Long-term care transitions during a global pandemic: Planning and decision-making of residents, care partners, and health professionals in Ontario, Canada

The COVID-19 pandemic appears to have shifted the care trajectories of many residents and care partners in Ontario who considered leaving LTC to live in the community for a portion or the duration of the pandemic. This type of care transition-from LTC to home care-was highly uncommon prior to the pandemic, therefore we know relatively little about the planning and decision-making involved. The aim of this study was to describe who was involved in LTC to home care transitions in Ontario during the COVID-19 pandemic, to what extent, and the factors that guided their decision-making. A qualitative description study involving semi-structured interviews with 32 residents, care partners and health professionals was conducted. Transition decisions were largely made by care partners, with varied input from residents or health professionals. Stakeholders considered seven factors, previously identified in a scoping review, when making their transition decisions: (a) institutional priorities and requirements; (b) resources; (c) knowledge; (d) risk; (e) group structure and dynamic; (f) health and support needs; and (g) personality preferences and beliefs. Participants' emotional responses to the pandemic also influenced the perceived need to pursue a care transition. The findings of this research provide insights towards the planning required to support LTC to home care transitions, and the many challenges that arise during decision-making.

"My Biggest Fear Is She'll Die Alone": Care Partner Perspectives of Institutional COVID-19 Visitor Restrictions in Ontario, Canada

In March 2020, the Government of Ontario, Canada implemented public health measures, including visitor restrictions in institutional care settings, to protect vulnerable populations, including older adults (> 65 years), against COVID-19 infection. Prior research has shown that visitor restrictions can negatively influence older adults' physical and mental health and can cause increased stress and anxiety for care partners. This study explores the experiences of care partners separated from the person they care for because of institutional visitor restrictions during the COVID-19 pandemic. We interviewed 14 care partners between the ages of 50 and 89; 11 were female. The main themes that emerged were changing public health and infection prevention and control policies, shifting care partner roles as a result of visitor restrictions, resident isolation and deterioration from the care partner perspective, communication challenges, and reflections on the impacts of visitor restrictions. Findings may be used to inform future health policy and system reforms.

"We have to save him": a qualitative study on care transition decisions in Ontario's long-term care settings during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic has contributed to a global crisis in long-term care (LTC) with devastating consequences for residents, families and health professionals. In Ontario, Canada the severity of this crisis has prompted some care partners to move residents home with them for the duration or a portion of the pandemic. This type of care transition, from LTC to home care, was highly unusual pre-pandemic and arguably suboptimal for adults with complex needs. This paper presents the findings of a qualitative study to better understand how residents, care partners, and health professionals made care transition decisions in Ontario's LTC settings during the pandemic.

METHODS

Semi-structured interviews were conducted with 32 residents, care partners and health professionals who considered, supported or pursued a care transition in a LTC setting in Ontario during the pandemic. Crisis Decision Theory was used to structure the analysis.

RESULTS

The results highlighted significant individual and group differences in how participants assessed the severity of the crisis and evaluated response options. Key factors that had an impact on decision trajectories included the individuals' emotional responses to the pandemic, personal identities and available resources.

CONCLUSIONS

The findings from this study offer novel important insights regarding how individuals and groups perceive and respond to crisis events.

Rheumatoid arthritis and older age are associated with lower humoral and cellular immune response to primary series COVID-19 mRNA vaccine

OBJECTIVE

People with autoimmune disease have worse COVID-19 infection-related outcomes, lower antibody responses to COVID-19 vaccine, and higher rates of breakthrough infection. Immunosuppressive medications used to treat rheumatoid arthritis (RA) are associated with lower COVID-19 vaccine responses, though independent contributions of comorbidities, T-cell immunity, and age are less clear. We sought to test the hypothesis that RA, immunosuppressive medications used to treat RA, and older age, contribute to reduced B and T cell response to COVID-19 vaccine.

METHODS

We evaluated serum samples, taken the day of 1st vaccine dose, the day of 2nd dose, 2-6 weeks after 2nd dose, 7-12 weeks after 2nd dose, 13-24 weeks after 2nd dose, and 2-6 weeks after the 3rd dose, for anti-spike IgG and neutralizing antibody levels to Wuhan and Omicron BA.1 and peripheral blood mononuclear cells (PBMC) for spike-specific IFN-γ and IL-2 production by ELISPOT assay in 46 RA and 101 non-autoimmune control participants before and after the primary series COVID-19 mRNA vaccination.

RESULTS

RA participants had lower spike-specific IgG and Wuhan-strain neutralizing antibody levels 2-6 weeks compared to controls after the second dose of primary vaccine series. Neutralizing antibody levels against Omicron BA.1 were low in both groups. IFN-γ production correlated with Wuhan neutralizing antibody levels, while older age negatively correlated with spike-specific IL-2, IFN-γ and IgG. Lower antibody levels were associated with older age, RA status, and medication usage, while lower T cell responses were associated primarily with older age.

CONCLUSIONS

These data indicate lower COVID-19 mRNA vaccine-induced antibody levels in persons with RA compared to individuals without RA, likely partially attributable to immune suppressive medications. At the same time, older age is associated with lower antibody and cellular immune response to COVID-19 vaccines.

Endotoxemia Associated with Liver Disease Correlates with Systemic Inflammation and T Cell Exhaustion in Hepatitis C Virus Infection

Both acute and chronic hepatitis C virus (HCV) infections are characterized by inflammation. HCV and reduced liver blood filtration contribute to inflammation; however, the mechanisms of systemic immune activation and dysfunction as a result of HCV infection are not clear. We measured circulating inflammatory mediators (IL-6, IP10, sCD163, sCD14), indices of endotoxemia (EndoCab, LBP, FABP), and T cell markers of exhaustion and senescence (PD-1, TIGIT, CD57, KLRG-1) in HCV-infected participants, and followed a small cohort after direct-acting anti-viral therapy. IL-6, IP10, Endocab, LBP, and FABP were elevated in HCV participants, as were T cell co-expression of exhaustion and senescence markers. We found positive associations between IL-6, IP10, EndoCab, LBP, and co-expression of T cell markers of exhaustion and senescence. We also found numerous associations between reduced liver function, as measured by plasma albumin levels, and T cell exhaustion/senescence, inflammation, and endotoxemia. We found positive associations between liver stiffness (TE score) and plasma levels of IL-6, IP10, and LBP. Lastly, plasma IP10 and the proportion of CD8 T cells co-expressing PD-1 and CD57 decreased after initiation of direct-acting anti-viral therapy. Although associations do not prove causality, our results support the model that translocation of microbial products, resulting from decreased liver blood filtration, during HCV infection drives chronic inflammation that results in T cell exhaustion/senescence and contributes to systemic immune dysfunction.

Development and validation of a hospital frailty risk measure using Canadian clinical administrative data

Background:

Accessible measures specific to the Canadian context are needed to support health system planning for older adults living with frailty. We sought to develop and validate the Canadian Institute for Health Information (CIHI) Hospital Frailty Risk Measure (HFRM).

Methods:

Using CIHI administrative data, we conducted a retrospective cohort study involving patients aged 65 years and older who were discharged from Canadian hospitals from Apr. 1, 2018, to Mar. 31, 2019. We used a 2-phase approach to develop and validate the CIHI HFRM. The first phase, construction of the measure, was based on the deficit accumulation approach (identification of age-related conditions using a 2-year look-back). The second phase involved refinement into 3 formats (continuous risk score, 8 risk groups and binary risk measure), with assessment of their predictive validity for several frailty-related adverse outcomes using data to 2019/20. We assessed convergent validity with the United Kingdom Hospital Frailty Risk Score.

