Outcomes after early return to theatre following hip hemiarthroplasty for intracapsular fracture of the femoral neck.

AIMS: Hip hemiarthroplasty is a standard treatment for intracapsular proximal femoral fractures in the frail elderly. In this study we have explored the implications of early return to theatre, within 30 days, on patient outcome following hip hemiarthroplasty. PATIENTS AND METHODS: We retrospectively reviewed the hospital records of all hip hemiarthroplasties performed in our unit between January 2010 and January 2015. Demographic details, medical backround, details of the primary procedure, complications, subsequent procedures requiring return to theatre, re-admissions, discharge destination and death were collected. RESULTS: A total of 705 procedures were included; 428 Austin Moore and 277 Exeter Trauma Stems were used. A total of 34 fractures (in 33 patients) required early return to theatre within 30 days. Age, gender, laterality, time from admission to primary procedure, American Society of Anesthesiologists grade, and implant type were similar for those requiring early return to theatre and those who did not. Early return to theatre was associated with a significantly higher length of stay (mean 33.6 days (7 to 107) versus 18.6 days (0 to 152), p < 0.001), re-admission rate (38.2% versus 8.6%, p < 0.001), and subsequent revision rate (17.6% versus 1.3%, p < 0.001). We found no difference in level of care required on discharge or mortality. CONCLUSION: Proximal femoral fractures are common in the elderly population, with far-reaching medical and economic implications. Factors such as infection or dislocation may require early return to theatre, and this is associated with outcomes which may be both medically and economically detrimental. This illustrates the importance of avoiding early complications to improve longer term outcome. Return to theatre within 30 days is associated with longer length of stay, higher re-admission rate, and higher subsequent revision rate. It may be a useful short-term quality indicator for longer term outcome measures following hip hemiarthroplasty for intracapsular fractures of the proximal femur. Cite this article: Bone Joint J 2017;99-B:958-63.

Screening for maternal coeliac disease as a potential risk factor for orofacial clefts--a pilot study.

There is increasing evidence that dietary folic acid deficiency in utero may increase the risk of developing the 'cleft lip with or without cleft palate' (CL±P) variant of orofacial cleft. Coeliac disease is a common cause of folic acid malabsorption, and in the majority of cases remains undiagnosed. This pilot study assessed the seroprevalence of undiagnosed coeliac disease in a cohort of mothers of infants with CL±P in the Hyderabad area of India. The seroprevalence of coeliac disease of 1.15% (95% confidence interval 0.37-2.66%) was little different from the expected figure based on published population studies, making a clinically significant association unlikely.

Prevalence of Trichomonas vaginalis and coinfection with Chlamydia trachomatis and Neisseria gonorrhoeae in the United States as determined by the Aptima Trichomonas vaginalis nucleic acid amplification assay.

Our aim was to determine Trichomonas vaginalis prevalence using the Aptima Trichomonas vaginalis assay (ATV; Gen-Probe) and the prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae coinfections in U.S. women undergoing screening for C. trachomatis/N. gonorrhoeae. Discarded urogenital samples from 7,593 women (18 to 89 years old) undergoing C. trachomatis/N. gonorrhoeae screening using the Aptima Combo 2 assay (Gen-Probe) in various clinical settings were tested with ATV. Overall, T. vaginalis, C. trachomatis, and N. gonorrhoeae prevalences were 8.7%, 6.7%, and 1.7%, respectively. T. vaginalis was more prevalent than C. trachomatis or N. gonorrhoeae in all age groups except the 18- to 19-year-old group. The highest T. vaginalis prevalence was in women ≥ 40 years old (>11%), while the highest C. trachomatis prevalence (9.2%) and N. gonorrhoeae prevalence (2.2%) were in women <30 years old. Coinfection prevalences were 1.3% for C. trachomatis/T. vaginalis, 0.61% for C. trachomatis/N. gonorrhoeae and N. gonorrhoeae/T. vaginalis, and 0.24% for C. trachomatis/N. gonorrhoeae/T. vaginalis and highest in women <30 years old. T. vaginalis prevalence differed by race/ethnicity, with the highest prevalence in black women (20.2%). T. vaginalis prevalence ranged from 5.4% in family planning clinics to 22.3% in jails. Multivariate analysis determined that ages of ≥ 40 years, black race, and patient locations were significantly associated with T. vaginalis infection. T. vaginalis is the most common sexually transmitted infection (STI) in women of >40 years, while C. trachomatis and N. gonorrhoeae prevalence is lowest in that age group. Higher T. vaginalis prevalence in women of >40 years is probably attributed to the reason for testing, i.e., symptomatic status versus routine screening in younger women. Coinfections were relatively low. High T. vaginalis prevalence in all age groups suggests that women screened for C. trachomatis/N. gonorrhoeae, whether asymptomatic or symptomatic, should be screened for T. vaginalis.

