Preoperative CT improves the assessment of stability in trochanteric hip fractures.

Aims: To investigate if preoperative CT improves detection of unstable trochanteric hip fractures. Methods: A single-centre prospective study was conducted. Patients aged 65 years or older with trochanteric hip fractures admitted to Stavanger University Hospital (Stavanger, Norway) were consecutively included from September 2020 to January 2022. Radiographs and CT images of the fractures were obtained, and surgeons made individual assessments of the fractures based on these. The assessment was conducted according to a systematic protocol including three classification systems (AO/Orthopaedic Trauma Association (OTA), Evans Jensen (EVJ), and Nakano) and questions addressing specific fracture patterns. An expert group provided a gold-standard assessment based on the CT images. Sensitivities and specificities of surgeons' assessments were estimated and compared in regression models with correlations for the same patients. Intra- and inter-rater reliability were presented as Cohen's kappa and Gwet's agreement coefficient (AC1). Results: We included 120 fractures in 119 patients. Compared to radiographs, CT increased the sensitivity of detecting unstable trochanteric fractures from 63% to 70% (p = 0.028) and from 70% to 76% (p = 0.004) using AO/OTA and EVJ, respectively. Compared to radiographs alone, CT increased the sensitivity of detecting a large posterolateral trochanter major fragment or a comminuted trochanter major fragment from 63% to 76% (p = 0.002) and from 38% to 55% (p < 0.001), respectively. CT improved intra-rater reliability for stability assessment using EVJ (AC1 0.68 to 0.78; p = 0.049) and for detecting a large posterolateral trochanter major fragment (AC1 0.42 to 0.57; p = 0.031). Conclusion: A preoperative CT of trochanteric fractures increased detection of unstable fractures using the AO/OTA and EVJ classification systems. Compared to radiographs, CT improved intra-rater reliability when assessing fracture stability and detecting large posterolateral trochanter major fragments.

Improving the quality of the fracture liaison service through the implementation of a structured health record.

OBJECTIVE: According to the best practice framework for secondary fracture prevention, all patients aged ≥50 years with a fracture should be assessed for osteoporosis within the fracture liaison service (FLS). The framework includes an FLS quality registry database to ensure quality. The input of data into our FLS registry was time-consuming and required entering data twice: into both the journal record and the registry. A '3-in-1' solution was required: (1) developing a structured health record (SHR) to provide decision-support to FLS nurses during patient consultations; (2) making a structured journal record from the SHR and (3) exporting data to the quality registry database. The SHR needed to be web based, secure and available for use all over the world. DESIGN: One provider at Stavanger University Hospital met all the criteria for further development of the record (CheckWare). An interdisciplinary working group was established, following the Plan-Do-Study-Act working model. Depending on the answers given, the FLS nurses were provided decision-making support. A significant loss of height (≥4 cm) was highlighted as one of the process quality indicators. All clinically relevant data were summarised in a report, which was exported to the health record software. Data were exported to the FLS quality registry. RESULTS: All fracture patients in need of a dual-energy X-ray absorptiometry scan received an appointment at the FLS outpatient clinic and 96% attended. The minimum standard was met for the three quality indicators 1-3). In particular, the use of SHRs increased the number of patients investigated for vertebral fractures with a height loss ≥4 cm from 67% to 93%. CONCLUSION: The SHR was successful in regard to the '3-in-1' solution: providing decision support to FLS nurses, developing structured journal records and exporting data to the FLS quality registry. After implementation, all FLS registry quality indicators improved.

Excellent PROM results after fast-track hip and knee arthroplasty with no postoperative restrictions: a cohort study validation of fast-track surgery without postoperative restrictions.

BACKGROUND: Fast-track hip and knee arthroplasty (HA and KA) has been increasingly common over the last decade. In the same time period, there was a strong trend toward less restrictive mobilization. However, few reports have been published on combining these novel programs while measuring the postoperative results by patient-reported outcome measures (PROMs). Descriptions of fast-track surgery programs and their results are warranted. METHODS: The aim of this retrospective cohort study was to examine if it is possible to achieve excellent PROM results for hip and knee arthroplasty patients in a fast-track pathway without postoperative restrictions. During 2014-2017, the stepwise introduction of a PROM program was implemented at Stavanger University Hospital for all scheduled HA and KA patients, with preoperative assessments and postoperative follow-ups at the outpatient clinic. Standardized information with a focus on early mobilization and no postoperative restrictions was also initiated for the same patients. The generic EuroQol questionnaire (EQ-5D) and either the Hip or Knee disability/injury and Osteoarthritis Outcome Score (HOOS or KOOS) were used. RESULTS: PROM response rates varied from 80 to 99%. The median (interquartile range) change from preoperative to one-year postoperative results were as follows for HA and KA patients, respectively: pain, 55 (43-68) and 47 (31-61); other symptoms, 50 (40-65) and 36 (19-50); function in daily living, 54 (41-65) and 44 (31-55); function in sports and recreation, 56 (38-75) and 40 (15-64); joint-related quality of life, 69 (50-81) and 56 (38-75). The length of stay (LOS) was reduced by 1.9 days (mean), corresponding to a 40% reduction for HA patients and a 37% reduction for KA patients. CONCLUSIONS: We found excellent PROM results after fast-track HA and KA with no postoperative restrictions. We believe that a fast-track program focusing on mobilization without any postoperative restrictions is superior for most patients, but further comparative studies are warranted.