Results:

The cohort consisted of 788 701 patients. The CIHI HFRM included 36 deficit categories and 595 diagnosis codes that cover morbidity, function, sensory loss, cognition and mood. The median continuous risk score was 0.111 (interquartile range 0.056–0.194, equivalent to 2–7 deficits); 35.1% (n = 277 000) of the cohort were found at risk of frailty (≥ 6 deficits). The CIHI HFRM showed satisfactory predictive validity and reasonable goodness-of-fit. For the continuous risk score format (unit = 0.1), the hazard ratio (HR) for 1-year risk of death was 1.39 (95% confidence interval [CI] 1.38–1.41), with a C-statistic of 0.717 (95% CI 0.715–0.720); the odds ratio for high users of hospital beds was 1.85 (95% CI 1.82–1.88), with a C-statistic of 0.709 (95% CI 0.704–0.714), and the HR of 90-day admission to long-term care was 1.91 (95% CI 1.88–1.93), with a C-statistic of 0.810 (95% CI 0.808–0.813). Compared with the continuous risk score, using a format of 8 risk groups had similar discriminatory ability and the binary risk measure had slightly weaker performance.

Interpretation:

The CIHI HFRM is a valid tool showing good discriminatory power for several adverse outcomes. The tool can be used by decision-makers and researchers by providing information on hospital-level prevalence of frailty to support system-level capacity planning for Canada’s aging population.

Patients’ migration for orthopaedic intensive rehabilitation among Italian Regions

Background

Interregional patients’ migration, according to Italian Law, can be considered an expression of the (inviolable?) right to health and freedom of choice regarding place of care. It contributing, albeit perversely, to guaranteeing equity in the Italian National Health Service allowing citizens to overcome territorial inequalities in the distribution of healthcare services. The aim of our study was to analyze fulfilment of needs for orthopaedic intensive rehabilitation hospital services on site and interregional patients’ migration trends.

Methods

We conducted an observational cross sectional study on Hospital Discharge Cards provided by the Ministry of Health, upon specific request, from 2011 to 2019. The study of interregional patients’ migration, for orthopaedic intensive rehabilitation, relative to single Italian regions was carried out from data of Residents, Attractions and Escapes, which were graphically developed through Gandy’s Nomogram. Trend analysis (Cuzick’s Test) was performed through STATA. Were considered statistically significant at level of 95% (p < 0.05).

Results

In our studied period, Gandy’s Nomogram showed that only Piedmont, Lombardy, A.P. of Trento, E. Romagna, Umbria and Abruzzo had a good public hospital planning for orthopaedic intensive rehabilitation. Attractions increased significantly for Lombardy, A.P. of Trento, Veneto and Basilicata, while they decreased significantly for A.P. of Bolzano, Veneto, F.V. Giulia, Abruzzo, Calabria and Sicily. Escapes increased significantly for Veneto, F.V. Giulia, E. Romagna, Tuscany, Molise, Puglia and Basilicata, while they decreased significantly for Piedmont, Aosta Valley, A.P. of Trento, Umbria, Abruzzo and Sicily.

Conclusions

Only six regions (4 in the North, 1 in the Centre and 1 in the South) satisfied care needs of their Residents, with an Attractions minus Escapes positive balance. Only A.P. of Trento appears to have been able to reduce Escapes and increase Attractions at the same time.

Key messages

• Studying patients’ migration by type of health benefit makes it possible to identify specific situations of lack of supply.

• Patients’ migration is an indirect Index of a region’s health policy.

Stakeholder involvement in care transition planning for older adults and the factors guiding their decision-making: a scoping review

OBJECTIVE

To synthesise the existing literature on care transition planning from the perspectives of older adults, caregivers and health professionals and to identify the factors that may influence these stakeholders' transition decision-making processes.

DESIGN

A scoping review guided by Arksey and O'Malley's six-step framework. A comprehensive search strategy was conducted on 7 January 2021 to identify articles in five databases (MEDLINE, Embase, CINAHL Plus, PsycINFO and AgeLine). Records were included when they described care transition planning in an institutional setting from the perspectives of the care triad (older adults, caregivers and health professionals). No date or study design restrictions were imposed.

SETTING

This review explored care transitions involving older adults from an institutional care setting to any other institutional or non-institutional care setting. Institutional care settings include communal facilities where individuals dwell for short or extended periods of time and have access to healthcare services.

PARTICIPANTS

Older adults (aged 65 or older), caregivers and health professionals.

RESULTS

39 records were included. Stakeholder involvement in transition planning varied across the studies. Transition decisions were largely made by health professionals, with limited or unclear involvement from older adults and caregivers. Seven factors appeared to guide transition planning across the stakeholder groups: (a) institutional priorities and requirements; (b) resources; (c) knowledge; (d) risk; (e) group structure and dynamic; (f) health and support needs; and (g) personality preferences and beliefs. Factors were described at microlevels, mesolevels and macrolevels.

CONCLUSIONS

This review explored stakeholder involvement in transition planning and identified seven factors that appear to influence transition decision-making. These factors may be useful in advancing the delivery of person and family-centred care by determining how individual-level, group-level and system-level values guide decision-making. Further research is needed to understand how various stakeholder groups balance these factors during transition planning in different health contexts.

Glenoid version: the role of genetic and environmental factors on its variability. An MRI study on asymptomatic elderly twins

BACKGROUND

Glenoid version is the most variable parameter of the shoulder joint. No authors investigated if intrinsic genetic factors or influences from extrinsic sources are responsible for its variability.

AIM

We compared glenoid version between elderly monozygotic and dizygotic twins intending to separate the contributions of genetics from shared and unique environments.

METHODS

Glenoid version of the dominant shoulder was assessed by MRI using Friedman's method in 30 pairs of elderly twins (16 monozygotic-14 dizygotic; mean age ± SD: 63.72 ± 3.37, 53-72). Heritability was estimated as twice the difference between the intraclass correlation coefficients for monozygotic and dizygotic pairs. The influence of shared environment was calculated as the difference between monozygotic correlation coefficient and the heritability index. According to job category, one way analysis of variance was used to estimate the differences between groups in the total sample and within zygosity groups.

RESULTS

Glenoid version angle in monozygotic and dizygotic twins was -2° (SD: 2°) and -3° (SD: 3°), respectively (p = 0.334). Heritability index was 0.98, while the contributions of shared and unique environment were 0 and 0.02, respectively. According to working classes, no significant differences were found between the groups (p = 0.732, F = 0.31).

CONCLUSIONS

Glenoid version is mainly genetically determined and only marginally influenced by environments.Level of evidence: III.

Effect of oral chlorhexidine de-adoption and implementation of an oral care bundle on mortality for mechanically ventilated patients in the intensive care unit (CHORAL): a multi-center stepped wedge cluster-randomized controlled trial

Purpose

Oral chlorhexidine is used widely for mechanically ventilated patients to prevent pneumonia, but recent studies show an association with excess mortality. We examined whether de-adoption of chlorhexidine and parallel implementation of a standardized oral care bundle reduces intensive care unit (ICU) mortality in mechanically ventilated patients.

Methods

A stepped wedge cluster-randomized controlled trial with concurrent process evaluation in 6 ICUs in Toronto, Canada. Clusters were randomized to de-adopt chlorhexidine and implement a standardized oral care bundle at 2-month intervals. The primary outcome was ICU mortality. Secondary outcomes were time to infection-related ventilator-associated complications (IVACs), oral procedural pain and oral health dysfunction. An exploratory post hoc analysis examined time to extubation in survivors.

Results

A total of 3260 patients were enrolled; 1560 control, 1700 intervention. ICU mortality for the intervention and control periods were 399 (23.5%) and 330 (21.2%), respectively (adjusted odds ratio [aOR], 1.13; 95% confidence interval [CI] 0.82 to 1.54; P = 0.46). Time to IVACs (adjusted hazard ratio [aHR], 1.06; 95% CI 0.44 to 2.57; P = 0.90), time to extubation (aHR 1.03; 95% CI 0.85 to 1.23; P = 0.79) (survivors) and oral procedural pain (aOR, 0.62; 95% CI 0.34 to 1.10; P = 0.10) were similar between control and intervention periods. However, oral health dysfunction scores (− 0.96; 95% CI − 1.75 to − 0.17; P = 0.02) improved in the intervention period.

