Resting energy expenditure in non-ventilated, non-sedated patients recovering from serious traumatic brain injury: comparison of prediction equations with indirect calorimetry values.

BACKGROUND & AIMS: Little is known about energy requirements in brain injured (TBI) patients, despite evidence suggesting adequate nutritional support can improve clinical outcomes. The study aim was to compare predicted energy requirements with measured resting energy expenditure (REE) values, in patients recovering from TBI. METHODS: Indirect calorimetry (IC) was used to measure REE in 45 patients with TBI. Predicted energy requirements were determined using FAO/WHO/UNU and Harris-Benedict (HB) equations. Bland-Altman and regression analysis were used for analysis. RESULTS: One-hundred and sixty-seven successful measurements were recorded in patients with TBI. At an individual level, both equations predicted REE poorly. The mean of the differences of standardised areas of measured REE and FAO/WHO/UNU was near zero (-9 kcal) but the variation in both directions was substantial (range -591 to +573 kcal). Similarly, the differences of areas of measured REE and HB demonstrated a mean of 1.9 kcal and range -568 to +571 kcal. Glasgow coma score, patient status, weight and body temperature were significant predictors of measured REE (p<0.001; R(2)=0.47). CONCLUSIONS: Clinical equations are poor predictors of measured REE in patients with TBI. The variability in REE is substantial. Clinicians should be aware of the limitations of prediction equations when estimating energy requirements in TBI patients.

Factors affecting adherence to use of hip protectors amongst residents of nursing homes--a correlation study.

BACKGROUND: Hip protectors are protective pads designed to cover the greater trochanter and attenuate or disperse the force of a fall sufficiently to prevent a hip fracture. Promising results from randomised controlled trials in nursing homes have resulted in hip protectors being widely recommended in the health care literature and in national guidelines. OBJECTIVES: The objectives of the study were to identify characteristics of individual residents, and the organisational features of the homes in which they live, which may affect adherence to wearing hip protectors. DESIGN: An observational, correlation study designed to identify factors related to adherence. SETTING: Forty nursing and residential homes in the UK. PARTICIPANTS: 1346 residents of the homes who were not confined to bed and with no pressure sore on the hip. METHODS: The introduction of an evidence-based policy to offer Safehip hip protectors to residents free of charge and with support from a nurse facilitator. Adherence to wearing the hip protectors was observed over 72 weeks. RESULTS: Initial acceptance of the hip protectors was 37.2%. Continued adherence was 23.9% at 24 weeks; 23.2% at 48 weeks; and 19.9% at 72 weeks. Greater adherence was associated with the following individual resident characteristics: a greater degree of dependency (95% CI 1.39-3.78) and cognitive impairment (95% CI 1.01-2.98); being male rather than female (95% CI 1.06-2.48). Greater adherence was also associated with the following organisational characteristics of homes: fewer changes of senior manager during the study period (95% CI 1.01-8.51), and being resident in a home with a resident profile showing a greater proportion of residents with a higher degree of dependency (95% CI 1.04-1.27). There was wide a variation in the degree of success in implementation between homes (adherence of 0-100% at 24 weeks). CONCLUSIONS: Those implementing a policy of introducing hip protectors into nursing and residential homes should consider targeting residents with cognitive impairment. Such residents are at greater risk of hip fracture and appear to be more likely to continue wearing hip protectors. Those charged with implementing changes in practice or policy should consider how the context for implementation can be optimised to increase the likelihood of success.

Plasma fibrinogen and serum C-reactive protein are associated with non-small cell lung cancer.

