analogues for fracture healing in adults. METHODS AND ANALYSIS: MEDLINE, EMBASE and Cochrane databases will be searched to identify all randomised controlled trials (RCTs) and quasi-RCTs that compare the different effects between PTH analogues and any other treatments in adults with any type of fracture. The primary outcome is the functional recovery. And the secondary outcomes are fracture union and adverse events. The meta-analysis will be performed using a random effects model. Heterogeneity will be assessed by the P values and I² statistic. And subgroup analyses and sensitivity analyses will be used to explore the heterogeneity. Risk of bias will be assessed using the Cochrane tool and the quality of evidence will be assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. ETHICS AND DISSEMINATION: Ethical approval is not required because this proposed systematic review and meta-analysis is based on published data, without including confidential personal data or data on interventions on patients. The findings of this study will be published in a peer-reviewed journaland presented at a relevant conference. PROSPERO REGISTRATION NUMBER: CRD42017062093.

Exosome-Mediated Genetic Information Transfer, a Missing Piece of Osteoblast-Osteoclast Communication Puzzle.

The skeletal system functions and maintains itself based on communication between cells of diverse origins, especially between osteoblasts (OBs) and osteoclasts (OCs), accounting for bone formation and resorption, respectively. Previously, protein-level information exchange has been the research focus, and this has been discussed in detail. The regulative effects of microRNAs (miRNAs) on OB and OC ignite the question as to whether genetic information could be transferred between bone cells. Exosomes, extracellular membrane vesicles 30-100 nm in diameter, have recently been demonstrated to transfer functional proteins, mRNAs, and miRNAs, and serve as mediators of intercellular communication. By reviewing the distinguishing features of exosomes, a hypothesis was formulated and evaluated in this article that exosome-mediated genetic information transfer may represent a novel strategy for OB-OC communication. The exosomes may coordinately regulate these two cells under certain physiological conditions by transferring genetic information. Further research in exosome-shuttered miRNAs in OB-OC communication may add a missing piece to the bone cells communication "puzzle."

The effects of low-intensity pulsed ultrasound on fresh fracture: A meta-analysis.

BACKGROUND: Low-intensity pulsed ultrasonography (LIPUS) is a form of mechanical stimulation that is delivered via a special device to the fracture site for the acceleration of fracture healing. We conducted a meta-analysis to assess the effect of LIPUS for fresh fractures in adults. METHODS: MEDLINE, EMBASE and the Cochrane Library searched between Jan 1980 and Nov 2016. Studies should be quasi-randomized and randomized controlled trials (RCTs) comparing treatment with LIPUS to placebo or no treatment in adults with fresh fractures, reporting outcomes such as function; time to union; delayed union or non-union. Summary standard mean difference (SMD) and the risk ratio (RR) with their 95% confidence interval (CI) calculated with a random effects model. I statistic was used to assess the heterogeneity. Risk of bias was assessed by the Cochrane risk-of-bias tool. The GRADE system was used to evaluate the evidence quality. RESULTS: A total of 12 trials with 1099 patients were included. The pooled results showed that LIPUS significantly reduced the time to fracture union (SMD: 0.65, 95% CI: 1.13 to 0.17), improved the quality of life (SMD: 0.20, 95% CI: 0.03-0.37) without affecting the time to full weight bearing (SMD: 0.76, 95% CI: 1.92 to 0.4), the time to return to work (SMD: 0.06, 95% CI: 0.14 to 0.27), or the incidence rate of delayed union and nonunion (RR: 1.02, 95% CI: 0.60-1.74). CONCLUSIONS: Moderate-to-high quality evidence shows that LIPUS treatment reduces the time to fracture union and improves the quality of life without affecting functional recovery and incident rate of delayed union and nonunion, suggesting that LIPUS treatment may be a good treatment modality for adults with fresh fractures. However, there are some methodological limitations in the eligible trials, further studies are needed to determine the clinical circumstances under which LIPUS is truly valid and to examine the optimal approach for the use of this adjunctive therapy.

The effect of sequential therapy for postmenopausal women with osteoporosis: A PRISMA-compliant meta-analysis of randomized controlled trials.