Conclusion

Among mechanically ventilated ICU patients, no benefit was observed for de-adoption of chlorhexidine and implementation of an oral care bundle on ICU mortality, IVACs, oral procedural pain, or time to extubation. The intervention may improve oral health.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00134-021-06475-2.

Recombinant Interleukin-1 receptor antagonist for the treatment of ST-segment elevation acute myocardial infarction prevents future heart failure events: a pooled analysis of the VCUART program

Background

ST segment elevation myocardial infarction (STEMI) is associated with an intense acute inflammatory response and an increased risk of death and heart failure (HF). We analyzed the effect of recombinant interleukin-1 receptor antagonist (anakinra) 100 mg subcutaneous injection given once or twice daily for 14 days on the occurrence of HF in a pooled analysis of 3 clinical trials.

Methods

Enrollment criteria and study procedures were the same across the three studies. High-sensitivity C-reactive protein (CRP) was measured at baseline, 72 hours, and 14 days to construct an area under the curve (AUC0–14). Clinical events up to 1 year were adjudicated by an independent committee blinded to treatment allocation. Data for anakinra once daily and anakinra twice daily were pooled into a single anakinra group. CRP data are presented as median and interquartile range to allow for deviation from Gaussian distribution and non-parametric tests were used to evaluate differences between groups. Kaplan-Meier survival analyses were conducted and the intervention groups were compared using a log-rank test.

Results

Between 2008 and 2017, 139 patients with STEMI were enrolled. 84 patients were randomized to anakinra and 55 patients were randomized to placebo. Anakinra significantly reduced the CRP AUC0–14 (76 [42–147] vs 222 [117–339] mg*day/L; P<0.001), the composite of death or HF hospitalization (Chi2=7.167; P=0.007), and the composite of death or new onset HF (Chi2=9.43; P=0.002) compared with placebo. Treatment with anakinra had no effect on ischemic events (composite of death, myocardial infarction, and unstable angina; (Chi2=0.574; P=0.45) or the composite of death, myocardial infarction and cerebrovascular accident (Chi2=0.065; P=0.80). Patients receiving anakinra had increased injection site reactions (20.2% vs 3.6%; P=0.005) but no change in infections (14.3% vs 9.1%, P=0.435) versus placebo.

Conclusions

Treatment with anakinra for 14 days following STEMI blunts the inflammatory response and appears to reduce the occurrence of HF events at 1 year. These results support the hypothesis that early and targeted modification of the inflammatory response in STEMI may be a viable strategy to improve patient outcomes.

Adjudicated events at 1 year

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Heart Lung and Blood Institute (USA), American Heart Association (USA)

Recall of pain and discomfort during oral procedures experienced by intubated critically ill patients in the intensive care unit: A qualitative elicitation study

Background: Intubated and mechanically ventilated patients in the intensive care unit (ICU) may experience pain during routine oral procedures such as oral suctioning and tooth brushing. Despite the importance of pain prevention and management, little is known about patients’ experiences of procedural oral pain.

Aims: The aim of this study was to explore patients’ recollections and recommendations for pain and discomfort during routine oral procedures.

Methods: A qualitative descriptive design was used. Adult patients were recruited from a mixed medical–surgical–trauma ICU in an academic hospital in Toronto, Canada. Participants were interviewed using object elicitation methods within 7 days of discharge from the ICU. Data were analyzed using directed content analysis methods.

Results: We recruited 33 participants who were primarily male (23, 70%), with an average age of 54 (SD = 18) years, admitted with a medical (13, 39%), trauma (11, 33%), or surgical (9, 27%) diagnosis and dentate (27, 82%). Most participants described oral procedures as painful, discomforting, and emotionally distressing. Identified sources of pain included dry, inflamed oral tissues and procedural technique. Procedural pain behaviors were perceived to be frequently misinterpreted by clinicians as agitation, with consequences including physical restraint and unrelieved suffering. Participants advocated for greater frequency of oral care to prevent oral health deterioration, anticipatory procedural guidance, and structured pain assessment to mitigate the dehumanizing experience of unmanaged pain.

Conclusions: Patients described routine oral care procedures as painful and recalled suboptimal management of such pain. Procedural oral pain is an important target for practice improvement.

Education Experiences of Adult Subjects and Caregivers for Mechanical Insufflation-Exsufflation at Home

BACKGROUND

In 2014, the Ministry of Health of Ontario, Canada, approved a program of public funding for specialist-prescribed mechanical insufflation-exsufflation (MI-E) devices for home use by individuals with neuromuscular respiratory insufficiency. Since 2014, 1,926 MI-E devices have been provided, exceeding device-use projections. Few studies describe the initial and ongoing education and support needs of home MI-E users and their family caregivers. This study aimed to explore the requirements of initial and ongoing education and support for MI-E device use, user confidence, and barriers and facilitators to home MI-E.

METHODS

We conducted semi-structured interviews with new (< 6 months) and established (6-48 months) MI-E users and family caregivers. Device users rated their confidence on a numeric rating scale of 1 (not confident) to 10 (very confident).

RESULTS

We recruited 14 new and 14 established MI-E users and caregivers (including 9 dyads), and we conducted 28 interviews. Both new and established users were highly confident in use of MI-E (mean ± SD scores were 8.8 ± 1.2 and 8.3 ± 2.1, respectively). Overall, the subjects were satisfied with their initial education, which consisted of a 1-2 h one-on-one session at home or in the clinic with a device demonstration and hands-on practice. Subjects viewed hands-on practice and teaching of caregivers as more beneficial than written materials. Ongoing support for device use was variable. Most subjects indicated a lack of specific follow-up, which resulted in uncertainty about whether they were using the MI-E device correctly or whether MI-E was effective. Facilitators to device utilization were ease of use, initial training, support from formal or informal caregivers, and symptom relief. Barriers were inadequate education on MI-E purpose, technique, and benefit; lack of follow-up; and inadequate knowledge of MI-E by nonspecialist health providers.

CONCLUSIONS

The current model of home MI-E education at initiation meets user and caregiver needs. Better ongoing education and follow-up are needed to sustain the benefits through assessment of MI-E technique and its effectiveness.

A transition program to adult health services for teenagers receiving long-term home mechanical ventilation: A longitudinal qualitative study

OBJECTIVE

Adolescents receiving long-term home mechanical ventilation (HMV) who survive into adulthood must transition to adult health care services. Lack of transition readiness is reported to result in poor health outcomes. The objective of this study is to explore longitudinally the pediatric-to-adult health care transition experience involving a transition program for adolescents receiving HMV including transition readiness, barriers, facilitators, and modifiable features.

DESIGN

A prospective qualitative longitudinal interview study of adolescent and family caregiver dyads recruited through a pediatric-to-adult HMV transition program jointly established by two collaborating health centers: The Hospital for Sick Children and West Park Healthcare Centre in Toronto, Canada. Eligible dyads were interviewed at three time points: pretransition, transition, and 12-months posttransition. Interviews were transcribed verbatim and analyzed using directed content analysis methods.

RESULTS

Ventilator-assisted adolescents (VAAs) and caregiver participants perceived a lack of transition readiness in their ability to manage health communication and coordination across multiple adult providers. Transition facilitators included early transition discussion, opportunities for VAAs to speak directly with HMV providers during appointments, receipt of print informational materials regarding adult services, and a joint pediatric-adult team handover meeting. Modifiable transition barriers included lack of other specialist referrals, insufficient information about adult homecare service funding, and limited involvement of family doctors. Unresolved transition barriers resulted in perceptions of service fragmentation.