OBJECTIVES: There is an association between coagulation and lung cancer. Therefore, pre-operative plasma fibrinogen and serum C-reactive protein (CRP) concentration were assessed to determine their association with tumour characteristics and to ascertain any role in patient selection for curative resection. METHODS: These parameters were compared with tumour size, pTNM stage, and possibility of complete resection in 93 patients with non-small cell lung cancer who underwent surgical resection. RESULTS: Plasma fibrinogen concentration (r(s)=0.34, P=0.001) and serum CRP concentration (r(s)=0.34, P=0.001) were positively correlated with maximum pathological tumour size. A higher plasma fibrinogen concentration was associated with squamous cell carcinoma versus adenocarcinoma (4.5+/-0.13 g/L versus 3.6+/-0.28 g/L; P=0.008), with a trend towards a similar association for CRP (P=0.06). Pathological T stage was also associated with mean plasma fibrinogen and serum CRP concentration (P=0.01 and 0.04, respectively), but pN stage was not associated with either parameter. Incomplete resection occurred in 23% of patients with plasma fibrinogen > 5 g/L or serum CRP > 40 mg/L (versus only 8% when fibrinogen < or = 5 g/L and CRP < or = 40 mg/L; P=0.09). CONCLUSIONS: Plasma fibrinogen and serum CRP are associated with tumour characteristics. High values were associated with inability to achieve complete resection which may refine patient selection for thoracotomy when used with other staging modalities. Attempted resection may be justified in a patient of borderline fitness who has favourable plasma fibrinogen and serum CRP concentration, where a high resection rate is possible. As the relationship was with T stage rather than N stage it may be complimentary to PET scanning, which has only marginally better accuracy for T stage than CT scanning.

Cathepsin S expression: An independent prognostic factor in glioblastoma tumours--A pilot study.

Cysteine proteinases have been implicated in astrocytoma invasion. We recently demonstrated that cathepsin S (CatS) expression is up-regulated in astrocytomas and provided evidence for a potential role in astrocytoma invasion (Flannery et al., Am J Path 2003;163(1):175-82). We aimed to evaluate the significance of CatS in human astrocytoma progression and as a prognostic marker. Frozen tissue homogenates from 71 patients with astrocytomas and 3 normal brain specimens were subjected to ELISA analyses. Immunohistochemical analysis of CatS expression was performed on 126 paraffin-embedded tumour samples. Fifty-one astrocytoma cases were suitable for both frozen tissue and paraffin tissue analysis. ELISA revealed minimal expression of CatS in normal brain homogenates. CatS expression was increased in grade IV tumours whereas astrocytoma grades I-III exhibited lower values. Immunohistochemical analysis revealed a similar pattern of expression. Moreover, high-CatS immunohistochemical scores in glioblastomas were associated with significantly shorter survival (10 vs. 5 months, p = 0.014). With forced inclusion of patient age, radiation dose and Karnofsky score in the Cox multivariate model, CatS score was found to be an independent predictor of survival. CatS expression in astrocytomas is associated with tumour progression and poor outcome in glioblastomas. CatS may serve as a useful prognostic indicator and potential target for anti-invasive therapy.

Impact of coronary artery bypass grafting on survival after aortic valve replacement.

Treatment of coronary artery disease by coronary artery bypass grafting (CABG) concurrently with aortic valve replacement (AVR) improves outcome but survival compared to isolated AVR remains uncertain, as does the role of the left internal mammary artery (LIMA) graft to the left anterior descending (LAD) artery. All 799 patients undergoing elective primary AVR, using the St. Jude Medical mechanical prosthesis, with or without CABG, between March 1986 and May 2000, were reviewed with 100% follow-up. Operative mortality was 1.6% in 574 patients undergoing isolated AVR, 2.6% in 78 patients undergoing combined AVR and CABG with LIMA to LAD grafting (LIMA-AVR), 6.25% in 64 patients receiving vein grafts only to circumflex or right coronary artery territories (Non-LAD VG-AVR) and 2.4% in 83 patients receiving vein grafts to vessels including the LAD (LAD VG-AVR). Cox regression analysis showed improved survival after AVR compared to LAD VG-AVR (P=0.008), but with no significant difference to survival after LIMA-AVR (P=0.18) and Non-LAD VG-AVR (P=0.08). Multivariable regression analysis identified advanced age (P<0.001), male sex (P<0.001), absence of diabetes (P=0.02), number of grafts performed during surgery (P=0.04), non-congenital valvular pathology (P=0.001) and regurgitant valve disease (P=0.008) as independent predictors of reduced survival. LIMA-LAD grafting was not a significant variable in the multivariable model.

