Subjects with osteoporosis to remain at high risk for fracture despite benefit of prior bisphosphonate treatment-a Danish case-control study.

The benefits of pharmaceutical treatment for osteoporosis may be limited for a number of patients, as they continue to experience fractures. Alternative treatments may be considered for subjects whom remain at high risk for future fractures. INTRODUCTION: Previous studies have investigated the effects of good adherence to anti-osteoporosis medication. However, very few studies have described why some patients experience fractures and loss of BMD despite adherence to treatment. The aim of this study was to estimate the proportion of patients at high risk for fracture despite being compliant to bisphosphonate treatment and examine which factors influence why some osteoporotic patients remain at a high risk for fracture despite being compliant to bisphosphonate treatment. METHODS: This case-control study is based on Danish national health registry data. The subjects had to have either one BMD test or a fracture prior to inclusion. "High-risk" subjects (cases) were defined as BMD t-score < =-2.5 SD, any drop in BMD from baseline or a fracture 24-36 months following inclusion. RESULTS: A total of 2406 subjects (66.3 % women; 33.7 % men) fulfilled the inclusion criteria, and of these, 352 (14.6 %) were identified as high risk subjects. A multiple logistical regression analysis showed that high risk subjects were more likely to have lower plasma calcium and/or vitamin D levels (OR: 2.9) and were more frequently diagnosed with hyperparathyroidism (OR: 2.6). CONCLUSION: Based on Danish national health registry data, 14.6 % patients were identified as patients remaining at high risk for fracture despite being compliant to bisphosphonate treatment. Lower plasma calcium and/or vitamin D level is the greatest predictor of high risk for fracture despite persistent bisphosphonate treatment. Secondary causes of osteoporosis should be considered and alternative treatments may be advised for subjects whom remain at high risk.

Subsequent fracture rates in a nationwide population-based cohort study with a 10-year perspective.

SUMMARY: Fractures after the age of 50 are frequently observed in Denmark, and many of these may be osteoporotic. This study examined the incidence of all and subsequent fractures in a 10-year period from 2001 to 2011. The incidence of subsequent fractures was high, especially following hip fracture. INTRODUCTION: The purpose of this study is to examine patterns of subsequent fractures and mortality rates over a 10-year period in patients already suffering from fracture. METHODS: The study was designed as a nationwide, register-based follow-up study. Patients were included if diagnosed with an index fracture (ICD-10 codes: S22.x, S32.x, S42.x, S52.x, S62.x, S72.x, S82.x, S92.x, T02.x, T08.x, T10.x and T12.x) between January 1st, 2001 and December 31st, 2001 and if older than 50 years at time of fracture. The patients were investigated for future subsequent fractures from January 1st, 2002 to December 31st, 2011. RESULTS: In this study, we demonstrated that patients with fractures (especially hip fractures) have a high risk of subsequent fractures, especially hip fracture. Other fractures, which are not commonly considered as osteoporotic fractures, such as lower leg, were frequently observed in the 10 years following index fracture. The cumulative incidence proportion (CIP) of subsequent fractures during the 10-year follow-up period was high for all recurrent fractures (9-46 %). Subsequent hip fracture, regardless of index fracture, had the highest CIP across the study period, ranging from 9 to 40 %. Appendicular fractures were often followed by a recurrent fracture, or subsequent fractures at a more proximal location in the same limb, i.e. forearm fractures were followed by humerus fractures. These results have not been previously demonstrated to this extent, and according to our knowledge, no previous studies have estimated cumulative 10-year subsequent fracture incidences for any non-hip fractures. CONCLUSION: Patients suffering a fracture (and especially a hip fracture) have a high incidence of subsequent fracture. Fractures after the age of 50 may be considered an early warning of increased risk for future fractures in many patients.

Small-scale mantle convection produces stratigraphic sequences in sedimentary basins.