CONCLUSIONS

Although the pediatric-to-adult HMV transition program conferred benefits service fragmentation was perceived. Transition barriers may be overcome through early planning and staged transition with all specialists, community providers, and the family and adolescent working in collaboration.

Support needs and health-related quality of life of family caregivers of patients requiring prolonged mechanical ventilation and admission to a specialised weaning centre: A qualitative longitudinal interview study

OBJECTIVES

Family caregivers of patients requiring prolonged mechanical ventilation may experience physical and psychological morbidity associated with a protracted intensive care unit experience. Our aim was to explore potentially modifiable support needs and care processes of importance to family caregivers of patients requiring prolonged mechanical ventilation and transition from the intensive care unit to a specialised weaning centre.

RESEARCH METHODOLOGY/DESIGN

A longitudinal qualitative descriptive interview study. Data was analysed using directed content analysis.

SETTING

A 6-bed specialised weaning centre in Toronto, Canada.

FINDINGS

Eighteen family caregivers completed interviews at weaning centre admission (100%), and at two-weeks (40%) and three-months after discharge (22%) contributing 29 interviews. Caregivers were primarily women (61%) and spouses (50%). Caregivers perceived inadequate informational, emotional, training, and appraisal support by health care providers limiting understanding of prolonged ventilation, participation in care and decision-making, and readiness for weaning centre transition. Participants reported long-term physical and psychological health changes including alterations to sleep, energy, nutrition and body weight.

CONCLUSIONS

Deficits in informational, emotional, training, and appraisal support of family caregivers of prolonged mechanical ventilation patients may increase caregiver burden and contribute to poor health outcomes. Strategies for providing support and maintaining family caregiver health-related quality of life are needed.

Protocol for a multi-centered, stepped wedge, cluster randomized controlled trial of the de-adoption of oral chlorhexidine prophylaxis and implementation of an oral care bundle for mechanically ventilated critically ill patients: the CHORAL study

BACKGROUND

Routine application of chlorhexidine oral rinse is recommended to reduce risk of ventilator-associated pneumonia (VAP) in mechanically ventilated patients. Recent reappraisal of the evidence from two meta-analyses suggests chlorhexidine may cause excess mortality in non-cardiac surgery patients and does not reduce VAP. Mechanisms for possible excess mortality are unclear. The CHORAL study will evaluate the impact of de-adopting chlorhexidine and implementing an oral care bundle (excluding chlorhexidine) on mortality, infection-related ventilator-associated complications (IVACs), and oral health status.

METHODS

The CHORAL study is a stepped wedge, cluster randomized controlled trial in six academic intensive care units (ICUs) in Toronto, Canada. Clusters (ICU) will be randomly allocated to six sequential steps over a 14-month period to de-adopt oral chlorhexidine and implement a standardized oral care bundle (oral assessment, tooth brushing, moisturization, and secretion removal). On study commencement, all clusters begin with a control period in which the standard of care is oral chlorhexidine. Clusters then begin crossover from control to intervention every 2 months according to the randomization schedule. Participants include all mechanically ventilated adults eligible to receive the standardized oral care bundle. The primary outcome is ICU mortality; secondary outcomes are IVACs and oral health status. We will determine demographics, antibiotic usage, mortality, and IVAC rates from a validated local ICU clinical registry. With six clusters and 50 ventilated patients on average each month per cluster, we estimate that 4200 patients provide 80% power after accounting for intracluster correlation to detect an absolute reduction in mortality of 5.5%. We will analyze our primary outcome of mortality using a generalized linear mixed model adjusting for time to account for secular trends. We will conduct a process evaluation to determine intervention fidelity and to inform interpretation of the trial results.

DISCUSSION

The CHORAL study will inform understanding of the effectiveness of de-adoption of oral chlorhexidine and implementation of a standardized oral care bundle for decreasing ICU mortality and IVAC rates while improving oral health status. Our process evaluation will inform clinicians and decision makers about intervention delivery to support future de-adoption if justified by trial results.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03382730 . Registered on December 26, 2017.

P6388Effects of Interleukin-1 blockade with anakinra in patients with ST-segment elevation acute myocardial infarction on recurrent ischemic events: results from the VCUART3 study

Background

ST-segment elevation myocardial infarction (STEMI) is associated with an intense acute inflammatory response and an increased risk of recurrent ischemic events. Prior studies of IL-1 blockade have shown conflicting results regarding the risk of future events.

Methods

We enrolled patients with STEMI within 12 hours of presentation at 3 sites in the United States of America. After revascularization, patients were randomly assigned to receive anakinra 100 mg twice daily, anakinra 100 mg once daily (standard dose) alternated with placebo once daily every 12 hours, or placebo every 12 hours for 14 days in 1:1:1 ratio. Prespecified exploratory endpoints for recurrent ischemic events, adjudicated by an independent committee, evaluated the composite risk of subsequent acute myocardial infarction (AMI, World Health Organization classification Type 1), unstable angina, or urgent revascularization. Data are expressed as median and interquartile range or number and percentage. Cox regression analysis was used to generate unadjusted hazard ratios and confidence intervals. (ClinicalTrials.gov number, NCT01950299)

Results

Of 311 patients screened, 99 subjects (81% males, 58% Caucasians, 55 [49–62] years of age) were randomly assigned to anakinra twice daily (N=31), anakinra once daily (N=33) or placebo (N=35). The cohort included patients with hypertension (57%), tobacco use (55%), diabetes mellitus (30%), and prior diagnosis of coronary artery disease (21%) without statistically significant imbalances in the demographic characteristics between groups (all P>0.05). Discharge medications for the index STEMI admission, in addition to the study medication, included aspirin (100%), statins (100%), P2Y12 inhibitors (100%), beta-blockers (90%), and angiotensin converting enzyme inhibitor/angiotensin receptor blocker (84%), without statistically significant imbalances between the 3 groups. Over the 1-year follow-up, recurrent ischemic events occurred in 5/35 (14.3%) patients treated with placebo and 6/64 (9.1%) patients treated with anakinra (hazard ratio = 0.68 [0.20–2.24], P=0.53). No differences were observed between high- and low-dose anakinra treatment groups.

Conclusions

A two week treatment with IL-1 receptor antagonist, anakinra, did not significantly decrease or increase recurrent ischemic events over the course of a 1-year follow-up in patients with STEMI.

Acknowledgement/Funding

Funded by NHLBI 1R34HL121402; Drug supply by Swedish Orphan Biovitrum

5233Interleukin-1 blockade with Anakinra in ST-segment elevation acute myocardial infarction: Results from the VCUART3 study

Background

ST-segment elevation myocardial infarction (STEMI) is associated with an intense inflammatory response that predicts an increased risk of death and heart failure (HF). In the current study we tested whether anakinra, a recombinant Interleukin-1 (IL-1) receptor antagonist, given once daily (standard dose) or twice daily reduced systemic inflammation in patients with STEMI.