The epidemiology of coeliac disease in East Dorset 1993-2002: an assessment of the 'coeliac iceberg', and preliminary evidence of case clustering.

BACKGROUND: Coeliac disease (CD) results from mucosal exposure to dietary gluten in genetically predisposed individuals, although other environmental factors may be involved. The seroprevalence of CD is approximately 1%, with a high ratio of undiagnosed to diagnosed cases, leading to the concept of a 'coeliac iceberg'. AIM: To provide contemporary estimates of the incidence of diagnosed CD and the size of the submerged 'coeliac iceberg', and to seek evidence of disease clustering. DESIGN: Prospective observational study in a defined local population. METHODS: Data were collected prospectively for all biopsy-proven cases diagnosed at Poole Hospital, 1993-2002. Age-specific incidence was calculated and point prevalence estimated for cases within the defined study zone. Evidence of disease clustering was sought using a space-time scan statistic based on a Poisson model. RESULTS: The overall incidence of CD was 8.7 cases/100,000/year (95%CI 7.4-10.1), with a median age at diagnosis of 53 years. Incidence increased progressively during the study period, and the estimated point prevalence of biopsy-proven CD rose from 0.18% to 0.4%. An area of significant space-time clustering was identified, with an incidence of 22.9 cases/100,000/year (95%CI 16.1-31.6), but there was no evidence of seasonality. DISCUSSION: The submerged component of the 'coeliac iceberg' may be diminishing due to increasing case ascertainment, with a projected ratio of undiagnosed to diagnosed cases as low as 1.5:1. Our identification of clustering must be interpreted with caution, but suggests that an additional environmental factor may influence the pathogenesis of CD.

Steroid-responsive subacute polymyositis in an adult following respiratory syncytial virus infection.

The role of viral infections in the aetiopathogenesis of polymyositis remains speculative. We report a case of profound subacute polymyositis with incipient ventilatory failure following serologically confirmed infection by respiratory syncytial virus (RSV), with a dramatic and sustained response to pulse corticosteroid therapy. We suggest a possible autoimmune mechanism to account for this sequence of events.

Does increased leukotriene B4 in type 1 diabetes result from elevated cholesteryl ester transfer protein activity?

Elevated cholesteryl ester transfer protein (CETP) activity has been reported in type 1 diabetic subjects and may be one cause of the high incidence of macrovascular complications in these patients. LDL delivers arachidonic acid (AA), in the form of cholesteryl ester (CE), to cells such as monocytes and fibroblasts, as precursor for eicosanoid synthesis. We discovered that AA content in LDL CE was significantly correlated with CETP activity, even after controlling for CETP concentration, in type 1 diabetic children. The production of LTB(4), a potent chemotactic and pro-inflammatory factor which plays a role in atherogenesis, has been shown to be increased in type 1 diabetic patients. We hypothesized that in these subjects, increased AA content in LDL CE, resulting from increased CETP activity and transient hyperinsulinemia, may lead to enhanced synthesis of LTB(4) and subsequently the higher incidence of cardiovascular disease.

Risk factors for coronary heart disease in type 1 diabetic children: the influence of apoE phenotype and glycemic regulation.

The effects of apolipoprotein E (apoE) phenotype and glycemic regulation on plasma levels of lipids and lipoproteins, low density lipoprotein (LDL) composition, LDL particle size, and LDL oxidation were examined in 35 type 1 diabetic children aged 5-12 years. All subjects were classified according to glycemic regulation (HbA(1c)<8% vs. HbA(1c)>8%). ApoE phenotypes were identified by isoelectric focusing (IEF) followed by immunoblotting. Results from two-way analysis of variance (ANOVA) showed that subjects with apoE 4/3 and HbA(1c)>8% had higher concentrations of total cholesterol (TC), LDL-cholesterol (LDL-C), and LDL-cholesterol ester (LDL-CE) than subjects with the same apoE phenotype and HbA(1c)<8%. LDL particles in all subjects were classified as the subclass pattern A. Both LDL particle size and susceptibility of LDL to oxidation were not different among subjects stratified by apoE phenotype. In conclusion, children with type 1 diabetes mellitus included in this study did not have high-risk lipoprotein profiles at this early stage of life. However, there was some indication that those with the apoE 4/3 phenotype were more likely to have more favorable lipid profiles when HbA(1c) levels were <8%.