The effect of type of hip protector and resident characteristics on adherence to use of hip protectors in nursing and residential homes--an exploratory study.

OBJECTIVES: To investigate the factors influencing the acceptability of hip protectors to residents of nursing and residential homes, especially the effect of hip protector type, and resident characteristics. DESIGN: A randomised controlled trial with 12 weeks follow-up. Participants were randomised to receive either Safehip or HipSaver hip protectors. SETTING/PARTICIPANTS: 109 residents aged 61 to 98 years from seven residential homes and two nursing homes in Northern Ireland. MAIN OUTCOME MEASURES: Percentage day-time use of the hip protectors over 12 weeks and ongoing use at 12 weeks. RESULTS: 42% (119/285) of residents invited to enter the study agreed to take part, and 109 started to wear the hip protectors. 43.1% (47/109) were still using them at 12 weeks. Mean percentage day-time use for all residents during 12 weeks was 48.6%. There was no significant difference in percentage day-time use (p=0.40), or use at 12 weeks (p=0.56) between the residents wearing Safehip and HipSaver protectors. Greater percentage daytime use of hip protectors was associated with being resident in a home for the elderly mentally infirm (75.1%, p

Tracking of physical activity, fitness, body composition and diet from adolescence to young adulthood: The Young Hearts Project, Northern Ireland.

BACKGROUND: The assumption that lifestyles formed early in life track into adulthood has been used to justify the targeting of health promotion programmes towards children and adolescents. The aim of the current study was to use data from the Northern Ireland Young Hearts Project to ascertain the extent of tracking, between adolescence and young adulthood, of physical activity, aerobic fitness, selected anthropometric variables, and diet. METHODS: Males (n 245) and females (n 231) were assessed at age 15 y, and again in young adulthood [mean (SD) age 22 (1.6) y]. At both timepoints, height, weight and skinfold thicknesses were measured, and physical activity and diet were assessed by questionnaire and diet history method respectively. At 15y, fitness was assessed using the 20 metre shuttle run, while at young adulthood, the PWC170 cycle ergometer test was used. For each measurement made at 15y, subjects were ranked into 'low' (L1; lowest 25%), 'medium' (M1; middle 50%) or 'high' (H1; highest 25%) categories. At young adulthood, similar categories (L2, M2, H2) were created. The extent of tracking of each variable over time was calculated using 3 x 3 matrices constructed using these two sets of categories, and summarised using kappa (kappa) statistics. RESULTS: Tracking of diet and fitness was poor (kappa

Fruit and vegetable consumption and bone mineral density: the Northern Ireland Young Hearts Project.

BACKGROUND: Studies examining the relation between bone mineral density (BMD) and fruit and vegetable consumption during adolescence are rare. OBJECTIVE: Our objective was to determine whether usual fruit and vegetable intakes reported by adolescents have any influence on BMD. DESIGN: BMD was measured by dual-energy X-ray absorptiometry at the nondominant forearm and dominant heel in a random sample of 12-y-old boys (n = 324), 12-y-old girls (n = 378), 15-y-old boys (n = 274), and 15-y-old girls (n = 369). Usual fruit and vegetable consumption was assessed by an interviewer-administered diet history method. Relations between BMD and fruit and vegetable intake were assessed by using regression modeling. RESULTS: Using multiple linear regression to adjust for the potential confounding influence of physical and lifestyle factors, we observed that 12-y-old girls consuming high amounts of fruit had significantly higher heel BMD (beta = 0.037; 95% CI: 0.017, 0.056) than did the moderate fruit consumers. No other associations were observed. CONCLUSION: High intakes of fruit may be important for bone health in girls. It is possible that fruit's alkaline-forming properties mediate the body's acid-base balance. However, intervention studies are required to confirm the findings of this observational study.