Methods

We enrolled patients with STEMI within 12 hours of presentation at 3 sites. After revascularization, patients were randomly assigned to receive anakinra 100 mg twice daily, anakinra 100 mg once daily alternating with placebo once daily every 12 hours, or placebo twice daily, for 14 days in a 1:1:1 ratio. The primary efficacy outcome was the area under the curve for C-reactive protein levels (CRP-AUC) using a high-sensitivity assay at 14 days comparing anakinra (both arms) versus placebo followed by a comparison between each of the anakinra arms with placebo. Two pre-specified exploratory clinical efficacy endpoints, adjudicated by a blinded event committee, were assessed: a composite endpoint of all-cause death for any reason or incidence of HF (defined as new-onset HF requiring hospitalization or a new prescription of a loop diuretic, D+HF) and a composite endpoint of death and HF hospitalization (D+HHF) at 1 year. Data are expressed as median and interquartile range or number and percentage. Kaplan-Meyer survival curves were compared using Log-rank test (Mantel-Cox). (ClinicalTrials.gov number, NCT01950299)

Results

Of 311 patients screened, 99 subjects (80 [81%] males, 57 [58%] Caucasians, 55 [49–62] years of age) were randomly assigned to anakinra twice daily (N=31), anakinra once daily (N=33) or placebo (N=35). There were no significant imbalances in the demographic characteristics between groups (all P>0.05). The CRP-AUC was significantly lower in the anakinra group than in the placebo group (67 [39–120] versus 214 [131–394] mg/dl, P<0.001; and P<0.001 for each anakinra arm versus placebo separately, without significant differences between the two anakinra arms, P=0.41). Treatment with anakinra was associated with a significant reduction versus placebo in the incidence of D+HF (6/64 [9.4%] versus 9/35 [25.7%], P=0.046), and of D+HHF (0/64 [0] versus 4/35 [11.4%], P=0.011), without any significant difference between the two anakinra arms. Anakinra was not associated with any treatment-related serious adverse events, nor with excess infections compared with placebo (14.1% vs 14.3%, P=0.87).

Conclusions

Among patients with STEMI, IL-1 blockade significantly reduced the systemic inflammatory response compared with placebo, without any significant difference between standard or high dose regimens. Prespecified exploratory analyses on clinical endpoints demonstrate reduced incidence of HF and reduced HF hospitalizations, supporting the concept of beneficial effects with IL-1 blockade in patients with acute myocardial infarction.

Acknowledgement/Funding

Funded by NHLBI 1R34HL121402; Drug supply from Swedish Orphan Biovitrum

253Effects of Interleukin-1 blockade with Anakinra on cardiac function in ST-segment elevation acute myocardial infarction: results from the VCUART3 echocardiography study

Background

ST-segment elevation myocardial infarction (STEMI) is associated with an intense acute inflammatory response further promoting cardiac dysfunction and heart failure (HF). Pilot proof-of-concept studies with anakinra, recombinant Interleukin-1 (IL-1) receptor antagonist, have shown feasibility and safety of IL-1 blockade in patients with STEMI. In the current study we analyzed the effects of anakinra on left ventricular (LV) dimensions and function in patients with STEMI.

Methods

We enrolled patients with STEMI within 12 hours of presentation at 3 sites in the United States of America. After revascularization, patients were randomly assigned to receive anakinra 100 mg twice daily, anakinra 100 mg once daily alternated with placebo once daily every 12 hours, or placebo twice daily, for 14 days in a 1:1:1 ratio. A transthoracic echocardiogram was completed within 24 hours of admission and at 1 year follow up to measure LV end-diastolic and end-systolic volumes (LVEDV and LVESV, respectively), stroke volume (SV) and ejection fraction (LVEF). (ClinicalTrials NCT01950299)

Results

Paired echocardiography studies (follow up study obtained 362 days [336–375] after the baseline study) were available in 63 of the 99 patients (63%): 23 of 35 patients in the placebo group (66%) and 40 of the 64 patients in the anakinra group (62%, P>0.05 for missing studies between the 2 groups; P>0.05 for duration of follow up). Baseline LVEDV, LVESV, SV and LVEF was not significantly different comparing placebo and anakinra (all P>0.05). Patients treated with anakinra had a significant improvement in LVEF from 49.8% (41.8–60.0%) to 54.0% (46.0–58.4%, P=0.028) and SV from 43.6 ml (37.6–52.1 ml) to 48.7 ml (40.9–62.5 ml, P=0.008), whereas no significant changes occurred within the placebo group (LVEF: from 51.7% [40.1–56.0%] to 53.5% [43.4–59.4%], P=0.25; SV: from 47.7 ml [40.1–56.8 ml], to 53.0 ml [44.9–57.4 ml], P=0.81). The between-groups differences, however, were not statistically significant. No significant changes were noted in LVEDV and LVESV in either group. The interval changes in CRP between admission and 72 hours, expression of the acute inflammatory response, inversely correlated with the LVEF at follow up (R=-0.30, P=0.026), with higher levels of CRP corresponding to lower LVEF values

Conclusions

A significant improvement in cardiac systolic function was seen in patients treated with IL-1 receptor antagonist, anakinra, following STEMI, and not in patients with placebo. Further studies are however required to determine whether the benefits of IL-1 blockade in the prevention and treatment of HF are mediated by the effects on cardiac function.

Acknowledgement/Funding

Funded by NHLBI 1R34HL121402; Drug supply from Swedish Orphan Biovitrum

5947Predictive role of C-reactive protein levels in patients with ST-segment elevation acute myocardial infarction for heart failure related events

Background

ST-segment elevation myocardial infarction (STEMI) is associated with an intense acute inflammatory response and an increased risk of death and heart failure (HF). C-reactive protein (CRP) is the inflammatory biomarker most commonly used for risk stratification in patients with cardiovascular diseases. CRP levels are known to rise and fall during STEMI in response to myocardial injury. In this study, we analyzed whether admission CRP or delayed CRP (measured at 72 hours after admission) held a greater predictive value for adverse HF events in patients with STEMI.

Methods

We analyzed data from the VCUART3 clinical trial enrolling 99 patients with STEMI within 12 hours of presentation at 3 sites in the United States of America treated with anakinra or placebo. CRP levels were measured with a high-sensitivity assay at time of admission and again at 72 hours later. A dedicated committee composed of individuals not involved in the conduct of the trial adjudicated HF events including a composite endpoint of death from any reason or incidence of HF defined as new-onset HF requiring hospital admission or a new prescription for a loop diuretic (D+HF) and a composite endpoint of death and HF hospitalization (D+HHF) at 1 year. We used a time-dependent Cox-regression analysis to determine the association of CRP at admission or at 72 hours with the outcomes of interest in univariate and multivariate analysis. Data are presented as median and interquartile range. (ClinicalTrials NCT01950299)

Results

CRP levels from admission and 72 hours were available in 90 and 87 subjects respectively and they increased from 4.6 [2.8–8.5] mg/L to 11.6 [4.6–24.5] mg/L (P<0.001). Both admission CRP (CRP0) and CRP at 72 hours (CRP72) were associated with the risk of D+HF (P=0.011 and <0.001, respectively) and of D+HHF (P=0.010 and P<0.001, respectively); however at multivariate analysis, only CRP72 remained significantly associated with the risk of D+HF (P=0.001) and D+HHF (P=0.004) while CRP0 was not. CRP72 significantly correlated with NTproBNP levels at 72 hours (NTproBNP72, Spearman rho R=+0.37, P=0.001). NTproBNP72 predicted D+HF (P=0.030) but not independently of CRP72 (P=0.096 for NTproBNP72 and P=0.007 for CRP72 at multivariate analysis including the 2 variables). NTproBNP72 did not predict D-HHF.

Conclusions

Among contemporary patients with STEMI, the levels of CRP at 72 hours after admission was superior to admission CRP levels for predicting the incidence of HF events, and independent of NTproBNP levels. Our results indicate the importance of the inflammatory response during STEMI, supporting the concept of inhibiting the inflammatory response as a therapeutic strategy.