Cholesteryl ester transfer and cholesterol esterification in type 1 diabetes: relationships with plasma glucose.

The activities of two crucial enzymes of reverse cholesterol transport, cholesterol ester transfer protein (CETP) and lecithin:cholesterol acyltransferase (LCAT), and their relationships with lipid profile and fasting plasma glucose were examined in 35 type 1 diabetic children. The CETP and LCAT activities were significantly lower (p<0.05) in the 4 subjects with normal fasting plasma glucose levels (<6.39 mmol/l) than in the 28 with high plasma glucose levels (CEPT activity, 10.63+/-3.81 vs. 32.18+/-13.94 nmol/ml h; LCAT activity, 25.52+/-4.53 vs. 39.52+/-12.52 nmol/ml h; both p<0.05). The subjects with high plasma glucose levels also had higher total and LDL-cholesterol than those with normal glucose levels. CETP activity was positively correlated with fasting plasma glucose, CETP concentration, LCAT activity, total cholesterol, free cholesterol, LDL-C, and LDL-cholesteryl ester, while negatively correlated with cholesteryl ester to free cholesterol ratio, LDL triglyceride to protein ratio, and LDL triglyceride to cholesteryl ester ratio. LCAT activity was found to positively correlate with CETP activity, total cholesterol, free cholesterol, LDL-C, CETP concentration, and LDL-cholesteryl ester, while it negatively correlated with cholesteryl ester to free cholesterol ratio. The results observed in type 1 diabetic subjects suggest that (1) accelerated LCAT and CETP activities may result in the accumulation of LDL-cholesteryl ester; and (2) fasting plasma glucose may be a major determinant of CETP activity.

Adult endomysial antibody-negative coeliac disease and cigarette smoking.

OBJECTIVE: To determine the relative incidence and characteristics of endomysial antibody (EMA)-negative coeliac disease in adults. DESIGN: Retrospective analysis of prospectively collected data on adults with newly diagnosed coeliac disease, with determination of EMA status before gluten withdrawal. SETTING: District general hospital (secondary care institution). PARTICIPANTS: Sixty consecutive incident cases. MAIN OUTCOME MEASURES: (i) Proportion of cases who were EMA-negative; (ii) comparison of clinical and laboratory variables at diagnosis for EMA-positive and EMA-negative subjects. RESULTS: Fifteen subjects (25%, 95% CI 15-38%) were EMA negative, of whom only two were IgA deficient. There was clinical evidence in all 15 patients and histological evidence in 13 patients of a response to gluten withdrawal. No significant differences were found between EMA-positive and EMA-negative subjects with respect to histological features, age, gender, clinical manifestations, concurrent autoimmune disorders, family history of coeliac disease, or haemoglobin and albumin concentrations at diagnosis. However, EMA-negative status at diagnosis was associated strongly with current or recent cigarette smoking (OR 7.0, 95% CI 1.7-31.5, P= 0.003). CONCLUSIONS: A substantial minority of patients with otherwise typical coeliac disease are EMA negative, and most of these are IgA replete. The value of EMA as a screening tool is therefore limited. EMA status in untreated coeliac disease correlates strongly with cigarette smoking history: this may be of pathogenic significance, given the previously demonstrated association between smoking and the risk of coeliac disease.

The cholesterolaemic effects of dietary fats in cholesteryl ester transfer protein transgenic mice.

