Risk factors for hip impact during real-life falls captured on video in long-term care.

UNLABELLED: Hip fracture risk is increased by landing on the hip. We examined factors that contribute to hip impact during real-life falls in long-term care facilities. Our results indicate that hip impact is equally likely in falls initially directed forward as sideways and more common among individuals with dependent Activities of Daily Living (ADL) performance. INTRODUCTION: The risk for hip fracture in older adults increases 30-fold by impacting the hip during a fall. This study examined biomechanical and health status factors that contribute to hip impact through the analysis of real-life falls captured on video in long-term care (LTC) facilities. METHODS: Over a 7-year period, we captured 520 falls experienced by 160 residents who provided consent for releasing their health records. Each video was analyzed by a three-member team using a validated questionnaire to determine whether impact occurred to the hip or hand, the initial fall direction and landing configuration, attempts of stepping responses, and use of mobility aids. We also collected information related to resident physical and cognitive function, disease diagnoses, and use of medications from the Minimum Data Set. RESULTS: Hip impact occurred in 40 % of falls. Falling forward or sideways was significantly associated with higher odds of hip impact, compared to falling backward (OR 4.2, 95 % CI 2.4-7.1) and straight down (7.9, 4.1-15.6). In 32 % of sideways falls, individuals rotated to land backward. This substantially reduced the odds for hip impact (0.1, 0.03-0.4). Tendency for body rotation was decreased for individuals with dependent ADL performance (0.43, 0.2-1.0). CONCLUSIONS: Hip impact was equally likely in falls initially directed forward as sideways, due to the tendency for axial body rotation during descent. A rotation from sideways to backward decreased the odds of hip impact 10-fold. Our results may contribute to improvements in risk assessment and strategies to reduce risk for hip fracture in older adults.

Plasma chromium after glucose administration.

Sharp increases in the concentration of chromium in plasma were found in five subjects with normal glucose utilization after administration of glucose by mouth. This rise was not observed in two diabetics when glucose tolerance was impaired; however, it appeared when glucose tolerance was improved and when trace amounts of trivalent chromium were given as a dietary supple-ment. The source of chromium which became elevated was most likely an internal pool. Possibly there is a relation between chromium and insulin function.

Development of a stick-on hip protector: A multiple methods study to improve hip protector design for older adults in the acute care environment.

INTRODUCTION: Over 90% of hip fractures in older adults result from falls, and hospital patients are at especially high risk. Specific types of wearable hip protectors have been shown to reduce hip fracture risk during a fall by up to 80%, but user compliance has averaged less than 50%. We describe the development and evaluation of a "stick-on" hip protector (secured over the hip with a skin-friendly adhesive) for older patients in acute care. METHODS: An initial version of the product was evaluated with six female patients (aged 76-91) in a hospital ward, who were asked to wear it for one week. We subsequently refined the product through biomechanical testing and solicited feedback from 43 health professionals on a second prototype. RESULTS: The first prototype was worn by five of six patients for the full week or duration of their hospital stay. The second prototype (20 mm thick, surface area 19 × 15.5 cm) provided 36% force attenuation, more than common garment-based models (20-21%). Feedback from patients and health professionals highlighted usability, comfort, cost, and appearance. CONCLUSIONS: Our results from biomechanical and user testing support the need for further work to determine the value of stick-on hip protectors in acute care.

Muscle compromise in diabetes.

Muscle compromise associated with diabetes includes muscle infarction, myositis, pyomyositis, and abscess formation. These conditions may also be seen in various other conditions, such as trauma, alcoholism, neoplasia, vasculopathy, HIV infection, and other immunocompromised states and hemoglobinopathies. Due to recent advances in imaging technology, these entities are readily detected and treated at an earlier stage. Different diagnostic modalities may be used, particularly magnetic resonance imaging (MRI), which is best for soft-tissue pathologies. Muscle infarction appears with acute edema and inflammatory changes on T1- and T2-weighted images, enhancing peripherally postcontrast, and nonenhancing central areas suggestive of necrosis, lacking focal fluid collections. The latter feature may help to exclude abscesses, as these mostly present with fluid collections. Pyomyositis in its early period demonstrates ill-defined muscle enlargement with increased signal on T2-weighted images. Myositis shows no signal changes or mild hypointensity on T1-weighted images, but diffuse hyperintensity on T2-weighted images, with no or minimal enhancement following intravenous contrast media. Recognition of these pathologies is important, since management approaches vary depending on the etiology of the muscle involvement and overall status of the patient.