The co-use of conventional drugs and herbs among patients in Norwegian general practice: a cross-sectional study.

BACKGROUND: Different patient groups are known to use herbal remedies and conventional drugs concomitantly (co-use). This poses a potential risk of herb-drug interaction through altering the drug's pharmacokinetics or pharmacodynamics. Little is known about co-use among patients in general practice. The primary aim of this study was to compare patients in general practice that co-use herbal remedies and conventional drugs with those who do not. The secondary aim was to register the herb-drug combinations with potential clinical relevant interactions among the co-users. METHOD: A questionnaire based cross-sectional study conducted in the autumn 2011 in a general practice office with four general practitioners (GPs) and one intern in Western Norway. Adults >18 years who came for an office visit were invited. The questionnaire asked about demographics, herbal use, conventional drug use and communication about herbal use. Multivariable logistic regression was used to compare co-users to the other patients. RESULTS: Of the 381 patients who completed the questionnaire, the prevalence of herbal use was 44%, with bilberry (41%), green tea (31%), garlic (27%), Aloe vera (26%) and echinacea (18%) as the most frequently used. Among those using conventional drugs regularly, 108 (45%) co-used herbs. Close to 40% of patients on anticoagulants co-used herbs, with garlic and bilberry as the most frequent herbs. Compared to all other patients, co-users had significantly (p < 0.05) increased odds to be female (adjOR 2.0), age above 70 years (adjOR 3.3), use herbs to treat an illness (adjOR 4.2), use two or more herbs (polyherbacy, adjOR 12.1) and having experienced adverse effects of herbal use (adjOR 37.5). Co-use was also associated with use of analgesics or dermatological drugs (adjOR 5.1 and 7.9 respectively). Three out of four patients did not discuss herbal use with any health care professional. CONCLUSION: A sizable proportion of the GP patients co-used herbs with conventional drugs, also combinations with reported interaction potential or additive effects like anticoagulants and garlic. The low disclosure of herbal use to their GP, polyherbacy and the risk of interactions in vulnerable groups like elderly and chronically ill patients, warrant increased awareness among GPs.

Aloe vera juice: IC50 and dual mechanistic inhibition of CYP3A4 and CYP2D6.

The aim of this study was to evaluate the inhibitory potency (IC50 values) of ethanol extracts of two commercially available aloe vera juice (AVJ) products, on CYP3A4 and CYP2D6 activities in vitro and to determine if such inhibitions could be mechanism-based. Recombinant human CYP3A4 and CYP2D6 enzymes were used and the activities were expressed by the metabolism of testosterone and dextromethorphan with ketoconazole and quinidine as positive inhibitor controls, respectively. The formed metabolites were quantified by validated HPLC techniques. Time- and NADPH- dependent inhibition assays were performed to evaluate a possible mechanism-based inhibition. One of the AVJ extracts showed about twice the inhibitory potency towards both CYP enzymes over the other with IC50 values of 8.35 ± 0.72 and 12.5 ± 2.1 mg/mL for CYP3A4 and CYP2D6, respectively. The AVJ was found to exert both CYP mediated and non-CYP mediated inhibition of both CYP3A4 and CYP2D6. This dual mechanistic inhibition, however, seems to be governed by different mechanisms for CYP3A4 and CYP2D6. Estimated IC50 inhibition values indicate no major interference of AVJ with drug metabolism in man, but the dual mechanistic inhibition of both enzymes might be of clinical significance.

Caco-2 cell methodology and inhibition of the P-glycoprotein transport of digoxin by Aloe vera juice.

The aims of this study were to carry out a thorough quality control setup for essential Caco-2 cell characteristics in P-glycoprotein (P-gp) inhibition studies and to explore if Aloe vera juice (AVJ) inhibits the bidirectional transport of the P-gp substrate digoxin (30 nm). Seven AVJ concentrations (0.00001-1.0 mg/mL), anticipated to cover a clinically relevant range, were tested and digoxin apparent permeability coefficients (Papp), net Papp values (Papp(Net)) and net flux values (J(Net)) were calculated. Relevant validation parameters for P-gp inhibition studies in Caco-2 cells are suggested to include, as a minimum, an assay linearity test with and without a known P-gp inhibitor, cell cytotoxicity testing (MTT-test) for substrates and inhibitors, and cell integrity testing by TEER and mannitol transport measurements. The question is also raised whether a minimum effect of a reference P-gp inhibitor as verapamil should be demanded. Cell cytotoxicity was seen for digoxin at concentrations >or=3 microM and for AVJ at 10 mg/mL. AVJ did not inhibit the P-gp transport of digoxin in any of the concentrations tested. This indicates that AVJ is no inhibitor of the P-gp mediated transport of digoxin in vitro if AVJ is present in clinically relevant concentrations.