Acknowledgement/Funding

Funded by NHLBI 1R34HL121402; Drug supply from Swedish Orphan Biovitrum

Pharmacologic strategies to reduce cardiovascular disease in type 2 diabetes mellitus: focus on SGLT-2 inhibitors and GLP-1 receptor agonists

Patients with type 2 diabetes mellitus (T2D) present an increased risk for cardiovascular (CV) complications. In addition to improvement in glycaemic control, glucose-lowering therapies, such as glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium-dependent glucose cotransporter (SGLT)-2 inhibitors, have been shown to significantly reduce CV events. In 2008, the US Food and Drug Administration mandated that all new glucose-lowering drugs undergo CV outcomes trials (CVOTs) to determine their CV safety. These trials have largely demonstrated no major CV safety concerns. Most notably, the GLP-1RAs and SGLT-2 inhibitors have been found to be not only safe, but also cardioprotective compared to placebo. The SGLT-2 inhibitors have opened a new perspective for clinicians treating patients with T2D and established CV disease in light of their 'pleiotropic' effects, specifically on heart failure, while GLP-1RAs seem to present more favourable effects on atherosclerotic events. In this review, we discuss the role of GLP-1RAs and SGLT-2 inhibitors to reduce CV risk in T2D patients and suggest an individualized therapeutic approach in this population based on the presence of metabolic and CV comorbidities.

Low complication rates in Minimally Invasive Plate Osteosynthesis (MIPO) for proximal humeral fractures at 5 years of follow-up

INTRODUCTION

Purpose of this study was to analyse the medium term follow-up of minimally invasive plate osteosynthesis (MIPO) for proximal humeral fractures in terms of postoperative shoulder function, radiological outcome and complications.

METHODS

76 consecutive patients with unstable proximal humeral fractures were treated using locking plate with a minimally invasive antero-lateral approach in two surgical centers. Constant score and radiographic evaluation of 74 patients were available at mean follow up of 5 years (minimum 4 years).

RESULTS

Mean Constant score was 74 (range to 28-100). Results were comparable in the two centers. Younger patients registered significantly higher scores (p < 0.05). 20 patients (27%) developed complications. Subacromial impingement occurred in 16,2% of cases for varus malreduction (6,7%) and for too proximal plate positioning (9,5%). Primary screws perforation (2,7%), secondary perforation due to cut-out (1,4%), avascular necrosis (AVN) of humeral head (1,4%), partial resorption of greater tuberosity (2,7%), secondary displacement of the greater tuberosity (2,7%) and stiffness (2,7%) were observed.

DISCUSSION AND CONCLUSIONS

Even at a medium term follow-up, MIPO for proximal humeral fractures ensured good and reproducible results for most common pattern of fractures. Major complications were lower respect to open procedures, because of soft tissue, deltoid muscle and circumflex vessels sparing.

Developing a tool to measure the reciprocal benefits that accrue to health professionals involved in global health

Research to date on global health collaborations has typically focused on documenting improvements in the health outcomes of low/middle-income countries. Recent discourse has characterised these collaborations with the notion of ‘reciprocal value’, namely, that the benefits go beyond strengthening local health systems and that both partners have something to learn and gain from the relationship. We explored a method for assessing this reciprocal value by developing a robust framework for measuring changes in individual competencies resulting from participation in global health work. The validated survey and evidence-based framework were developed from a comprehensive review of the literature on global health competencies and reciprocal value. Statistical analysis including factor analysis, evaluation of internal consistency of domains and measurement of floor and ceiling effects were conducted to explore global health competencies among diverse health professionals at a tertiary paediatric health facility in Toronto, Canada. Factor analysis identified eight unique domains of competencies for health professionals and their institutions resulting from participation in global health work. Seven domains related to individual-level competencies and one emphasised institutional capacity strengthening. The resulting Global Health Competency Model and validated survey represent useful approaches to measuring the reciprocal value of global health work among diverse health professionals and settings. Insights gained through application of the model and survey may challenge the dominant belief that capacity strengthening for this work primarily benefits the recipient individuals and institutions in low/middle-income settings.

Effect of di(2-ethylhexyl) phthalate on the neuroendocrine regulation of reproduction in adult male rats and its relationship to anxiogenic behavior: Participation of GABAergic system

The endocrine disruptor di-(2-ethylhexyl) phthalate (DEHP) is used in a variety of consumer products made with polyvinyl chloride and also in the manufacture of medical devices. DEHP disrupts reproductive tract development in an antiandrogenic manner and also may induce neurobehavioral changes. The aim of this study was to investigate the effects of chronic postnatal exposure to DEHP (30 mg/kg body weight/day, orally from birth to day 60) on the neuroendocrine regulation of the gonadal axis and its impact on the anxiety-like behavior in adult male rats, as well as the probable participation of the GABAergic system in these effects. DEHP produced a significant increase in plasmatic luteinizing hormone and follicle stimulating hormone, as well as significant testosterone decrease, accompanied with a decrease in hypothalamic gamma-aminobutyric acid (GABA) concentration. On the other hand, DEHP increased the anxiety-like behavior in the elevated plus maze test, evidenced by a significant decrease in the percentages of time spent in the open arms and the frequency in the open arm entries and a significant increase in the percentage of time spent in closed arms. Neuroendocrine and behavioral effects were reversed by GABA agonists, muscimol (2 mg/kg i.p. ) and baclofen (10 mg/kg i.p.). In conclusion, chronic DEHP postnatal exposure induced a disruption in the neuroendocrine regulation of the testicular axis in young adult male rats, and this effect was correlated with an anxiety-like behavior. Since GABA agonists reversed these effects, the results suggest that GABA could participate in the modulation of reproductive and behavioral DEHP effects.

Retroverted glenoid reconstruction using glenoid plate in reverse shoulder arthroplasty

PURPOSE

The objective of this study is to evaluate the clinical and radiological results of reverse shoulder arthroplasty (RSA) with glenoid plating in a consecutive series of patients affected by cuff tear glenohumeral arthropathy with glenoid retroversion >15°. We hypothesized that autologous humeral head graft may be better stabilized between the baseplate and the native glenoid surface with the use of a glenoid plate.

METHODS

Twenty consecutive patients affected by cuff tear arthropathy with glenoid retroversion >15° (B2 or C according to Walch classification) were enrolled in this study. To reconstruct the glenoid, a dedicated plate was used in addition to the standard reverse shoulder baseplate and the glenosphere. Clinical and radiological assessment was performed using constant score (CS), subjective shoulder value (SSV), X-rays and CT scan at 6, 12 and 24 months of follow-up. Healing and resorption of the graft and detection of the glenoid version were assessed.

RESULTS

Sixteen patients were available for final follow-up. The mean preoperative retroversion of the glenoid was 24°, while the post-op was 2° (p = 0.002). At 24 months of follow-up, mean CS and SSV were 61 and 70. Respect to preoperative scores, the results were statistically significant (p < 0.001). The last CT scan revealed: a complete healing of the graft in 100% of cases; graft resorption less than 25% in two patients (12.5%); glenoid retroversion of 4°. A negative statistically significant correlation was found between final CS and preoperative glenoid retroversion (0.039).

CONCLUSIONS

The present study reports the favorable outcomes of retroverted glenoid reconstruction with glenoid plates in RSA, an alternative method to address severe glenoid deficiency.

LEVEL OF EVIDENCE

Level IV, case series with no comparison group.

Immediate intensive mobilization compared with immediate conventional mobilization for the impacted osteoporotic conservatively treated proximal humeral fracture: a randomized controlled trial

PURPOSE

To select in a 2-year survey of proximal humerus fractures accessing the emergency department, a population of osteoporotic stable impacted fractures and to randomize them into two groups, one with an immediate intensive mobilization program and the other with an immediate conventional mobilization program.

METHODS

In emergency department, patients with clinical signs of shoulder girdle fracture were submitted to standard X-ray examination and CT scan. Patients with stable (absence of metaphyseal comminution or fifth fragment) osteoporotic (cortical bone thickness lower than 6 mm) impacted (Is any part of metaphysis or head impacted into the shaft? YES/NO) proximal humerus fractures were selected for randomization in one of the two groups. Group 1: early intensive mobilization; Group 2: early conventional mobilization. Functional and radiographic assessment was recorded at 3, 6 and 12 months of follow-up.