Comparación de la tasa de cesáreas de dos maternidades públicas del Uruguay / Comparison of the caesarean section rate of two publics health maternity in Uruguay / Comparação da taxa de cesariana de duas maternidades públicas no Uruguai

e realizó un analisis de la tasa de cesáreas en dos maternidades públicas de referencia de Uruguay (Hospital de Clínicas y Centro Hospitalario Pereira Rossell) utilizando la clasificación de Robson para compararlas entre sí, mediante un estudio observacional, descriptivo, retrospectivo y transversal en un periodo de 10 años y 10 meses (2009-2019). Se analizaron 85.526 nacimientos (7.685 (8,9%) en el Clínicas vs 77.841 (91.1%) Pereira Rossell). El porcentaje de cesáreas por año en el Clínicas fue 49,2% ± 5 vs 29,3% ± 3 en Pereira Rossell. Los grupos de Robson más prevalentes fueron 1, 5A y 10 en el Clínicas vs 3, 1 y 5A en Pereira Rossell. En ambos centros los grupos con mayor contribución relativa a la tasa global de cesáreas fueron: 5A, 10 y 1. Ambos centros presentan un aumento en la tasa de cesárea en la última década, pese a que se asisten poblaciones dispares entre cada uno de ellos. Se debe seguir buscando estrategias que ayuden a reducir la tasa de cesáreas principalmente en pacientes sin cesáreas anteriores o con una única cesárea previa, en caso de no presentan contraindicaciones para el parto vaginal.(AU)

An analysis of the caesarean section rate was carried out in two reference public maternity wards in Uruguay (Hospital de Clínicas and Centro Hospitalario Pereira Rossell) using Robson's classification to compare them with each other, through an observational, descriptive, retrospective and cross-sectional study in a period 10 years and 10 months (2009-2019). 85,526 births were analyzed (7,685 (8.9%) in the Clinics vs 77,841 (91.1%) Pereira Rossell). The percentage of caesarean sections per year in the Clinics was 49.2% ± 5 vs 29.3% ± 3 in Pereira Rossell. The most prevalent Robson groups were 1, 5A and 10 in the Clinicas vs 3, 1 and 5A in Pereira Rossell. In both centers, the groups with the highest relative contribution to the overall rate of cesarean sections were: 5A, 10 and 1. Both centers show an increase in the rate of cesarean section in the last decade, despite the fact that different populations are attended between each of them. Strategies should continue to be sought to help reduce the rate of cesarean sections, mainly in patients without previous cesarean sections or with a single previous cesarean section, if they do not present contraindications for vaginal delivery. (AU)

Foi realizada análise da taxa de cesárea em duas maternidades públicas de referência do Uruguai (Hospital de Clínicas e Centro Hospitalario Pereira Rossell), utilizando a classificação de Robson para compará-las, por meio de estudo observacional, descritivo, retrospectivo e transversal. em um período de 10 anos e 10 meses (2009-2019). Foram analisados 85.526 partos (7.685 (8,9%) nas Clínicas vs 77.841 (91,1%) Pereira Rossell). A porcentagem de cesarianas por ano nas Clínicas foi de 49,2% ± 5 vs 29,3% ± 3 em Pereira Rossell. Os grupos de Robson mais prevalentes foram 1, 5A e 10 nas Clínicas vs 3, 1 e 5A em Pereira Rossell. Em ambos os centros, os grupos com maior contribuição relativa para a taxa global de cesárea foram: 5A, 10 e 1. Ambos os centros apresentam aumento da taxa de cesárea na última década, apesar de diferentes populações serem atendidas entre cada um deles. Estratégias devem continuar a ser buscadas para ajudar a reduzir a taxa de cesárea, principalmente em pacientes sem cesárea anterior ou com cesárea única, se não apresentarem contra-indicações para parto normal. (AU)

Glycosylated fetal hemoglobin. Correlation with hyperglycemia and birth weight in infants of diabetic mothers.

Glycosylated fetal hemoglobin levels were measured in umbilical cord blood of normal infants and infants of diabetic mothers. The glycosylated fraction proved to be a stable compound; its level remained unchanged over a 19-day period. Exposure of fetal and adult hemoglobins to the same concentrations of glucose in vitro resulted in similar levels of glycosylated hemoglobins, suggesting that both types of hemoglobin are about equally reactive with glucose. Levels of glycosylated hemoglobin were significantly increased above normal in umbilical cord blood of infants of both Class A and Class B diabetic mothers. A significant relationship was found between macrosomia, reflected in birth weight ratios, and glycosylated hemoglobin from fetal erythrocytes in infants of diabetic mothers. While these data are consistent with the conclusion that glycosylated fetal hemoglobin levels are a function of fetal blood glucose concentrations in utero during the 2 mo before delivery, it is not known whether the glycosylated hemoglobin contributes to the abnormalities other than macrosomia found in infants of diabetic mothers.

