This case presents a discussion of a frail 98-year-old woman in hospice care, with a history of dementia, previous hip fracture, and anemia, who is admitted with a left intertrochanteric fracture. Care is coordinated and expedited by an interdisciplinary team to optimize her outcome, in the context of her goals of care.
dementia; fragility fractures; metabolic bone disorders; geriatric medicine; osteoporosis
Older adults who sustain hip fractures usually have multiple coexisting medical problems that may impact their treatment and outcomes. The geriatric fracture center (GFC) provides a model of care that standardizes treatment and optimizes outcomes. The purpose of this study is to determine whether GFC patients with a higher burden of comorbidity or specific comorbidities are at risk for worsened perioperative outcomes, such as increased time to surgery (TTS), postoperative complications, and longer length of hospital stay (LOS).
A total of 1077 patients aged 60 years and older who underwent surgery for a proximal femur fracture between April 15, 2005, and September 30, 2010, were evaluated. Comorbidities measured in the Charlson Comorbidity index were abstracted through chart review. Outcomes were TTS, postoperative complications, and LOS.
Most patients were white, with an average age of 85. One half lived in either a nursing home or an assisted living facility. The mean Charlson score was 3.06 and the nursing home residents had a significantly higher score compared to community dwellers (3.4 vs 2.8; P < .0001). Dementia was the most common comorbidity. There was no difference in the LOS or TTS based on Charlson score. The overall complication rate was 44% with delirium being the most common postoperative complication. Peripheral vascular disease, history of solid tumor, and peptic ulcer disease predicted delirium incidence. Charlson score predicted complication risk, with an odds ratio of 1.12 for each point increase.
Frailty and comorbidity put this hip fracture population at high risk for adverse perioperative outcomes. This study shows that in the GFC model of care the comorbidity burden did not impact the TTS and LOS but did predict postoperative complication rate.
hip fractures; dementia; comorbidity; model of care; perioperative outcomes
This case presents a discussion of an 80-year-old woman with severe pulmonary hypertension (PH) on chronic intravenous treprostinil infusion and oxygen therapy who presents with a subcapital hip fracture. Care is closely coordinated by an interdisciplinary team, including her PH specialist, in order to optimize her outcome.
pulmonary hypertension; comanagement; palliative care; comorbidity
Hip fractures in older adults are common and serious events. Patients who sustain fragility hip fractures are defined as having osteoporosis. Patients with dementia or a history of a prior fragility fracture are at increased risk of a future fracture. This study assesses prefracture osteoporosis diagnosis and treatment in high-risk groups.
A case–control analysis of a database of all patients age ≥60 years admitted for surgical repair of nonpathological, low-impact femur fracture between May 2005 and October 2010 was performed.
Of 1070 patients, 511 (47.8%) had dementia and 435 (40.7%) had been diagnosed with osteoporosis prior to admission. Patients with dementia were more likely to have a diagnosis of osteoporosis prior to their fracture than those without dementia (43.8% vs 37.7%, P < .05). Twenty-five percent of the total study population had been treated with calcium and vitamin D (Cal+D) prior to admission, and 12% with other osteoporosis medications. There was a trend toward patients with dementia being more likely to have been on Cal+D prior to admission (27.6% vs 22.5%, P = .06), but no difference in treatment with other agents (10.8% vs 13.1%, P = .25). Patients with prior fragility fractures were more likely to be on Cal+D (32.3% vs 25.0%, P < .02); however, there was no difference in the use of other osteoporosis medications (12.3% vs 12%, P = .90).
Fewer than half of patients that presented with hip fractures were diagnosed with osteoporosis prior to fracture and primary preventative treatment rates were low. Although patients with dementia are more likely to be diagnosed with osteoporosis, they were not more likely to be treated, despite having a greater risk. Additionally, those with prior fragility fractures are often not on preventative treatment. This may represent a missed opportunity for prevention and room for improvement in order to reduce osteoporotic hip fractures.
dementia; fragility fractures; geriatric medicine; osteoporosis; metabolic bone disorders; hip fracture
Introduction: There has been a recent increase in interest in implementing organized geriatric fracture programs for care of older adults with fragility fractures in order to improve both the quality and costs of care. Because such programs are relatively new, there are no standardized methods for implementation and no published descriptions of barriers to implementation. Materials and Methods: An online survey tool was sent to 185 surgeons and physicians practicing in the United States, who are involved with geriatric fracture care. Sixty-eight responses were received and evaluated. Results: Barriers identified included lack of medical and surgical leadership, need for a clinical case manager, lack of anesthesia department support, lack of hospital administration support, operating room time availability, and difficulty with cardiac clearance for surgery. Other issues important to implementation included quality improvement, cost reductions, cost to the hospital, infection prevention, readmission prevention, and dealing with competing interest groups and competing projects mandated by the government. Physicians and surgeons felt that a site visit to a functioning program was most important when considering implementing a hip fracture program. Conclusions: This study provides useful insights into barriers to implementing an organized hip fracture program. The authors offer suggestions on ways to mitigate or overcome these barriers.