BACKGROUND: Osteoporosis, more likely to occur in postmenopausal women, is a chronic condition that usually requires a long-term treatment strategy, but the use of either antiresorptive or anabolic drugs should be limited to 18 to 24 months. Discontinuing antiosteoporosis drugs may result in rapidly declining bone mineral density (BMD). Therefore, many patients are treated with the sequential use of 2 or more drugs. However, whether switching treatment from anabolic to antiresorptive drugs or the reverse could maintain or further increase BMD; and whether the sequential therapy could outperform the monotherapy under the same treatment duration still remains unclear. Nowadays, no firm conclusions were drawn. METHODS: We searched Medline, Embase, and Cochrane Library from January 1, 1974 until February 1, 2016 to identify all randomized controlled trials for evaluating the effectiveness of sequential therapy of antiresorptive and anabolic drugs in postmenopausal osteoporosis women with the BMD changes of lumbar spine, femoral neck, and total hip as the outcomes. We evaluated the methodological quality and abstracted relevant data according to the Cochrane Handbook. RESULTS: Eight trials involving 1509 patients were included. The pooled data showed that after switching treatment, the alternative drugs maintained the BMD and significantly increased the percentage change in BMD at the lumbar spine (MD, 3.59; 95% CI, 2.26-4.93), femoral neck (MD, 1.44; 95% CI, 0.60-2.27), and total hip (MD, 1.24; 95% CI, -0.12 to 2.60), although change in BMD was not significantly increased at the total hip. The sequential therapy significantly increased BMD from baseline at the lumbar spine (SMD, 0.59; 95% CI, 0.26-0.91), femoral neck (SMD, 0.22; 95% CI, 0.06-0.37), and total hip (SMD, 0.28; 95% CI, 0.01-0.56). CONCLUSIONS: After switching treatment, sequential therapy further increased BMD. The sequential therapy showed a more significant improvement in BMD compared with any anti-resorptive drug given for the same treatment duration and was as effective as anabolic drugs. Thus, sequential therapy may be recommended as an effective treatment for osteoporotic women. However, more randomized controlled trials are still needed to determine the best sequence and the most appropriate drugs of sequential therapy.

The compliance of thromboprophylaxis affects the risk of venous thromboembolism in patients undergoing hip fracture surgery.

OBJECTIVE: Venous thromboembolism (VTE) is major problem after hip fracture surgery with substantial morbidity and mortality. This study aimed to assess the postoperative compliance of thromboprophylaxis in elderly patients undergoing hip fracture surgery and to confirm the correlation between compliance and VTE risk. METHODS: This retrospective cohort study included consecutive elderly hip fracture patients who undergoing surgery. According to the thromboprophylaxis regimens, patients were divided into non-compliant group (<14days), poor compliant group (14-27days) and good compliant group (≥28days). The primary outcome was the incidence of symptomatic DVT, PE within 6weeks postoperatively. RESULTS: Between 2008 and 2012, 1214 eligible patients were included in this study. 761 (64.7%) patients were non-compliant, 224 (19.0%) patients were poor compliant, and 192 (16.3%) patients were good compliant. The overall VTE rate was 7.9% (73/1177), PE rate was 0.3% (4/1177). The VTE rate in good compliant group was lowest among three groups (4.2 vs. 5.4 vs. 9.6%, P=0.013), but the PE rates showed no significant differences (0 vs. 0.9 vs. 0.3%, P=0.241). The multivariate analysis showed that non-compliance was an independent risk factor of suffering VTE undergoing hip fracture surgery. CONCLUSIONS: In this study we found fewer than 1 in 5 patients maintained compliant with thromboprophylaxis guidelines after discharge following hip surgery. This is particularly concerning because those who were non-compliant had a higher risk of VTE postoperatively compared with those who were good compliant.

The Effect of Teriparatide on Fracture Healing of Osteoporotic Patients: A Meta-Analysis of Randomized Controlled Trials.

Purpose. This meta-analysis is to assess the effectiveness of teriparatide in fracture healing and clinical function improvement of the osteoporotic patients. Methods. We searched PubMed, Embase, Web of Science, and the Cochrane databases for randomized and quasi-randomized controlled trials comparing teriparatide to placebo, no treatment, or comparator interventions in the osteoporotic patients. Results. Five studies with 251 patients were included. Patients treated with teriparatide therapy had a significant shorter radiological fracture healing time compared with those in the control group (mean difference [MD] -4.54 days, 95% confidence interval [CI] -8.80 to -0.28). Stratified analysis showed that lower limb group had significant shorter healing time (MD -6.24 days, 95% CI -7.20 to -5.29), but upper limb group did not (MD -1 days, 95% CI -2.02 to 0.2). Patients treated with teriparatide therapy showed better functional outcome than those in the control group (standardized mean difference [SMD] -1.02, 95% CI -1.81 to -0.22). Patients with therapy duration over 4 weeks would have better functional outcome (SMD -1.68, 95% CI -2.07 to -1.29). Conclusions. Teriparatide is effective in accelerating fracture healing and improving functional outcome of osteoporotic women. However, more clinical studies are warranted in order to determine whether the results are applicable to males and the clinical indications for teriparatide after osteoporotic fractures.

Anemia on Admission Is an Independent Predictor of Long-Term Mortality in Hip Fracture Population: A Prospective Study With 2-Year Follow-Up.