In order to investigate the role of cholesteryl ester transfer protein (CETP) in the cholesterolaemic response to dietary fats, we analysed plasma lipid profiles of CETP-transgenic and control C57BL/6 mice fed standard chow (AIN-93G; AIN), a low-fat diet, and diets high in butter (saturated fatty acids; SFA), high-oleic acid safflower oil (monounsaturated fatty acids; MUFA), and safflower oil (polyunsaturated fatty acids; PUFA) for 5 weeks. Each group contained four or five mice. There were significant diet and dietxgenotype effects on plasma total cholesterol (TC; and respectively), liver TC ( and respectively), and esterified cholesterol (EC; and respectively); diet effects on plasma triacylglycerol liver free cholesterol and body weight a genotype effect on body-weight gain and a dietxgenotype effect on energy intake In transgenic mice the SFA diet caused significantly higher plasma TC than the PUFA diet In control mice MUFA and PUFA diets, but not the SFA diet, caused significantly higher plasma TC than the low-fat and AIN diets Transgenic mice fed PUFA had lower plasma TC while transgenic mice fed MUFA had lower LDL+VLDL-cholesterol than controls in the same dietary groups. Transgenic mice fed MUFA and PUFA diets also had significantly higher liver TC and respectively) and EC and respectively) than controls fed the same diets. In the present study we showed that: (1) CETP transgenic mice had a cholesterolaemic response to dietary fats similar to that in human subjects; (2) CETP transgenic mice fed PUFA showed significantly lower plasma TC, while those fed MUFA had lower LDL+VLDL-cholesterol than controls; (3) hepatic accumulation of cholesterol, possibly resulting from the combination of the enhanced cholesteryl ester transfer to apolipoprotein B-containing lipoproteins and increased hepatic uptake of cholesterol, may contribute to the cholesterol-lowering effect of MUFA and PUFA in CETP-transgenic mice; (4) CETP may play a role in appetite and/or energy regulation.

Mechanisms mediating lipoprotein responses to diets with medium-chain triglyceride and lauric acid.

Medium-chain triglycerides (MCT) are often used in specialized formula diets or designer fats because of their special properties. Yet their influence on lipid metabolism is not completely understood. In this two-period cross-over study, the effects of MCT (8:0 + 10:0) in contrast to a similar saturated fatty acid (12:0) were compared. Eighteen healthy women ate a baseline diet [polyunsaturated (PUFA)/saturated fat = 0.9] for 1 wk. Then, they consumed test diets (PUFA/saturated fat = 0.2) for 4 wk. Monounsaturated fat and cholesterol were constant in baseline and treatment diets. MCT and 12:0, substituted for part of the PUFA, provided 14 energy (en)% of the test diets. In comparison to the PUFA baseline diet, a 16% increase in mean serum low density lipoprotein (LDL)-cholesterol (C) on the 12:0 diet was accompanied by a 21% decrease in mean receptor-mediated degradation of LDL by freshly isolated mononuclear cells (MNC) in vitro. The MNC assay theoretically gives an indication of receptor-mediated degradation of LDL. In contrast, the MCT diet raised mean receptor-mediated degradation of LDL by 42%, a finding out of line with the mean 11% increase in serum LDL-C. Perhaps MCT, by increasing the rate of LDL-C production, overcame the rate of LDL-C clearance. The 12:0 diet enhanced some factors involved in reverse cholesterol transport (e.g., high density lipoprotein fractions) while MCT had a different or less pronounced effect. The overall effects of MCT on cholesterol metabolism may or may not be desirable, whereas those of 12:0 appear largely undesirable as previously reported.

Effect of synthetic triglycerides of myristic, palmitic, and stearic acid on serum lipoprotein metabolism.

OBJECTIVES: To determine relative effects of diets high in synthetic sources of myristic (14:0), palmitic (16:0) or stearic (18:0) acid on concentrations and metabolism of serum lipoproteins. DESIGN: Eighteen healthy women participated in a three-way cross-over study for five week periods separated by seven week washout periods, diets were assigned in random order. SUBJECTS: Premenopausal women, not on medication, were from three races (Caucasian, African-American, Asian) and four apolipoprotein E phenotype groups (3/3, 3/2, 4/3, and 4/2). INTERVENTION: During the first week the subjects consumed a baseline diet providing 11 energy (en)% saturated fat, 10en% polyunsaturated fat and 14en% monounsaturated fat. Followed by test diets with 19en% saturated fat (including 14en% test saturated fatty acid), 3en% polyunsaturated fat, and 14en% monounsaturated fat for four weeks. Synthetic fats (trimyristin, tripalmitin, and tristearin) were used in blends with natural fats and oils. RESULTS: Mean concentrations of serum total, esterified and LDL cholesterol were significantly lower after 18:0 than after 16:0 (n = 16-18, P < 0.01 for treatment effect). Myristic acid (14:0) had an intermediate effect. Receptor-mediated degradation of 125I-LDL in mononuclear cells obtained from the subjects was lower after 16:0 than after 14:0 and 18:0 (n = 16-18, P=0.05 for treatment effect). Differences in the digestibilities of the fats were not a major factor in the results. Strong cholesterolemic responses to the 16:0 diet were partly explained by apoE phenotype. CONCLUSIONS: As noted previously, stearic acid was neutral compared to 14:0 and 16:0. In contrast to studies involving natural fats, 14:0, fed as a synthetic triglyceride, was less cholesterolemic than 16:0 in a majority of subjects. ApoE phenotype influenced the cholesterolemic response particularly when diets high in 16:0 were eaten.