fragility fractures; systems of care; geriatric fracture program; orthogeriatrics; barriers; implementation science
Spouses and partners (“partners”) of women at-risk for (“previvors”) and surviving with hereditary breast/ovarian cancer are a primary source of support within their families. Yet, little is known about partners’ needs for psychoeducational intervention to enhance their cancer risk knowledge, coping, and support role functioning.
To determine the type and range of need for psychoeducational intervention among partners of hereditary breast cancer previving and surviving women, and to understand the potential role of the Internet and other communication channels in meeting that need.
We conducted a secondary data analysis on partners’ needs that were originally assessed via an online community-based organization devoted to hereditary breast cancer. Partners’ demographic characteristics, need for psychoeducation, and likelihood of using various communication channels were assessed along with other constructs. Analyses examined commonly-occurring clusters of likely intervention use and by communication channel.
Partners (n =143) endorsed a moderately high level of need for psychoeducation and did so across multiple content areas (e.g., role functioning, decision making, communication, intimacy). Factor analysis identified three commonly-preferred communication channels: 1) self-help materials, 2) online interactions, and 3) interpersonal interactions. A cluster analysis among these factors identified three groups of partners based on their likelihood of psychoeducational intervention use (low [18%], moderate [55%], and high [27%] users). In a covariate-adjusted MANOVA, moderate and high intervention users reported significantly greater need for psychoeducation compared to low users (F2,132 = 9.15, P < .001).
A majority of assessed partners perceived a need for psychoeducational interventions surrounding hereditary breast cancer risk. Internet-based, interactive resources may be an efficient mechanism to reach large numbers of partners with tailored content. Research is warranted to inform the design and deployment of these resources to ensure quality and high impact, and ultimately to examine ways to integrate these resources into clinical care.
Breast cancer; hereditary cancer; social support; psychoeducation; psychosocial intervention
This case presents a discussion of a 92-year-old man with multiple comorbidities, who presents with a subtrochanteric fracture. His course is complicated by large volume blood loss intraoperatively, requiring intensive care unit (ICU) monitoring postoperatively. His course is also complicated by delirium.
dementia; delirium; fragility fractures; systems of care; physical therapy
Hip fractures and dementia increase exponentially with age, and patients who are afflicted by both conditions suffer significant morbidity and mortality. The aging of our population heightens the need to recognize the interaction of these conditions in order to improve our efforts to prevent hip fractures, provide acute care that improves outcomes, and provide secondary prevention and rehabilitation that returns patients to their previous level of functioning. Identification and treatment of vitamin D deficiency and osteoporosis and assessment and interventions to reduce falls in patients with dementia can significantly impact the incidence of first and subsequent hip fractures. Acute management of hip fractures that focuses on comanagement by orthopedic surgeons and geriatricians and uses protocol-driven geriatric-focused care has been shown to decrease mortality, length of hospitalization, readmission rates, and complications including delirium. Patients with mild-to-moderate dementia benefit from intensive geriatric rehabilitation to avoid nursing home placement. Recognizing the need to optimize primary and secondary prevention of hip fractures in patients with dementia and educating providers and families will lead to improved quality of life for patients affected by dementia and hip fractures.
dementia; fragility fractures; prevention; practice patterns; hip fractures; comanagement
Dementia and hip fractures are 2 conditions that are seen primarily in older adults, and both are associated with substantial morbidity and mortality. An individual with dementia is up to 3 times more likely than a cognitively intact older adult to sustain a hip fracture. This may occur via several mechanisms, including (1) risk factors that are common to both outcomes; (2) the presence of dementia increasing hip fracture incidence via intermediate risk factors, such as falls, osteoporosis, and vitamin D; and (3) treatment of dementia causing side effects that increase hip fracture risk. We describe a model that applies these 3 mechanisms to explain the relationship between dementia and hip fractures. Comprehensive understanding of these pathways and their relative influence on the outcome of hip fracture will guide the development of effective interventions and potentially improve prevention efforts.