Anemia is a disputable factor for long-term mortality in hip fracture population in previous studies. Previous studies indicated that the level of hemoglobin (Hb) might fluctuate due to various factors, such as comorbidities and in-hospital interventions, and the changing level of Hb, may lead to discordance diagnosis of anemia and thus to the conflicting conclusions on prognostic value of anemia. So in this study, we aim to compare factors affecting the diagnosis of anemia at different time-points, admission, postoperation, and discharge, and to determine which the time point is most suitable for mortality prediction.This prospective cohort study included 1330 hip fracture patients from 1 January 2000 to 18 November 2012. Hb levels at 3 different time points, such as admission, postoperation, and discharge, were collected and used to stratify the cohort into anemia and nonanemia groups. Candidate factors including commodities, perioperative factors, blood transfusion, and other in-hospital interventions were collected before discharge. Logistic regression analyses were performed to detect risk factors for anemia for the 3 time points separately. Kaplan-Meier and multivariate Cox regression analyses were used to evaluate the association between anemia and 2-year mortality.Factors affecting the diagnosis of anemia were different for the 3 time points. Age, female sex, American Society of Anesthesiologists score (ASA), and intertrochanteric fracture were associated with admission anemia, while surgical procedure, surgical duration, blood transfusion, blood loss during the operation, and drainage volume were major risk factors for postoperation anemia. Cox proportional-hazards regression analysis suggested that the risk of all-cause mortality was higher in the anemia group on admission (1.680, 95%CI: 1.201-2.350, P < 0.01), but not postoperation or on discharge, after adjustment for confounding factors.Our study showed that risk factors for anemia varied at different time points, and therapy interventions would greatly affect the status of postoperation and discharge anemia in hip fracture patients. The take-home message is when anemia is used for mortality prediction in these patients, a specific time point should be chosen. We suggest that only admission anemia should be used for mortality prediction, but not postoperation nor discharge anemia.

Use of combination therapy in the treatment of primary osteoporosis: protocol for a network meta-analysis of randomised trials.

INTRODUCTION: The existing medications approved for treatment of primary osteoporosis can be divided into antiresorptive drugs and anabolic drugs. According to the mechanisms of action, the combined therapy may produce a synergistic effect on bone mineral density (BMD) compared with monotherapy, and thus improves the efficacy of fracture resistance. This network meta-analysis aims to compare the efficacies of different combined methods for the treatment of primary osteoporosis. METHODS AND ANALYSIS: MEDLINE, EMBASE and Cochrane databases will be searched to identify all randomised controlled trials (RCTs) and quasi-RCTs that evaluate the effectiveness of combined therapy versus monotherapy for primary osteoporosis. The primary outcome will be the BMD changes at the lumbar spine and total hip, and the secondary outcome will be the risks of vertebral fracture and non-vertebral fracture. The efficacies of different combined methods will be compared via traditional pairwise meta-analysis, trial sequential analysis and Bayesian network meta-analysis. Risk of bias will be assessed using the Cochrane tool and the quality of evidence will be assessed using the Grading of Recommendations Assessment, Development and Evaluation for network meta-analysis. ETHICS AND DISSEMINATION: Ethical approval is not required because this is a protocol for a systematic review without including confidential personal data or data on interventions on patients. Our results will be published in a peer-review journal. TRIAL REGISTRATION NUMBER: PROSPERO CRD42016038569.

Percutaneous Anterior Column Fixation for Acetabulum Fractures, Does It Have to Be Difficult?-The New Axial Pedicle View of the Anterior Column for Percutaneous Fixation.

Anterior column percutaneous screw fixation can be challenging. The purpose of this new technique is to offer a rapid, simple, and safe method to place an anterior screw. The authors used a 3-dimensional reconstruction simulation, cadaver study, and a clinical case series to demonstrate this new alternative to standard previously described techniques.

Red Cell Distribution Width as an Independent Predictor of Long-Term Mortality in Hip Fracture Patients: A Prospective Cohort Study.

Red blood cell distribution width (RDW) has been found to be a significant prognostic factor of mortality in many cardiovascular diseases. However, a link between RDW at admission with long-term mortality in the hip fracture population has not been well established. Therefore, we sought to evaluate the long-term prognostic value of RDW in a well-defined hip fracture cohort, and to compare the effect of RDW in patients with and without anemia. A prospective cohort study was performed on 1479 hip fracture patients admitted at the General Hospital of Chinese PLA between January 2000 and October 2011 with a follow-up study over a 2-year period. A total of 1479 patients were used for the evaluation of 2-year all-cause mortality, while 804 patients with more than 4 years of follow-up were extracted for further evaluation of 4-year all-cause mortality. Cox proportional regression was used to evaluate the association between admission RDW and long-term mortality, adjusting for potential confounding variables. Higher RDW values were strongly associated with increased all-cause mortality. After adjusting for age, mean corpuscular volume, admission hemoglobin, comorbidities, and complications, RDW had a significant independent association with both 2-year mortality with a hazard ratio (HR) of 1.183 (95% confidence interval [CI], 1.017 to 1.376) and 4-year mortality with an HR of 1.244 (95% CI, 1.052 to 1.471). In stratified analysis, the effect of RDW was even more pronounced, with 2-year mortality HR of 1.341 (95% CI, 1.095 to 1.643) and 4-year mortality HR of 1.345 (95% CI, 1.071 to 1.688) in non-anemic patients. In non-anemic patients, elevated RDW values are significantly associated with increased odds of all-cause mortality, implying that RDW may be a possible laboratory biomarker for risk stratification in non-anemic hip fracture patients. Further studies are needed to confirm the current finding in different and larger hip fracture cohorts.