RESULTS

In the considered period, 120 patients were affected by a stable impacted osteoporotic proximal humerus fracture. At the final follow-up, 36 patients in group 1 and 39 patients in group 2 were available for statistical analysis. Functional and radiographic scores were comparable, with a trend of significance in favor of group 2. No fracture in any of the group showed significant loss of reduction respect to 6 months of follow-up. 4 (10%) and 1 (2.5%) patients in groups 1 and 2 were not compliant with the rehabilitation program (p = 0.037).

CONCLUSIONS

This randomized controlled trial showed that impacted osteoporotic proximal humerus fractures can be managed non-operatively with an early conventional rehabilitation program composed by 10 sessions of passive motion twice a week, followed by recovery of active range of motion for further 10 sessions thrice a week, while no advantage is given by a more aggressive rehabilitation regimen. Self-assisted exercises should be explained to patients to maximize the effects of the assisted program.

LEVEL OF EVIDENCE

Level 1, randomized controlled double-blinded trial.

Perceived reciprocal value of health professionals' participation in global child health-related work

Background

Leading children’s hospitals in high-income settings have become heavily engaged in international child health research and educational activities. These programs aim to provide benefit to the institutions, children and families in the overseas locations where they are implemented. Few studies have measured the actual reciprocal value of this work for the home institutions and for individual staff who participate in these overseas activities. Our objective was to estimate the perceived reciprocal value of health professionals’ participation in global child health-related work. Benefits were measured in the form of skills, knowledge and attitude strengthening as estimated by an adapted Global Health Competency Model.

Methods

A survey questionnaire was developed following a comprehensive review of literature and key competency models. It was distributed to all health professionals at the Hospital for Sick Children with prior international work experience (n = 478).

Results

One hundred fifty six health professionals completed the survey (34%). A score of 0 represented negligible value gained and a score of 100 indicated significant capacity improvement. The mean respondent improvement score was 57 (95% CI 53–62) suggesting improved overall competency resulting from their international experiences. Mean scores were >50% in 8 of 10 domains. Overall scores suggest that international work brought value to the hospital and over half responded that their international experience would influence their decision to stay on at the hospital.

Conclusions

The findings offer tangible examples of how global child health work conducted outside of one’s home institution impacts staff and health systems locally.

Electronic supplementary material

The online version of this article (doi:10.1186/s12992-017-0250-8) contains supplementary material, which is available to authorized users.

Interleukin-18 mediates cardiac dysfunction induced by western diet independent of obesity and hyperglycemia in the mouse

Obesity and diabetes are independent risk factors for heart failure and are associated with the consumption of diet rich in saturated fat and sugar, Western diet (WD), known to induce cardiac dysfunction in the mouse through incompletely characterized inflammatory mechanisms. We hypothesized that the detrimental cardiac effects of WD are mediated by interleukin-18 (IL-18), pro-inflammatory cytokine linked to cardiac dysfunction. C57BL/6J wild-type male mice and IL-18 knockout male mice were fed high-saturated fat and high-sugar diet for 8 weeks. We measured food intake, body weight and fasting glycemia. We assessed left ventricular (LV) systolic and diastolic function by Doppler echocardiography and cardiac catheterization. In wild-type mice, WD induced a significant increase in isovolumetric relaxation time, myocardial performance index and left ventricular end-diastolic pressure, reflecting an impairment in diastolic function, paired with a mild reduction in LV ejection fraction. IL-18 KO mice had higher food intake and greater increase in body weight without significant differences in hyperglycemia. Despite displaying greater obesity, IL-18 knockout mice fed with WD for 8 weeks had preserved cardiac diastolic function and higher left ventricular ejection fraction. IL-18 mediates diet-induced cardiac dysfunction, independent of food intake and obesity, thus highlighting a disconnect between the metabolic and cardiac effects of IL-18.

The amount of impaction and loss of reduction in osteoporotic proximal humeral fractures after surgical fixation

After surgical fixation, osteoporotic proximal humeral fractures often show high impaction and loss of reduction. This study aims at assessing the amount of impaction and loss of reduction at a short and medium follow-up. We found an alarming percentage of cases showing these complications in the first postoperative months.

INTRODUCTION

This study seeks to quantify the amount of humeral head impaction and loss of reduction in a consecutive series of osteoporotic proximal humerus fractures treated with a locking plate.

METHODS

A series of displaced proximal humerus fractures were prospectively treated with minimally invasive reduction and ostheosynthesis using a locking plate. Diagnosis and classification of fractures were based on X-ray examination and CT scan. Proximal humerus cortical bone thickness (CBTAVG) was studied to assess osteoporosis. Amount of loss of reduction and head fragment impaction were noted at 3 and 18 months of follow-up. Constant score was calculated at 6 and 18 months of follow-up.

RESULTS

Thirty-one osteoporotic fractures were studied. Most of the fractures (21, 67.7 %) had a CBTAVG of less than 4 mm. At 3 months of follow-up, 7 cases (22.5 %) had significant loss of reduction and the mean amount of impaction was 2.8 mm. At 18 months of follow-up, only 1 additional fracture showed loss of reduction and mean impaction was 3 mm (p < 0.05). At 6 months follow-up, the mean Constant score was 58 %; while at 18 months, it was 70 % (p = 0.02). Amount of impaction was significantly correlated to age of patients (p = 0.031), female sex (p = 0.011), CBTAVG (p = 0.019), and metaphyseal comminution (p = 0.013).

CONCLUSIONS

Osteoporotic proximal humerus fractures may present an important impaction and loss of reduction in the first 3 months after surgery even if treated with a rigid device and multiple head screws. Surgeons treating these osteoporotic fractures should be aware of these complications even when using a rigid device.

Vascular Targeting of a Gold Nanoparticle to Breast Cancer Metastasis

The vast majority of breast cancer deaths are due to metastatic disease. Although deep tissue targeting of nanoparticles is suitable for some primary tumors, vascular targeting may be a more attractive strategy for micrometastasis. This study combined a vascular targeting strategy with the enhanced targeting capabilities of a nanoparticle to evaluate the ability of a gold nanoparticle (AuNP) to specifically target the early spread of metastatic disease. As a ligand for the vascular targeting strategy, we utilized a peptide targeting alpha(v) beta(3) integrin, which is functionally linked to the development of micrometastases at a distal site. By employing a straightforward radiolabeling method to incorporate Technetium-99m into the AuNPs, we used the high sensitivity of radionuclide imaging to monitor the longitudinal accumulation of the nanoparticles in metastatic sites. Animal and histological studies showed that vascular targeting of the nanoparticle facilitated highly accurate targeting of micrometastasis in the 4T1 mouse model of breast cancer metastasis using radionuclide imaging and a low dose of the nanoparticle. Because of the efficient targeting scheme, 14% of the injected AuNP deposited at metastatic sites in the lungs within 60 min after injection, indicating that the vascular bed of metastasis is a viable target site for nanoparticles.

Exposure to a low dose of bisphenol A impairs pituitary-ovarian axis in prepubertal rats: effects on early folliculogenesis

The research work studies the effect of providing a low dose of bisphenol A (BPA), on the reproductive axis of prepubertal female rats. Wistar mated rats were treated with either 0.1% ethanol or BPA in their drinking water until their offspring were weaned on the 21 day of birth. The estimated average dose of exposure to dams was approximately 3μg/kg/day. The pups were sacrificed at the 30th day of life. Body weight at the moment of the sacrifice was significantly higher in the group exposed to BPA; ovarian weight and its relative weight were not modified. LH and estradiol levels increased significantly, meanwhile FSH ones showed no significant changes. The number of primary, secondary and atretic follicles increased and antral ones was decreased. Our results demonstrated that early exposure to a low dose of BPA disrupts the normal function of the reproductive axis in prepubertal female rats.