A cluster randomised controlled trial to evaluate a policy of making hip protectors available to residents of nursing homes.

OBJECTIVES: to evaluate the effectiveness of a policy of making hip protectors available to residents of nursing homes. DESIGN: a cluster randomised controlled trial of the policy in nursing and residential homes, with the home as the unit of randomisation. SETTING: 127 nursing and residential homes in the greater Belfast area of Northern Ireland. PARTICIPANTS: 40 homes in the intervention group (representing 1,366 occupied beds) and 87 homes in the control group (representing 2,751 occupied beds). INTERVENTIONS: a policy of making hip protectors available free of charge to residents of nursing homes and supporting the implementation process by employing a nurse facilitator to encourage staff in the homes to promote their use, over a 72-week period. MAIN OUTCOME MEASURES: the rate of hip fractures in intervention and control homes, and the level of adherence to use of hip protectors. RESULTS: there were 85 hip fractures in the intervention homes and 163 in the control homes. The mean fracture rate per 100 residents was 6.22 in the intervention homes and 5.92 in the control homes, giving an adjusted rate ratio for the intervention group compared to the control group of 1.05 (95% CI 0.77, 1.43, P = 0.76). Initial acceptance of the hip protectors was 37.2% (508/1,366) with adherence falling to 19.9% (272/1,366) at 72 weeks. CONCLUSIONS: making hip protectors available to residents of nursing and residential homes did not reduce the rate of hip fracture. This research does not support the introduction of a policy of providing hip protectors to residents of nursing homes.

Dislocation of the rotating platform after low contact stress total knee arthroplasty.

From a one-surgeon series of 2485 patients, we report on 10 patients with rotating platform dislocation after primary Low Contact Stress total knee arthroplasty. All dislocations occurred within 2 years of the index procedure. Of the 10 patients, nine required open reduction. Five of these patients also had exchange of the original insert. One patient was treated by closed reduction. All knees were immobilized in a cast for 8 weeks. Eight of the 10 patients had no additional dislocation and at followup (average, 35 months; range, 12 months-5 years), had a stable functional joint. Two patients had recurrent spinout of the rotating platform develop. One patient had arthrodesis whereas the other patient had the insert cemented to the tibial tray as a salvage procedure. Increasing age, a preoperative valgus deformity, and prior patellectomy were significantly associated with rotating platform spinout. Surgical experience and an improved understanding of the soft tissue constraints, particularly in the valgus knee, are important in minimizing this complication.

Trends in blood pressure over 10 years in adolescents: analyses of cross sectional surveys in the Northern Ireland Young Hearts project.

OBJECTIVE: To examine secular trends in blood pressure over a 10 year period between two representative cohorts of adolescents from Northern Ireland. DESIGN: Repeat cross sectional study. SETTING: Randomly selected post-primary schools from Northern Ireland. PARTICIPANTS: 1015 adolescents studied between 1989 and 1990, and 2017 adolescents studied between 1999 and 2001. Participants were aged 12 or 15 years. MAIN OUTCOME MEASURES: Systolic and diastolic blood pressure measured by one observer in each study. RESULTS: The four groups for sex and age showed decreases in both systolic blood pressure (mean decrease 7.7 mm Hg to 10.0 mm Hg) and diastolic blood pressure (8.8 mm Hg to 11.0 mm Hg). These decreases were not accounted for by adjustment for potential confounders including age, height, body mass index, smoking, physical activity, aerobic fitness, and stratification of school by education board area and type. The findings were not altered by additional adjustment for social class, pubertal status, birth weight, and infant feeding. No evidence was found of systematic variation between observers. CONCLUSIONS: Substantial decreases in systolic and diastolic blood pressure over the past decade in adolescents from Northern Ireland are likely to have important benefits to public health and may help offset the increasing risk of cardiovascular disease due to increases in obesity.