Cyclic sedimentary deposits link stratigraphic sequences that are now geographically distant but were once part of the same depositional environment. Some of these sequences occur at periods of 2 to 20 million years, and eustatic sea-level variations or regional tectonic events are likely causes of their formation. Using numerical modeling, we demonstrate that small-scale mantle convection can also cause the development of stratigraphic sequences through recurrent local and regional vertical surface movements. Small-scale convection-driven stratigraphic sequences occur at periods of 2 to 20 million years and correlate only at distances up to a few hundred kilometers. These results suggest that previous sequence stratigraphic analyses may contain erroneous conclusions regarding eustatic sea-level variations.

Quality of life in rhinoconjunctivitis assessed with generic and disease-specific questionnaires.

BACKGROUND: Illness as perceived by the allergic patient with asthma and/or rhinoconjunctivitis (RC) can be assessed by measurements of their health-related quality of life (HRQL). For this purpose the RC Quality of Life Questionnaire (RQLQ) has gained general acceptance; however, as most allergic patients experience symptoms from multiple organs, disease-specific HRQL measures may be deficient. This study compares a generic and a disease-specific HRQL instrument in grass and/or mite-allergic patients. METHODS: Two hundred and forty-eight patients with RC and 121 patients with both RC and asthma were studied. Questionnaire information was obtained about allergy-related RQLQ and a generic 15-dimensional instrument for measuring HRQL (15D). Doctors provided general and disease-specific information to classify disease severity according to the global initiative for asthma and allergic rhinitis and its impact on asthma guidelines. RESULTS: Rhinoconjunctivitis patients with persistent moderate-to-severe disease had an impaired quality of life on all items of RQLQ during allergen exposure. The 15D mean score was 0.98 on a day without allergy and 0.83 on a day with allergy (P < 0.001). The correlation between 15D and RQLQ was r = -0.42 on a day with allergy (P < 0.001). Only 15D scores showed statistically significant differences in HRQL between patients with and without asthma. CONCLUSION: During allergen exposure patients with RC experience a serious deterioration in HRQL measured with the disease-specific RQLQ instrument and the generic 15D instrument. The 15D instrument seems to generate a more comprehensive view of the impact of allergen exposure on patient's quality of life than RQLQ.

Health-economic analyses of subcutaneous specific immunotherapy for grass pollen and mite allergy.

OBJECTIVE: To investigate the health and monetary consequences of treating allergy with specific immunotherapy (SIT) compared with symptomatic treatment/standard care among patients with grass pollen or mite allergy. METHODS: We performed an economic analysis based on 253 grass- and/or mite allergic patients who started SIT from 1.1.1996 to 1.1.2002 at the Allergy Unit, Aarhus University Hospital and at a specialist practice in Aarhus. Relevant data were collected before, during and after SIT treatment from the national health service based on each patient's personal identification number and medical records and from a specifically designed questionnaire. A cost-benefit analysis including direct and indirect costs before, during and after SIT was performed. In addition direct costs were related to the clinical effect (improvement in well-being) in the form of a cost-effectiveness analysis. RESULTS: The direct cost per patient/year before SIT (equivalent to standard care) was DKK 2,580. The investment in SIT was DKK 27,545 (in present values) per patient over a 4-year period. After SIT the cost was reduced to DKK 1,072 per patient/year. In the long term, prospective introduction of SIT incurred additional present-value direct costs of DKK 13,676 per patient treated and DKK 2,784 per patient/year of improved well-being. However, when indirect costs were included in the economic evaluation SIT was shown to be net beneficial. CONCLUSION: This study reveals that SIT is associated with initial resource investments and subsequent resource savings in the long term compared with standard care. When all consequences are measured in monetary terms, and assuming that sick days are associated with a loss of productivity, this analysis suggests that SIT increases societal welfare. This conclusion also holds if there is no loss of productivity.

ICP is lower during propofol anaesthesia compared to isoflurane and sevoflurane.

