Fractures in older people - incidence, predictors and consequences

In older populations, fractures are common and the consequences of fractures may be serious both for an individual and for society. However, information is scarce about the incidence, predictors and consequences of fractures in population-based unselected cohorts including both men and women and a long follow-up. The objective of this study was to analyse the incidence and predictors of fractures as well as functional decline and excess mortality due to fractures, among 482 men and 695 women aged 65 or older in the municipality of Lieto, Finland from 1991 until 2002. In analyses, Poisson’s, Cox proportional Hazards and Cumulative Logistic regression models were used for the control of several confounding variables. During the 12-year follow-up with a total of 10 040 person-years (PY), 307 (26%) persons sustained altogether 425 fractures of which 77% were sustained by women. The total incidence of fractures was 53.4 per 1000 PY (95% confidence intervals [95% CI]: 47.9 - 59.5) in women and 24.9 per 1000 PY (95% CI: 20.4 - 30.4) in men. The incidence rates of fractures at any sites and hip fractures were associated with increasing age. No significant changes in the ageadjusted incidence rates of fractures were found in either gender during the 12-year follow-up. The predictors of fractures varied by gender. In multivariate analyses, reduced handgrip strength and body mass index (BMI) lower than 30 in women and a large number of depressive symptoms in men were independent predictors of fractures. A compression fracture in one or more thoracic or upper lumbar vertebras on chest radiography at baseline was associated with subsequent fractures in both genders. Lower body fractures independently predicted both short- (0-2 years) and long-term (up to 8 years) functional decline in mobility and activities of daily living (ADL) performance during the 8-year follow-up. Upper body fractures predicted decline in ADL performance during longterm follow-up. In the 12-year follow-up, hip fractures in men (Hazard Ratio [HR] 8.1, 95% CI: 4.4-14.9) and in women (HR 3.0, 95% CI: 1.9-4.9), and fractures at the proximal humerus in men (HR 5.4, 95% CI: 1.6-17.7) were independently associated with excess mortality. In addition, leisure time inactivity in physical exercise predicted independently both functional decline and excess mortality. Fractures are common among older people posing serious individual consequences. Further studies about the effectiveness of preventing falls and fractures as well as improving care and rehabilitation after fractures are needed.

Bioactive Glass in Lumbar Spondylodesis. A Pre-Clinical and Clinical Study

Bioactive glasses (BGs) form a group of synthetic, surface-active, composition-dependent, silica-based biomaterials with osteoconductive, osteopromotive, and even angiogenic, as well as antibacterial, properties. A national interdisciplinary research group, within the Combio Technology Program (2003–2007), developed a porous load-bearing composite for surgical applications made of BG 1–98 and polymer fibers. The pre-clinical part of this thesis focused on the in vitro and in vivo testing of the composite materials in a rabbit femur and spinal posterolateral fusion model. The femur model failed to demonstrate the previously seen positive effect of BG 1–98 on osteogenesis, probably due to the changed resorption properties of BG in the form of fibers. The spine study was terminated early due to adverse events. In vitro cultures showed the growth inhibition of human mesenchymal stems next to BG 1–98 fibers and radical pH changes. A prospective, long-term, follow-up study was conducted on BG–S53P4 and autogenous bone used as bone graft substitutes for instrumented posterolateral spondylodesis in the treatment of degenerative spondylolisthesis (n=17) and unstable burst fractures (n=10) during 1996–1998. The operative outcome was evaluated from X-rays and CT scans, and a clinical examination was also performed. On the BG side, a solid fusion was observed in the CT scans of 12 patients, and a partial fusion was found in 5 patients, the result being a total fusion rate in all fusion sites (n=41) 88% for levels L4/5 and L5/S1 in the spondylolisthesis group. In the spine fracture group, solid fusion was observed in five patients, and partial fusion was found in five resulting in a total fusion rate of 71% of all fusion sites (n=21). The pre-clinical results suggest that under certain conditions the physical form of BG can be more critical than its chemical composition when a clinical application is designed. The first long-term clinical results concerning the use of BG S53P4 as bone graft material in instrumented posterolateral spondylodesis seems to be a safe procedure, associated with a very low complication rate. BG S53P4 used as a stand-alone bone substitute cannot be regarded as being as efficient as AB in promoting solid fusion.