Tumor-induced osteomalacia: clinical and basic studies.

A patient with classic clinical and biochemical features of tumor-induced osteomalacia (hypophosphatemia, phosphaturia, and undetectable serum concentrations of 1,25-dihydroxyvitamin D [1,25(OH)2D]) was studied before and after resection of a benign extraskeletal chondroma from the plantar surface of the foot. Presurgical laboratory evaluation was notable for normal serum concentrations of calcium, intact parathyroid hormone (PTH), parathyroid hormone-related protein (PTHrP), and osteocalcin, increased serum alkaline phosphate activity, and frankly elevated urinary cyclic adenosine monophosphate (cAMP) and pyridinium cross-link excretion. Quantitative histomorphometry showed severe osteomalacia and deep erosions of the cancellous surface by active osteoclasts. After resection, serum 1,25(OH)2D normalized within 24 h, while renal tubular phosphorus reabsorption and serum phosphorus did not normalized until days 2 and 3, respectively; serum Ca declined slightly, and serum intact PTH, osteocalcin, and urinary pyridinium cross-link excretion increased dramatically. Urinary cAMP excretion declined immediately after resection and then began to increase concomitant with the increase in serum intact PTH. A second bone biopsy taken 3 months after resection demonstrated complete resolution of the osteomalacia, increased mineral apposition rate (1.09 mu/day), resorption surface (9.2%), mineralizing surface (71%), and bone formation rate (0.83 mm3/mm2/day), and marked decrease in cancellous bone volume (13.1%) and trabecular connectivity compared with first biopsy. Tumor extracts did not affect phosphate transport in renal epithelial cell lines or 1 alpha-hydroxylase activity in a myelomonocytic cell line. The patient's course suggests that the normal 1,25(OH)2D and phosphorus metabolism is due to a tumor product that may be acting via stimulation of adenylate activity. Increased bone resorption prior to surgical resection suggests that the tumor may also produce an osteoclast activator. The rise in resorption surface and pyridinium cross-link excretion, increase in serum osteocalcin and bone mineralization, normalization of osteoid width, and fall in cancellous bone volume after resection are consistent with healing of osteomalacia by rapid remodeling.

Skeletal disease in primary hyperparathyroidism.

Most patients with primary hyperparathyroidism in the 1980s do not have evidence of bone disease when they are evaluated by conventional radiography. We sought to determine whether skeletal involvement can be appreciated when more sensitive techniques, such as bone densitometry and bone biopsy, are utilized. We investigated 52 patients with primary hyperparathyroidism. They had mild hypercalcemia, 2.8 +/- 0.03 mmol/liter (11.1 +/- 0.1 mg/dl), low normal phosphorus, 0.9 +/- 0.03 mmol/liter (2.8 +/- 0.1 mg/dl), and no symptoms or specific radiological signs of skeletal involvement. The greatest reduction in bone mineral density was found at the site of predominantly cortical bone, the radius (0.54 +/- 0.1 g/cm; 79 +/- 2% of expected), whereas the site of predominantly cancellous bone, the lumbar spine (1.07 +/- 0.03 g/cm2), was normal (95 +/- 3% of expected). The site of mixed composition, the femoral neck (0.78 +/- 0.14 g/cm2), gave an intermediate value (89 +/- 2% of expected). Preferential involvement of cortical bone with apparent preservation of cancellous bone in primary hyperparathyroidism was confirmed by percutaneous bone biopsy. Over 80% of patients had a mean cortical width below the expected mean, whereas cancellous bone volume in over 80% of patients was above the expected mean. The results indicate that the majority of patients with asymptomatic primary hyperparathyroidism have evidence by bone densitometry and bone biopsy for cortical bone disease. The results also indicate that the mild hyperparathyroid state may be protective of cancellous bone. The therapeutic implications of these observations await further longitudinal experience with this study population.

Diphosphonate therapy of paget's disease of bone.