OBJECTIVES: Propofol is a cerebral vasoconstrictor while inhalation anaesthetics like isoflurane and sevoflurane act as cerebral vasodilators in both animal and human studies. This difference of action upon cerebral vessels might implicate a lower ICP during propofol anaesthesia. Cerebral metabolism is decreased by all three anaesthetics. In a prospective, randomised multicenter study ICP was compared during anaesthesia with propofol, isoflurane and sevoflurane. METHODS: 117 patients subjected to elective craniotomy for supratentorial tumour. Propofol: N = 41; isoflurane: N = 38; sevoflurane: N = 38. Nitrous oxide was omitted and all anaesthetics were supplemented with a continuous infusion of fentanyl. ICP was measured subdurally after removal of the bone flap. MABP, CPP, PCO2, AVDO2, rectal temperature, tumour size and midline shift were registered too. STATISTICS: Kruskal-Wallis Variance on Ranks. All values in medians with range. P < 0.05 was considered significant. RESULTS: ICP (mmHg): propofol 7 (-1-20), isoflurane 12 (1-29), sevoflurane 11 (2-32). ICP was significantly lower in the propofol group compared to the isofluane and sevoflurane groups. CPP (mmHg): propofol 80 (45-104), isoflurane 60 (32-84), sevoflurane 63 (44-77). CPP was significantly higher in the propofol group compared to the isoflurane and sevoflurane groups. AVDO2 (mmol/l): propofol 3.1 (0.9-5.1), isoflurane 2.5 (1.1-4.5), sevoflurane 2.6 (0.8-4.1). AVDO2 was significantly higher in the propofol group compared to the isoflurane and sevoflurane groups. No significant differences in PCO2, rectal temperature, tumour size and midline shift were found. CONCLUSIONS: Subdural ICP is significantly lower during propofol anaesthesia compared to isoflurane and sevoflurane anaesthesia. CPP and AVDO2 are significantly higher during propofol anaesthesia compared to isoflurane and sevoflurane anaesthesia.

Virulence of Pasteurella multocida subsp. multocida isolated from outbreaks of fowl cholera in wild birds for domestic poultry and game birds.

Chickens, turkeys, partridges and pheasants were experimentally infected with Pasteurella multocida subsp. multocida to investigate whether outbreaks of fowl cholera in avifauna might represent a risk for organic, backyard and industrial poultry production. Birds were infected intra-tracheally with a strain of P. multocida subsp. multocida (40605-1) isolated from outbreaks of fowl cholera in wild birds in Denmark. P. multocida subsp. multocida strain P-1059 was included as a reference strain. The outbreak strain was highly virulent for turkeys, partridges and pheasants, while chickens were more resistant. The present findings underline the importance of wild birds as a reservoir for P. multocida. Intratracheal challenge proved useful for studying the virulence of P. multocida.

Identification of members of the Pasteurellaceae isolated from birds and characterization of two new taxa isolated from psittacine birds.

A collection of 43 unclassified members of the Pasteurellaceae, most of which were obtained from lesions, were investigated using an extensive battery of phenotypical tests as well as by ribotyping. The isolates had been made from Anser anser forma (f) domestica (d), Agapornis fischer, Amazona spp., Ara macao, Columba livia f.d., Melanopsittacus undulatus, and Psittacus erithacus. Comparison of results with those obtained from reference strains allowed classification of 25 strains. Three strains were identified as Pasteurella dagmatis, P. sp. A, and [P.] aerogenes, respectively. Twenty strains were classified as taxon 3 and two as taxon 14. Eighteen strains, all originating from psittacine species, belonged to two new taxa, tentatively named Bisgaard taxon 33 and taxon 37. Characters obtained with taxon 33 allowed classification within the family Pasteurellaceae, while the final classification of taxon 37 remains to be investigated. The present investigation underlines the problems confronting diagnostic laboratories attempting to identify members of the family Pasteurellaceae isolated from birds.

Phenotypic and genotypic diversity of organisms previously classified as maltose positive Pasteurella multocida.