Implementation of a perioperative management protocol for patients undergoing orthopedic surgery

OBJECTIVE: To evaluate the initial results after the implementation of perioperative protocol in patients over 60 years of age undergoing surgical treatment for femur fractures.METHODS: We conducted a prospective study of patients older than 60 years who were hospitalized with femur fracture. They were operated under spinal anesthesia and analgesia by lumbar plexus blockade. Data evaluation was performed before arrival in the operating room during surgery, in the post-anesthesia recovery room and in the ward the next morning of the operation.RESULTS: 105 patients underwent various types of surgical corrections of the femur. The hospital stay ranged from three to 86 days. Fasting ranged from 9h15min to 19h30mn. Hypotension occurred in 5.7%. The duration of motor blockade ranged from 1h45min to 5h30imn. Maltodextrin feeding ranged from 50min to 3h45min and the time spent in the post-anesthetic care unit ranged from 50 minutes to 4 hours. Onset of oral intake in the ward ranged from 4hto 8h15min. The duration of anesthesia ranged from 14 to 33 hours. No patient required a urinary catheter, nor was transferred to the ICU. All patients were able to be discharged on the first postoperative day.CONCLUSION: The use of a protocol to accelerate the postoperative period may reduce the fasting time, length of hospital stay and provide faster i discharge n elderly patients with femur fractures.

Comparative analysis between identified injuries of victims of fall from height and other mechanisms of closed trauma

OBJECTIVE: To analyze the lesions diagnosed in victims of falls, comparing them with those diagnosed in other mechanisms of blunt trauma.METHODS: We conducted a retrospective study of trauma protocol charts (prospectively collected) from 2008 to 2010, including victims of trauma over 13 years of age admitted to the emergency room. The severity of injuries was stratified by the Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS). Variables were compared between the group of victims of falls from height (Group 1) and the other victims of blunt trauma (Group 2). We used the Student t, chi-square and Fisher tests for comparison between groups, considering the value of p <0.05 as significant.RESULTS: The series comprised 4,532 cases of blunt trauma, of which 555 (12.2%) were victims of falls from height. Severe lesions (AISe"3) were observed in the extremities (17.5%), in the cephalic segment (8.4%), chest (5.5%) and the abdomen (2.9%). Victims of Group 1 had significantly higher mean age, AIS in extremities / pelvis, AIS in the thoracic segment and ISS (p <0.05). The group 1 had significantly (p <0.05) higher incidence of tracheal intubation on admission, pneumothorax, hemothorax, rib fractures, chest drainage, spinal trauma, pelvic fractures, complex pelvic fractures and fractures to the upper limbs.CONCLUSION: Victims of fall from height had greater anatomic injury severity, greater frequency and severity of lesions in the thoracic segment and extremities.

Factors associated with fragility fractures in women over 50 years of age: a population-based household survey

PURPOSE: To analyze the prevalence of and factors associated with fragility fractures in Brazilian women aged 50 years and older. METHODS: This cross-sectional population survey, conducted between May 10 and October 31, 2011, included 622 women aged >50 years living in a city in southeastern Brazil. A questionnaire was administered to each woman by a trained interviewer. The associations between the occurrence of a fragility fracture after age 50 years and sociodemographic data, health-related habits and problems, self-perception of health and evaluation of functional capacity were determined by the χ2 test and Poisson regression using the backward selection criteria. RESULTS: The mean age of the 622 women was 64.1 years. The prevalence of fragility fractures was 10.8%, with 1.8% reporting hip fracture. In the final statistical model, a longer time since menopause (PR 1.03; 95%CI 1.01-1.05; p<0.01) and osteoporosis (PR 1.97; 95%CI 1.27-3.08; p<0.01) were associated with a higher prevalence of fractures. CONCLUSIONS: These findings may provide a better understanding of the risk factors associated with fragility fractures in Brazilian women and emphasize the importance of performing bone densitometry.

Spinal cord compression in cattle after the use of an oily vaccine

An outbreak of compressive myelopathy in cattle associated with the improper use of an oil vaccine is described. Neurological signs were observed in 25 out of 3,000 cattle after 60 days of being vaccinated against foot and mouth disease. The clinical picture was characterized by progressive paralysis of the hind limbs, difficulty in standing up, and sternal recumbency during the course of 2-5 months. A filling defect between the L1 and L3 vertebrae was seen through myelography performed in one of the affected animals. A yellow-gray, granular and irregular mass was observed in four necropsied animals involving the spinal nerve roots and epidural space of the lumbar (L1-L4) spinal cord; the mass was associated with a whitish oily fluid. This fluid was also found in association with necrosis of the longissimus dorsi muscle. Microscopic changes in the epidural space, nerve roots, and spinal musculature were similar and consisted of granulomas or pyogranulomas around circular unstained spaces (vacuoles). These spaces were located between areas of severe diffuse hyaline necrosis of muscle fibers and resembled the drops of oil present in the vaccine.