The use of disodium ethane-1 hydroxy-1, 1-diphosphonate (EHDP) therapy for Paget's disease of bone was examined in 75 affected patients. Forty-eight patients received randomly assigned oral doses of either 0, 2.5, 5, 10, or 20 mg/kg/day in a controlled, double-blind protocol, and the remainder received either 10 or 20 mg/kg/day in a non-random protocol. The clinical status of the patients and appropriate laboratory tests were evaluated before treatment and at frequent intervals during a six-month period of initial therapy. There were no significant changes in either urinary hydroxyproline or serum alkaline phosphatase in those patients receiving placebos, while both these parameters decreased significantly at all dose levels of EHDP, with the greatest decline noted in the highest dose group. However, statistical analysis of the data related to changes in symptoms in the double-blind study revealed that patients receiving the higher dose of EHDP (10 or 20 mg/kg/day) had less favorable outcomes than those receiving the lower doses (2.5 or 5 mg/kg/day). The high does group had a relatively lower rate of symptom improvement and a relatively greater rate of deterioration than did the low dose group. Twenty-one of forty-nine patients followed for at least 18 months have shown a sustained suppression of their serum alkaline phosphatase and urinary hydroxyproline values for 12 months following cessation of EHDP, while therapy has been reinstituted for the other 28 patients because of increases in these measurements, with or without accompanying symptomatic deterioration. Eight patients sustained fractures through Pagetic bone during the period of study and all of these were treated with higher doses of EHDP. On the basis of the biochemical and clinical data in this study it appears that initial therapy of Paget's disease of bone with 5 mg EHDP/kg/day maximizes benefits while minimizing possible adverse effects.

Preclinical characterization of a new pasteurized monoclonal antibody purified factor VIIIC.

The treatment of hemophilia A patients has progressed in the last 30 years. The development of more pure factor VIII concentrates has been encouraged by the appearance of the human immunodeficiency virus in blood supply. Monoclate was the first essentially pure form of factor VIII available for hemophilia therapy. The liquid pasteurized form of Monoclate represents a new standard for therapy that attempts to eliminate a broad spectrum of viral content in factor VIII preparations.

Effect of soft-tissue pathology on detection of pedal osteomyelitis in diabetics.

Three-phase bone scans were performed on 30 diabetic patients suspected of having acute pedal osteomyelitis; 23 also had a pedal ulcer, seven had coexisting cellulitis, and 14 had diminished pedal pulses. Fifteen patients were receiving antibiotics at the time of the scan. A tissue diagnosis was available in 18 patients and 12 had no clinical evidence of infection on follow-up. Focal arterial hyperemia combined with focally increased activity on blood-pool and delayed (2-3 hr) scans were interpreted as acute osteomyelitis. Scans showing venous hyperemia were interpreted as soft-tissue pathology without acute osteomyelitis. Companion radiographs were reviewed independently. The sensitivity and specificity of the scans for osteomyelitis were 0.94 and 0.79, respectively, while radiographic sensitivity was 0.93 and specificity was 0.50. The presence of soft-tissue ulcers or cellulitis, peripheral vascular disease, or recent antibiotic therapy had no significant adverse effect on the accuracy of the three-phase scan in diagnosing osteomyelitis.

Magnetic resonance grid analysis of soft tissue lesions.

Soft tissue tumors of seven patients were imaged with magnetic resonance imaging (MRI) prior to operative resection. In four cases, gross surgical specimen biopsy sites were broadly selected from areas of diverse signal intensity. A subsequently developed "grid analysis" technique, used in three additional patients, better localized differing zonal intensities within individual gross specimens. Further investigation of this technique is warranted, since MR images, when analyzed by means of a detailed grid technique, appear to enhance histologic diagnostic accuracy. Examination of larger segments of inhomogeneous soft tissue tumors is facilitated, while pathologists' sampling time is diminished.

Daily assessment of ocular and hormonal variables throughout the menstrual cycle.

Eleven normal women, between the ages of 19 and 28, were examined at the same time of day, every day of a complete menstrual cycle. Measurements of intraocular pressure, anterior chamber depth, corneal thickness, and tear production were obtained. Tonographic values were obtained on eight days during the cycle. The results for ten of the women who were shown to have ovulated during the study, were then correlated with daily blood levels of luteinizing hormone, follicle-stimulating hormone, estrone, estradiol, progesterone, and testosterone, as measured by techniques of radioimmunoassay. No statistically valid correlations could be made when the various studies were analyzed and correlated.

Magnetic resonance imaging of the foot and ankle.

Beginning with its early success in the hip and knee, magnetic resonance has been universally acknowledged as a major advance in musculoskeletal imaging. Subsequent technical improvements encouraged its rapid adaptation for delineating wrist and shoulder joint pathology. In part because of the small, complex curvilinear structures involved, however, the required technology as well as the potential advantages of magnetic resonance imaging in the ankle and foot were realized only recently. This article illustrates some of the clinical applications of magnetic resonance imaging in foot and ankle pathology.