Bioavailability and biological effect of engineered silver nanoparticles in a forest soil

The extensive use of silver nanoparticles (SNPs) as antimicrobial in food, clothing and medicine, leads inevitably to a loss of such nanomaterial in soil and water. Little is known about the effects of soil contamination, in particular, on microbial cells, which play a fundamental ecological role. In this work, the impact of SNPs on forest soil has been studied, investigating eco-physiological indicators of microbial biomass and microbial diversity with culture-dependent and independent techniques. Moreover, SNPs bioavailability and uptake were assessed. Soil samples were spiked with SNPs at two different concentrations (10 and 100 μg g(-1)dw) and incubated with the relative controls for 30, 60 and 90 days. The overall parameters showed a significant influence of the SNPs on the soil microbial community, revealing a marked shift after 60 days of incubation.

Antiandrogenic effect of perinatal exposure to the endocrine disruptor di-(2-ethylhexyl) phthalate increases anxiety-like behavior in male rats during sexual maturation

Di-2-ethylhexyl phthalate (DEHP) is the most widely used phthalate to convey flexibility and transparency to plastic products made of polyvinyl chloride. It has been recognized as endocrine disruptor and associated with reproductive toxic effects. We examined the effects of perinatal exposure to DEHP on anxiety-like behavior, using the Elevated Plus Maze (EPM) test, in male and female rats at different stages of sexual development. Anxiety-like behavior was expressed as a) frequency of open arm entries over the total arm entries (% FEO); b) time spent in them compared with total time the animal stayed in the EPM (% TSO) and c) time spent in closed arms (TSC). Because DEHP has anti-androgenic action we also tested control and exposed immature male rats pretreated with testosterone. We found sex differences in behavior induced by DEHP; while male rats of 45 and 60 days of age showed a significant decrease in FEO and TSO percentages, as well as an increase in TSC, no changes were observed in anxiety-like behavior in perinatal DEHP exposed females at these ages of sexual maturation. In 60-day-old male rats, DEHP exposure produced a significant decrease in serum testosterone levels. Testosterone replacement was able to antagonize the adverse effects of DEHP exposure on LH, activating the negative feed-back mechanism of this steroid on reproductive axis, as well as increasing FEO and TSO percentages to similar values observed in the control group. These findings suggest that the anti-androgenic action of this chemical could be one possible mechanism underlie anxiogenic-like behavior produced by perinatal DEHP exposure in 60-day-old male rats.

The impact of aging on rotator cuff tear size

INTRODUCTION

The aim of our study was to establish if aging influences rotator cuff tear size.

PATIENTS AND METHODS

We studied 586 consecutive patients (280 M, 306 F) mean age 59 years old (range 46-73) who underwent arthroscopic rotator cuff repair. Tear size was determined during surgery. For the purpose of our study, patients were divided into two groups based on age older than 60 years. A multinomial logistic regression model was applied to explore the association between age older than 60 years and tear size. We used the ANCOVA method to determine whether the aging influences the severity of the tear. All analyses were adjusted for gender.

RESULTS

Age older than 60 years was associated with a twofold higher overall risk of tear occurrence (OR = 2.12, 95 % CI 1.44-3.01). While no association was detected between age older than 60 years and the probability of a small tear (OR = 0.58, 95 % CI 0.27-1.07), subjects older than 60 years were twice more likely to experience a large tear (OR = 2.29, 95 %CI 1.51-3.27) and three times more likely to experience a massive tear (OR = 3.09, 95 % CI 2.07-5.38) as opposed to younger subjects. Mean age significantly increased from small tear (53.8 years) to large tear (66.8 years) to massive tear (69.4 years) patients (ANCOVA: F(2, 437) = 16.487, p = 1.51 × 10(-7)).

DISCUSSION

We found a significantly older mean age in patients with a more severe tear. Our data provide and confirm evidence that aging is a significant risk factor for the occurrence and severity of rotator cuff tears.

Coracoid pain test: a new clinical sign of shoulder adhesive capsulitis

Patients with adhesive capsulitis were clinically evaluated to establish whether pain elicited by pressure on the coracoid area may be considered a pathognomonic sign of this condition. The study group included 85 patients with primary adhesive capsulitis, 465 with rotator cuff tear, 48 with calcifying tendonitis, 16 with glenohumeral arthritis, 66 with acromioclavicular arthropathy and 150 asymptomatic subjects. The test was considered positive when pain on the coracoid region was more severe than 3 points (VAS scale) with respect to the acromioclavicular joint and the anterolateral subacromial area. The test was positive in 96.4% of patients with adhesive capsulitis and in 11.1%, 14.5%, 6.2% and 10.6% of patients with the other four conditions, respectively. A positive result was obtained in 3/150 normal subjects (2%). With respect to the other four diseases, the test had a sensitivity of 0.96 and a specificity ranging from 0.87 to 0.89. With respect to controls, the sensitivity and specificity were 0.99 and 0.98, respectively. The coracoid pain test could be considered as a pathognomonic sign in physical examination of patients with stiff and painful shoulder.

Impact of the UV-B filter 4-(Methylbenzylidene)-camphor (4-MBC) during prenatal development in the neuroendocrine regulation of gonadal axis in male and female adult rats

4-(Methylbenzylidene)-camphor (4-MBC), a UV-B ray filter, is an endocrine disruptors (ED). Our goal was to study the effect of 4-MBC on the neuroendocrine parameters that regulate reproduction in adult female and male rats that received this disrupter during prenatal development. The 4-MBC was administered (sc) to female rats (FO) since pregnancy onset, in doses of 100mg/kg every other day. The litters (F1) were sacrificed at 70 days to determine gonadotrophin serum levels and also GnRH and the amino acids glutamate, aspartate and GABA release from the hypothalamus. The male litter rats (F1) present at adult age a decrease in serum LH and FSH concentration and so also GnRH, excitatory amino acids and GABA hypothalamic secretion. The female litters (F1) rats present at adult age an increase in serum LH and FSH concentration, whereas hypothalamic GnRH release was not modified. In these animals a significant increase of hypothalamic aspartate release as well as GABA secretion decrease were observed. Glutamate secretion was not modified. All these changes were accompanied by an advance (3 days) on the vaginal opening in 4-MBC rats group. In conclusion, prenatal administration of 4-MBC disrupts the gonadal axis in a sexual dimorphic mode that could be connected with the physiological sexual differences in the development of gonadotrophin secretion hypothalamic control mechanisms.

Regional variation in the neurochemical coding of the myenteric plexus of the human colon and changes in patients with slow transit constipation

There are differences in the structure and function between regions of the colon. In patients with slow transit constipation the activity of all regions is markedly slowed. Counts of colonic neurones in slow transit constipation have been semiquantitative and led to varying results. We have applied new methods of quantification of markers in whole mounts of the colonic myenteric plexus to compare density of innervation between regions and between normal patients and those undergoing resection for severe constipation. Whole mounts of colonic myenteric plexus were made from specimens removed for cancer treatment (controls) and cases of severe constipation. All neurones were labelled by anti-human neuronal protein antibodies. Neurones synthesizing acetyl choline were labelled for choline acetyltransferase (ChAT) and those for nitric oxide by antisera to nitric oxide synthase (NOS). Four populations of neurones were distinguished and quantified according to the two selective markers, ChAT and NOS. In the normal major populations were NOS alone (51% of ascending colon neurones and 44% of descending colon neurones) and ChAT alone (41% ascending colon, 48% descending colon). Nitric oxide synthase/ChAT and NOS-/ChAT-comprised only small populations. In all regions in severe constipation, the percentage of NOS-only colonic myenteric neurones was raised (54% ascending colon, 49% descending colon) and ChAT only was reduced (36% ascending colon, 42% descending colon). The other populations were not changed. Accurate quantification of neuronal populations in whole mounts of human colon reveals inter-regional differences in innervation and marked changes in innervation in cases of very severe constipation.