Morphology and topographic anatomy of the spinal cord of the red-footed tortoise (Geochelone carbonaria Spix, 1824)

The aim of this study was to describe the topography of the spinal cord of the red-footed tortoise to establish a morphological basis for applied research in anesthesiology and morphology. Six tortoises from the state of Maranhão (Brazil) that had died of natural causes were used. The common carotid artery was used to perfuse the arterial system with saline solution (heated to 37ºC) and to fix the material with a 20% formaldehyde solution. The specimens were then placed in a modified decalcifying solution for 72 hours to allow dorsal opening of the carapace with a chisel and an orthopedic hammer. Dissection of the dorsal musculature and sectioning of the vertebral arches were performed to access the spinal cord. The results revealed the spinal cord of G. carbonaria to be an elongated, whitish mass that reached the articulation between the penultimate and last caudal vertebrae. The cervical intumescence (Intumescentia cervicalis) was located between vertebral segments C5 and T1, whereas the lumbosacral intumescence (Intumescentia lumbalis) was located between T6 and Ca1.

Transitional cell carcinoma of urinary bladder with metastasis in lumbar vertebrae and spinal cord compression in an ocelot(Leopardus pardalis)

This paper reports a case of nonpapillary and infiltrative transitional cell carcinoma (TCC) of the urinary bladder with metastasis of lumbar vertebrae and spinal cord compression in an adult female ocelot (Leopardus pardalis), from the Mato Grosso state, Brazil. The ocelot had pelvic limb paralysis and skin ulcers in the posterior region of the body and was submitted to euthanasia procedure. At necropsy was observed a multilobulated and irregular shaped, yellowish to white nodule in the urinary bladder. The nodule had a soft consistency and arised from the mucosa of the urinary bladder extending throughout the muscular layers and the serosa. Nodules of similar appearance infiltrating the vertebral column the at L6 and L7 vertebrae with corresponding spinal canal invasion were also observed. The histological evaluation showed epithelial neoplastic proliferation in the urinary bladder with characteristics of nonpapillary and infiltrative TCC, with positive immunohistochemical staining for pancytokeratin, and strong immunostaining for cytokeratin of low molecular weight, and weak or absent labeling for high molecular weight cytokeratin. This is the first report of TCC of urinary bladder in ocelot in Brazil.

The Use of Nervous System Drugs and the Risk of Fractures in Old Adults

Hermostoon vaikuttavien lääkkeiden käyttö on yleistä iäkkäässä väestössä. Erityisen yleistä käyttö on pitkäaikaisessa laitoshoidossa asuvilla iäkkäillä. Hermostoon vaikuttavien lääkkeiden haittavaikutuksia on tutkittu paljon, ja useat hermostoon vaikuttavat lääkeaineryhmät on tunnistettu murtumien riskitekijöiksi. Aikaisemmin ei ole kuitenkaan tutkittu usean hermostoon vaikuttavan lääkkeen yhteiskäytön yhteyksiä murtuman riskiin 65 vuotta täyttäneillä. Väitöskirjatutkimuksessa havaittiin, että usean hermostoon vaikuttavan lääkeaineen yhtäaikainen käyttö oli hyvin yleistä Porin kaupunginsairaalan viidellä pitkäaikaisen laitoshoidon osastolla (n = 154) vuosien 2004 ja 2005 vaihteessa. Kolmasosa tutkituista käytti säännöllisesti kolmea tai useampaa hermostoon vaikuttavaa lääkettä samanaikaisesti. Kun huomioitiin myös tarvittaessa otettavat lääkkeet, vastaava luku oli 53 %. Tutkimuksessa havaittiin myös viitteitä lääkkeiden epäasianmukaisesta käytöstä, kun potilaiden käyttämiä lääkkeitä verrattiin heidän kognitiiviseen ja fyysiseen suorituskyynsä sekä asetettuihin diagnooseihin. Liedon kunnassa 1990-luvulla toteutettuun väestöpohjaiseen Liedon Iäkkäät -seurantatutkimukseen osallistui 1177 lietolaista 65 vuotta täyttänyttä. Lääkitystietoja sekä seuranta-aikana tapahtuneita murtumia analysoimalla havaittiin, että kahden tai useamman bentsodiatsepiinin sekä kahden tai useamman psykoosilääkkeen käyttö oli yhteydessä murtuman riskiin 65 vuotta täyttäneillä miehillä. Opioidin ja psykoosilääkkeen yhteiskäyttö sekä opioidin ja bentsodiatsepiinin yhteiskäyttö oli yhteydessä iäkkäiden miesten murtuman riskiin. Naisilla vastaavia tilastollisesti merkitseviä yhteyksiä ei havaittu. Väitöskirjatutkimuksen uusin osa-aineisto perustui Porissa vuosina 2009–2010 toteutetun Satauni-tutkimuksen aineistoon. Tutkimuksessa osoitettiin 89 potilaan aineistossa, että hallittu, yhden kuukauden aikana lääkärin ja hoitajan tuella toteutettu bentsodiatsepiinivieroitus paransi merkitsevästi 55 vuotta täyttäneiden naisten käden puristusvoimaa kuuden kuukauden seuranta-aikana. Vastaavaa yhteyttä ei havaittu miehillä. Bentsodiatsepiinivieroituksella ei ollut yhteyttä osallistujien tasapainotestin tulosten paranemiseen kuuden kuukauden seurantaaikana. Murtumilla on vakavia seurauksia sekä yksilötasolla että yhteiskunnallisesti iäkkäässä väestössä. Murtumien ehkäisy on hyvin tärkeää. Siinä tulee kiinnittää huomiota potilaan käyttämään lääkitykseen ja arvioida erityisesti usean hermostoon vaikuttavan lääkkeen yhteiskäytön tarpeellisuutta.