multimorbidity; pathogenesis; cognitive impairment; Alzheimer disease; fragility fractures
The increasing availability of personal genomic tests has led to discussions about the validity and utility of such tests and the balance of benefits and harms. A multidisciplinary workshop was convened by the National Institutes of Health and the Centers for Disease Control and Prevention to review the scientific foundation for using personal genomics in risk assessment and disease prevention and to develop recommendations for targeted research. The clinical validity and utility of personal genomics is a moving target with rapidly developing discoveries but little translation research to close the gap between discoveries and health impact. Workshop participants made recommendations in five domains: (1) developing and applying scientific standards for assessing personal genomic tests; (2) developing and applying a multidisciplinary research agenda, including observational studies and clinical trials to fill knowledge gaps in clinical validity and utility; (3) enhancing credible knowledge synthesis and information dissemination to clinicians and consumers; (4) linking scientific findings to evidence-based recommendations for use of personal genomics; and (5) assessing how the concept of personal utility can affect health benefits, costs, and risks by developing appropriate metrics for evaluation. To fulfill the promise of personal genomics, a rigorous multidisciplinary research agenda is needed.
behavioral sciences; epidemiologic methods; evidence-based medicine; genetics; genetic testing; genomics; medicine; public health
Comanagement of geriatric hip fracture patients with standardized protocols has been shown to improve short-term outcomes after surgery. A standardized, patient-centered, comanaged Hip Fracture Program for Elders is examined for 1-year mortality. Patients ≥60 years of age who were treated in the Hip Fracture Program for Elders were comanaged by orthopaedic surgeons and geriatricians. Data including age, place of origin, procedure, length of stay, 1-year mortality, Charlson score, and activities of daily living (ADLs) were retrospectively collected. A total of 758 patients ≥60 years of age with hip fractures between April 15, 2005, and March 1, 2009, were included. Their data were analyzed, and the Social Security Death Index and the hospital data system were searched for mortality data. Seventy-eight percent were female, with a mean age of 84.8 years. The mean Charlson score was 3. Fifty percent were admitted from an institutional setting. The overall 1-year mortality was 21.2%. Age (odds ratio [OR] = 1.03, 95% confidence interval [CI] = 1.00-1.05; P = .02), male gender (OR = 1.55, 95% CI = 1.01-2.36; P = .04), low Parker mobility score (OR = 2.94, 95% CI = 1.31-6.57; P = .01), and a Charlson score of 4 or greater (OR = 2.15, 95% CI = 1.30-3.55; P = .002) were predictive of 1-year mortality. ADL dependence was a borderline predictor, as was medium Parker mobility score. Prefracture residence and moderate comorbidity (Charlson score of 2-3) were not independently predictive of mortality at 1 year after adjusting for other characteristics. A comprehensive comanaged hip fracture program for elders not only improves the short-term outcomes but also demonstrates a low 1-year mortality rate, particularly in patients from nursing facilities.
geriatric trauma; systems of care; fragility fractures; hip; fractures; mortality
Objective: This study describes the financial impact of an organized hip fracture program for elderly patients age 65 years and older. Methods: This is a retrospective study of 797 fractures in 776 consecutive patients over a 50-month period (May 2005 to July 2009) treated in an organized hip fracture program for the elderly identified from a quality management database. Financial, demographic, and quality-of-care data were collected. The length of hospital stay, in-hospital complications, and Charlson comorbidity scores were collected from patient records, and all data were evaluated using standard statistical methods. Setting: 261-bed community-based, university-affiliated teaching hospital in an urban setting with a catchment area of approximately 1 million persons. This is a level 3 trauma center. Results: The average total net revenue per hip fracture was $12 159, with an average total cost to hospital of $8264. Physicians' fees consisted of fees collected by surgeons, anesthesiologists, medical specialty consultants, and consulting geriatricians and averaged $2024 per case. Thus, the average hospital charge to payers was $15 188. Compared to Agency for Healthcare Research and Quality average inpatient hospital costs in 2005 of $33 693, a savings of more than $18 000 was realized per patient. The average length of stay was 4.6 days, markedly less than the national average of 6.2 days. Conclusions: This organized geriatric fracture care model with geriatrics comanagement resulted in significant cost savings over a 50-month period, with associated increased quality. With an estimated 330 000 hip fractures annually in the United States, a large cost savings could potentially be realized if this model were more widely applied.
economics of medicine; fragility fractures; geriatric trauma; systems of care; hip fractures; costs of care
Anaplastic thyroid cancer (ATC) is one of the most lethal human malignancies. Its rapid onset and resistance to conventional therapeutics contribute to a mean survival of six months after diagnosis and make the identification of thyroid-cancer-initiating cells increasingly important.