Sandwich enzyme-linked immunosorbent assay for plasma cholesteryl ester transfer protein concentration.

OBJECTIVES: Cholesteryl ester transfer protein (CETP) mediates the transfer of HDL cholesterol to apoB-containing lipoproteins. Its mass and activity are increased in several pro-atherogenic conditions. The objective of this study is to develop a cost- and time-effective sandwich ELISA for plasma CETP concentration. DESIGN AND METHODS: Monoclonal anti-CETP, TP20, was used as the capture antibody, while the other biotinylated monoclonal anti-CETP, TP2, was used for detection. The results were expressed in an arbitrary unit, ng biotin-TP2 bound per microl plasma. Plasma CETP concentrations, activities and their relationship were assessed in 35 IDDM children. RESULTS: The assay had an intra-assay CV of 8.75% and an inter-assay CV under 10%. Plasma CETP concentration of these subjects ranged from 0.36-1.89 ng biotin-TP2/microL. CETP concentration was significantly correlated with CETP activity (r = 0.51, p < 0.01). CONCLUSION: The sandwich ELISA we have developed carried sufficient sensitivity for assaying plasma CETP concentration in human.

Effect of apolipoprotein E polymorphism on serum lipoprotein response to saturated fatty acids.

This report summarizes two studies which investigated the effects of apolipoprotein E (apoE) polymorphism on the serum total cholesterol (TC) and lipoprotein cholesterol responses to 8:0 + 10:0 and 12:0 diets (Study I) and 14:0, 16:0 and 18:0 diets (Study II). Eighteen healthy premenopausal women (3 apoE 3/2, 12 apoE 3/3, 3 apoE 4/3) in study I and another 18 healthy premenopausal women (4 apoE 3/2, 10 apoE 3/3, 3 apoE 4/3, 1 apoE 4/2) in study II consumed a baseline diet providing 40 en% total fat, 11 en% 18:2, 15 en% 18:1, 11.5 en% saturated fat for the first week of each 5-wk period. The experimental diets for both studies provided 40 en% total fat, 13-14 en% as one of five test saturated fatty acids (SFA), 14-16 en% 18:1, and 3-4 en% 18:2. Analysis by apoE phenotypes showed that both the 8:0 + 10:0 diet and the 12:0 diet in Study I induced significant increases in serum TC in subjects with different apoE phenotypes with the exception of apoE 3/2 in the medium-chain triglyceride group. In contrast, in Study II, individuals with apoE 4/3 consuming the 14:0 diet showed significant increases in serum TC, high density lipoprotein-cholesterol (HDL-C), and HDL2-C, but the same subjects consuming the 16:0 diet showed significant increases in serum TC and low density lipoprotein-cholesterol. The findings from both studies indicated serum lipoprotein responses to SFA were different and the variation of responsiveness may be regulated, at least in part, by apoE polymorphism, especially when 14:0, 16:0, or 18:0 was consumed.

A case-control study of measles vaccination and inflammatory bowel disease. The East Dorset Gastroenterology Group.

BACKGROUND: The cause of inflammatory bowel disease (IBD) remains to be established. Evidence has linked measles infection in early childhood with the subsequent risk of developing IBD, particularly Crohn's disease. A cohort study raised the possibility that immunisation with live attenuated measles vaccine, which induces active immunity to measles infection, might also predispose to the later development of IBD, provoking concerns about the safety of the vaccine. METHOD: We report a case-control study of 140 patients with IBD (including 83 with Crohn's disease) born in or after 1968, and 280 controls matched for age, sex and general practitioner (GP) area, designed to assess the influence of measles vaccination on later development of IBD. Documentary evidence of childhood vaccination history was sought from GP and community health records. FINDINGS: Crude measles vaccination rates were 56.4% in patients with IBD and 57.1% among controls. Matched odds ratios for measles vaccination were 1.08 (95% CI 0.62-1.88) in patients with Crohn's disease, 0.84 (0.44-1.58) in patients with ulcerative colitis, and 0.97 (0.64-1.47) in all patients with IBD. INTERPRETATION: These findings provide no support for the hypothesis that measles vaccination in childhood predisposes to the later development of either IBD overall or Crohn's disease in particular.