Fractures of the proximal femur: correlation with vitamin D receptor gene polymorphism

Fractures are the feared consequences of osteoporosis and fractures of the proximal femur (FPF) are those that involve the highest morbidity and mortality. Thus far, evaluation of bone mineral density (BMD) is the best way to determine the risk of fracture. Genetic inheritance, in turn, is one of the major determinants of BMD. A correlation between different genotypes of the vitamin D receptor (VDR) and BMD has been recently reported. On this basis, we decided to determine the importance of the determination of VDR genotype in the presence of an osteoporotic FPF in a Brazilian population. We studied three groups: group I consisted of 73 elderly subjects older than 65 years (78.5 ± 7.2 years) hospitalized for nonpathological FPF; group II consisted of 50 individuals older than 65 years (72.9 ± 5.2 years) without FPF and group III consisted of 98 young normal Brazilian individuals aged 32.6 ± 6.6 years (mean ± SD). Analysis of VDR gene polymorphism by restriction fragment length polymorphism (RFLP) was performed by PCR amplification followed by BsmI digestion of DNA isolated from peripheral leukocytes. The genotype distribution in group I was 20.5% BB, 42.5% Bb and 37% bb and did not differ significantly from the values obtained for group II (16% BB, 36% Bb and 48% bb) or for group III (10.2% BB, 47.6% Bb and 41.8% bb). No differences in genotype distribution were observed between sexes or between the young and elderly groups. We conclude that determination of VDR polymorphism is of no practical use for the prediction of FPF. Other nongenetic factors probably start to affect bone mass, the risk to fall and consequently the occurrence of osteoporotic fractures with advancing age.

Inflammatory response of the spinal cord to multiple episodes of blood-brain barrier disruption and toxic demyelination in Wistar rats

Multiple episodes of blood-brain barrier disruption were induced by sequential intraspinal injections of ethidium bromide. In addition to the barrier disruption, there was toxic demyelination and exposure of myelin components to the immune system. Twenty-seven 3-month-old Wistar rats received 2, 3 or 4 injections of 1 µl of either 0.1% ethidium bromide in normal saline (19 rats) or 0.9% saline (8 rats) at different levels of the spinal cord. The time intervals between the injections ranged from 28 to 42 days. Ten days after the last injection, all rats were perfused with 2.5% glutaraldehyde. The spinal sections were evaluated macroscopically and by light and transmission electron microscopy. All the lesions demonstrated a mononuclear phagocytic infiltrate apparently removing myelin. Lymphocytes were not conspicuous and were found in only 34% of the lesions. No perivascular cuffings were detected. In older lesions (38 days and older) they were found only within Virchow-Robin spaces. This result suggests that multiple blood-brain barrier disruptions with demyelination and exposure of myelin components to the immune system were not sufficient to induce an immune-mediated reaction in the central nervous system.