In prior studies of ATC cell lines, CD133+ cells exhibited stem-cell-like features such as high proliferation, self-renewal and colony-forming ability in vitro. Here we show that transplantation of CD133+ cells, but not CD133− cells, into immunodeficient NOD/SCID mice is sufficient to induce growth of tumors in vivo. We also describe how the proportion of ATC cells that are CD133+ increases dramatically over three months of culture, from 7% to more than 80% of the total. This CD133+ cell pool can be further separated by flow cytometry into two distinct populations: CD133+/high and CD133+/low. Although both subsets are capable of long-term tumorigenesis, the rapidly proliferating CD133+/high cells are by far the most efficient. They also express high levels of the stem cell antigen Oct4 and the receptor for thyroid stimulating hormone, TSHR. Treating ATC cells with TSH causes a three-fold increase in the numbers of CD133+ cells and elicits a dose-dependent up-regulation of the expression of TSHR and Oct4 in these cells. More importantly, immunohistochemical analysis of tissue specimens from ATC patients indicates that CD133 is highly expressed on tumor cells but not on neighboring normal thyroid cells.
To our knowledge, this is the first report indicating that CD133+ ATC cells are solely responsible for tumor growth in immunodeficient mice. Our data also give a unique insight into the regulation of CD133 by TSH. These highly tumorigenic CD133+ cells and the activated TSH signaling pathway may be useful targets for future ATC therapies.
Ongoing advances in stem cell research have opened new avenues for therapy for many human disorders. Until recently, however, thyroid stem cells have been relatively understudied. Here, we review what is known about thyroid stem cells and explore their utility as models of normal and malignant biological development. We also discuss the cellular origin of thyroid cancer stem cells and explore the clinical implications of cancer stem cells in the thyroid gland. Since thyroid cancer is the most common form of endocrine cancer and that thyroid hormone is needed for the growth and metabolism of each cell in the body, understanding the molecular and the cellular aspects of thyroid stem cell biology will ultimately provide insights into mechanisms underlying human disease.
To measure the prevalence of fear of falling in older adults at the time of long- term care (LTC) enrollment and identify potentially treatable risk factors for low fall related self-efficacy.
Prospective cohort study.
Three LTC programs in Upstate New York.
112 new enrollees in LTC, aged 55 or older, who passed a cognitive screen.
Self-reported falls, the falls efficacy scale (FES), medical conditions, the short geriatric depression scale, and physical performance measures (Berg balance scale, hip flexor, knee extensor and grip strength, gait speed and a six-minute walk).
Of the 54 subjects (48.2%) who reported fear of falling, 41 (75.9%) reported activity modification secondary to fear. Fearful subjects were more likely to be female (P=.003), report low back pain (P=.030) and lower extremity arthritis (P=.048). Fearful subjects were weaker at the hip (P<.001) and knee (P=.001), and had shorter six-minute walk distances. Subjects with better FES scores had better Berg scores (P<.001), had greater hip and knee strength, had faster gait speeds and walked further in six minutes (P<.001, P=.006, P=.001 and P=.001 respectively). Subjects with low FES scores and fearful subjects were more likely to have depressive symptoms (P=.003, P=.044, respectively).
Falls and fear of falling are more common in new LTC enrollees than in previously described community dwelling and SNF cohorts. Attention to associated characteristics like depression, arthritis, low back pain and lower extremity weakness may identify opportunities to reduce fear and improve patient safety during this transitional period.
accidental falls; fear of falling; long-term care; transitions of care
Mitochondrial DNA (MtDNA) with a neutral buoyant density of 1.681 g/cm3 has been isolated from unfertilized eggs of Drosophila melanogaster. This DNA is a circular molecule with an average length of 5.3 µm; it reassociates with a low C0t1/2 after denaturation, and in alkaline isopycnic centrifugation it separates into strands differing in density by 0.005 g/cm3. MtDNA isolated from purified mitochondria of unfertilized eggs or from total larval DNA melts with three distinct thermal transitions. The three melting temperature values suggest that the molecule may have three regions differing in average base composition. DNA isolated from unfertilized eggs of D. melanogaster contains approximately equal amounts of MtDNA and another DNA with a buoyant density of 1.697 g/cm3, slightly less dense than main peak DNA. The possibility that the heavier DNA fraction consists of amplified ribosomal DNA was excluded by hybridization experiments, but otherwise nothing is known of its origin or function.