Effectiveness of alternative treatments for reducing potential viral contaminants from plasma-derived products.

An issue of great importance and continuing concern with regard to all products derived from human plasma is their safety from potential contaminants in the source material from which they are purified. Since viral contaminants are a major safety consideration with these products, a number of different methods, including dry heating, vapor heating, filtration and nanofiltration, ultraviolet and gamma irradiation, pasteurization, solvent/detergent (S/D) treatment, sodium thiocyanate treatment, and chromatography (immunoaffinity, metal chelation, affinity, and ion exchange), have been developed to remove or inactivate potentially contaminating viruses. Pasteurization and S/D treatment have emerged as the dominant viral inactivation methods. Results summarized in this review demonstrate that pasteurization is the broadest and most rigorous currently available method for removal of potential viral contaminants from plasma-derived products. S/D treatment requires control over a large number of manufacturing parameters and has no ability to inactivate nonlipid-enveloped viruses. Pasteurization requires control over only a small number of manufacturing variables, is easily monitored, and remains effective even if deviations are encountered from specified protein and stabilizer concentrations and temperature. In addition, pasteurization is effective against a wide range of lipid- and nonlipid-enveloped viruses.

Effect of histamine-2 receptor blockade by cimetidine on intraocular pressure in humans.

The effect of an intravenous infusion of cimetidine (2 mg/kg of body weight/hr) on intraocular pressure and gastric acid secretion was determined in four healthy young adults and compared with the effect of a control infusion of normal saline. Cimetidine, a powerful histamine-2 receptor antagonist, abolished basal acid secretion, indicating that it was pharmacologically active, yet had no effect on intraocular pressure. Therefore, cimetidine may be given safely to patients with normal intraocular pressure. An additional observation was that intraocular pressure in all experiments declined linearly with repeated applanation tonometry for almost two hours before reaching a stable level.

Effect of indomethacin on the ocular hypotensive action of timolol maleate.

A randomized, double-masked, cross-over study of nine healthy normal subjects was conducted to determine whether indomethacin affected the ocular hypotensive action of timolol maleate. A significant decrease in intraocular pressure occurred with timolol maleate 0.5% eyedrops (used twice a day) alone. Indomethacin (25 mg three times a day, given orally) administered concurrently had no effect on timolol's hypotensive action. No subjective or objective side effects occurred and there were no significant changes in blood pressure, pulse rate, or respiratory rate with either treatment.

Effect of topical indomethacin and timolol maleate on intraocular pressure in normal subjects.

In a prospective randomized double-masked crossover study in ten healthy volunteers, conducted to determine if the intraocular hypotensive effect of timolol eyedrops was significantly affected by the concomitant use of the topically administered prostaglandin inhibitor, indomethacin, we found that significant ocular hypotension was achieved with timolol alone. This was not changed by the concurrent administration of indomethacin. The results provide further evidence that prostaglandins are not involved in the control of normal intraocular pressure.

Removal of hepatitis B surface antigen from a contaminated applanation tonometer.

Hepatitis B surface antigen was found in the conjunctival fluid of 43% of hepatitis B surface antigen carriers and could be detected on the tonometer tip after tonometry in one of four hepatitis B surface antigen carriers whose conjunctival fluid was positive for hepatitis B surface antigen. The Goldmann applanation tonometer tip was contaminated by immersion into solutions containing high concentrations of hepatitis B surface antigen (average 15,000 cpm). Prompt rinsing of the contaminated tonometer in running tap water for ten seconds proved sufficient to remove all detectable hepatitis B surface antigen from the tonometer.

Contact thermography of spinal root compression syndromes.

A thermographic technique is described that uses cholesteric liquid crystals that change color in response to variations in surface temperature. The crystals are embedded in elastic flexible sheets that conform to the contours of the torso and extremities. The technique is well suited to temperature measurement of individual skin dermatomes and myotomes. Typical heat patterns emanating from the torso and extremities have been observed and correlated with root compression syndromes at low cervical and low lumbosacral levels. The imaging results correlate well with clinical and surgical findings, particularly when the extremity dermatomes are included. The technique objectively documents the subjective complaint of pain and approaches myelography in accuracy. It was in agreement with myelography in 86% of cases and with surgery in 95% of cases. Liquid crystal thermography may, therefore, effectively screen patients of myelography and can complement it in identifying clinically significant abnormalities.