Decreased gastric emptying and gastrointestinal and intestinal transits of liquid after complete spinal cord transection in awake rats

We studied the effect of complete spinal cord transection (SCT) on gastric emptying (GE) and on gastrointestinal (GI) and intestinal transits of liquid in awake rats using the phenol red method. Male Wistar rats (N = 65) weighing 180-200 g were fasted for 24 h and complete SCT was performed between C7 and T1 vertebrae after a careful midline dorsal incision. GE and GI and intestinal transits were measured 15 min, 6 h or 24 h after recovery from anesthesia. A test meal (0.5 mg/ml phenol red in 5% glucose solution) was administered intragastrically (1.5 ml) and the animals were sacrificed by an iv thiopental overdose 10 min later to evaluate GE and GI transit. For intestinal transit measurements, 1 ml of the test meal was administered into the proximal duodenum through a cannula inserted into a gastric fistula. GE was inhibited (P<0.05) by 34.3, 23.4 and 22.7%, respectively, at 15 min, 6 h and 24 h after SCT. GI transit was inhibited (P<0.05) by 42.5, 19.8 and 18.4%, respectively, at 15 min, 6 h and 24 h after SCT. Intestinal transit was also inhibited (P<0.05) by 48.8, 47.2 and 40.1%, respectively, at 15 min, 6 h and 24 h after SCT. Mean arterial pressure was significantly decreased (P<0.05) by 48.5, 46.8 and 41.5%, respectively, at 15 min, 6 h and 24 h after SCT. In summary, our report describes a decreased GE and GI and intestinal transits in awake rats within the first 24 h after high SCT.

Axotomy increases NADPH-diaphorase activity in the dorsal root ganglia and lumbar spinal cord of the turtle Trachemys dorbigni

Seven days after transection of the sciatic nerve NADPH-diaphorase activity increased in the small and medium neurons of the dorsal root ganglia of the turtle. However, this increase was observed only in medium neurons for up to 90 days. At this time a bilateral increase of NADPH-diaphorase staining was observed in all areas and neuronal types of the dorsal horn, and in positive motoneurons in the lumbar spinal cord, ipsilateral to the lesion. A similar increase was also demonstrable in spinal glial and endothelial cells. These findings are discussed in relation to the role of nitric oxide in hyperalgesia and neuronal regeneration or degeneration.

Induction of Fos protein immunoreactivity by spinal cord contusion

The objective of the present study was to identify neurons in the central nervous system that respond to spinal contusion injury in the rat by monitoring the expression of the nuclear protein encoded by the c-fos gene, an activity-dependent gene, in spinal cord and brainstem regions. Rats were anesthetized with urethane and the injury was produced by dropping a 5-g weight from 20.0 cm onto the exposed dura at the T10-L1 vertebral level (contusion group). The spinal cord was exposed but not lesioned in anesthetized control animals (laminectomy group); intact animals were also subjected to anesthesia (intact control). Behavioral alterations were analyzed by Tarlov/Bohlman scores, 2 h after the procedures and the animals were then perfused for immunocytochemistry. The patterns of Fos-like immunoreactivity (FLI) which were site-specific, reproducible and correlated with spinal laminae that respond predominantly to noxious stimulation or injury: laminae I-II (outer substantia gelatinosa) and X and the nucleus of the intermediolateral cell column. At the brain stem level FLI was detected in the reticular formation, area postrema and solitary tract nucleus of lesioned animals. No Fos staining was detected by immunocytochemistry in the intact control group. However, detection of FLI in the group submitted to anesthesia and surgical procedures, although less intense than in the lesion group, indicated that microtraumas may occur which are not detected by the Tarlov/Bohlman scores. There is both a local and remote effect of a distal contusion on the spinal cord of rats, implicating sensory neurons and centers related to autonomic control in the reaction to this kind of injury.

Substance P immunoreactivity in the lumbar spinal cord of the turtle Trachemys dorbigni following peripheral nerve injury

Immunoreactive substance P was investigated in turtle lumbar spinal cord after sciatic nerve transection. In control animals immunoreactive fibers were densest in synaptic field Ia, where the longest axons invaded synaptic field III. Positive neuronal bodies were identified in the lateral column of the dorsal horn and substance P immunoreactive varicosities were observed in the ventral horn, in close relationship with presumed motoneurons. Other varicosities appeared in the lateral and anterior funiculi. After axotomy, substance P immunoreactive fibers were reduced slightly on the side of the lesion, which was located in long fibers that invaded synaptic field III and in the varicosities of the lateral and anterior funiculus. The changes were observed at 7 days after axonal injury and persisted at 15, 30, 60 and 90 days after the lesion. These findings show that turtles should be considered as a model to study the role of substance P in peripheral axonal injury, since the distribution and temporal changes of substance P were similar to those found in mammals.