Fifteen isolates tentatively classified as maltose positive Pasteurella multocida have been characterized in 79 biochemical tests and by ribotyping using HindIII and HpaII for digestion of DNA. Phenotypic and genotypic results were analysed using the computer programmes NTSYS and GelCompar, respectively. Two strains were classified as maltose positive P. multocida ssp. multocida while six strains were classified as maltose positive P. multocida ssp. septica. The remaining strains clustered with P. volantium and P. gallinarum, but remained unclassified. With the exception of a single isolate correlation was observed between phenotypic and genotypic results. The unclassified isolates which represented three different sources were heterogenous according to both phenotypic and genotypic results. The findings obtained support the 16S rRNA sequencing results indicating that the genus Pasteurella sensu stricto might represent two or more genera.

Flow-dependent properties of positive expiratory pressure devices.

Valves for positive expiratory pressure (PEP) can be characterized as threshold resistors, ideally providing pressure independent of the expiratory flow, or as flow-dependent resistors. The aim of the study was to evaluate the flow-dependence properties of PEP devices of the flow resistor type compared to threshold resistor devices. Pressures were measured on three different flow resistor valves: the PEP-mask, the Pari-PEP-System and the System 22-PEP with orifice diameters of 1.5-5.0 mm; and on three threshold resistors, the underwater seal, the Ambu Positive End-Expiratory Pressure (PEEP) valve and the Vital Signs PEEP valve with pressures of 0, 5, 10, 15 and 20 cmH2O. All devices were studied with constant flows of 3, 6, 9, 12, 15, 18, 30, 60, 90, 120 and 150 l.min-1. The PEP-mask, the Pari-PEP and the System 22-PEP showed the typical pattern of flow resistors, i.e. a pressure increasing with flow, dependent on the diameter of the orifice. The underwater seal and the Vital Signs PEEP valves acted as almost ideal threshold resistors. The Ambu PEEP valves acted as threshold resistors at the lower flows, but showed flow-dependency at higher flows. The Vital Signs PEEP valves gave lower pressures and Ambu PEEP valves gave higher pressures compared with indicated values, whereas the underwater seal gave the intended pressure. In clinical use of PEP treatment the actual pressure should be measured to ensure the intended pressure, no matter which type of resistor is used.

Increased blood loss after preoperative NSAID. Retrospective study of 186 hip arthroplasties.

We have evaluated bleeding during and after hip replacement in 186 patients in relation to preoperative intake of nonsteroidal anti-inflammatory drugs (NSAID) combined with low molecular weight heparin. NSAID was associated with increased preoperative bleeding and blood transfusion requirements.

[Continuous positive airway pressure (CPAP)--does the equipment live up to its name?]. / Continuous positive airway pressure (CPAP)--lever apparaturet op til navnet?

The purpose of this study was to evaluate the in- and expiratory pressures achieved by the use of different continuous positive airway pressure (CPAP) delivery systems. The study was performed on ten healthy adults breathing spontaneously with: 1) "simple CPAP", consisting of a fresh gas flow around 40 l/min and reservoir balloons of 2, 6 and 10 l and expiration against a water column, 2) a high-flow system CR60 CPAP, designed for home treatment and 3) another high-flow system Down's CPAP. Both high-flow systems used a venturi device (Downs Flow Generator, Vital Signs) giving flows around 90 and 170 l/min in our set-up, and the same PEEP valves (Vital signs) were used. All systems were tested with expiratory pressures set at 5, 10 and 20 cm H2O. Individual responses were found, but in general the simple CPAP with a 10 l latex balloon reservoir gave optimal CPAP. The high-flow systems were not found to provide better CPAP, however, CR60 CPAP was found also to be optimal with 5 and 10 cm H2O. Down's CPAP provided 3-5 cm higher expiratory pressure than the intended CPAP level. We recommend measurement of the pressure during the CPAP treatment to ensure that the intended CPAP is achieved.