Orthogeriatric co-management improves the outcome of long-term care residents with fragility fractures.

BACKGROUND: Fragility fractures are a major health care problem worldwide. Both hip and non-hip fractures are associated with excess mortality in the years following the fracture. Residents of long-term nursing homes represent a special high-risk group for poor outcomes. Orthogeriatric co-management models of care have shown in multiple studies to have medical as well as economic advantages, but their impact on this high-risk group has not been well studied. OBJECTIVE: We studied the outcome of long-term care residents with hip and non-hip fractures admitted to a geriatric fracture center. METHODS: The study design is a single center, prospective cohort study at a level-I trauma center in Austria running a geriatric fracture center. The cohort included all fragility fracture patients aged over 70 admitted from a long-term care residence from May 2009 to November 2011. The data set consisted of 265 patients; the mean age was 86.8 ± 6.7 years, and 80 % were female. The mean follow-up after the index fracture was 789 days, with a range from 1 to 1842 days. Basic clinical and demographic data were collected at hospital admission. Functional status and mobility were assessed during follow-up at 3, 6, and 12 months. Additional outcome data regarding readmissions for new fractures were obtained from the hospital information database; mortality was crosschecked with the death registry from the governmental institute of epidemiology. RESULTS: 187 (70.6 %) patients died during the follow-up period, with 78 patients (29.4 %) dying in the first year. The mean life expectancy after the index fracture was 527 (±431) days. Differences in mortality rates between hip and non-hip fracture patients were not statistically significant. Compared to reported mortality rates in the literature, hip fracture patients in this orthogeriatric-comanaged cohort had a significantly reduced one-year mortality [OR of 0.57 (95 % CI 0.31-0.85)]. After adjustment for confounders, only older age (OR 1.091; p = 0.013; CI 1.019-1.169) and a lower Parker Mobility Scale (PMS) (OR 0.737; p = 0.022; CI 0.568-0.957) remained as independent predictors. During follow-up, 62 patients (23.4 %) sustained at least one subsequent fracture, and 10 patients (3.4 %) experienced multiple fractures; 29 patients (10.9 %) experienced an additional fracture within the first year. Nearly, half (47.1 %) regained their pre-fracture mobility based on the PMS. CONCLUSION: Despite the generally poor outcomes for fragility fracture patients residing in long-term care facilities, orthogeriatric co-management appears to improve the outcome of high-risk fragility fracture patients. One-year mortality was 29.4 % in this cohort, significantly lower than in comparable trials. Orthogeriatric co-management may also have positive impacts on both functional outcome and the risk of subsequent fractures.

Fragility non-hip fracture patients are at risk.

INTRODUCTION: Fragility fractures are a growing worldwide health care problem. Hip fractures have been clearly associated with poor outcomes. Fragility fractures of other bones are common reasons for hospital admission and short-term disability, but specific long-term outcome studies of non-hip fragility fractures are rare. The aim of our trial was to evaluate the 1-year outcomes of non-hip fragility fracture patients. METHODS: This study is a retrospective cohort review of 307 consecutive older inpatient non-hip fracture patients. Patient data for analysis included fracture location, comorbidity prevalence, pre-fracture functional status, osteoporosis treatments and sociodemographic characteristics. The main outcomes evaluated were 1-year mortality and post-fracture functional status. RESULTS: As compared to the expected mortality, the observed 1-year mortality was increased in the study group (17.6 vs. 12.2 %, P = 0.005). After logistic regression, three variables remained as independent risk factors for 1-year mortality among non-hip fracture patients: malnutrition (OR 3.3, CI 1.5-7.1), Charlson comorbidity index (CCI) (OR 1.3, CI 1.1-1.5) and the Parker Mobility Score (PMS) (OR 0.85, CI 0.74-0.98). CCI and PMS were independent risk factors for a high grade of dependency after 1 year. Management of osteoporosis did not significantly improve after hospitalization due to a non-hip fragility fracture. CONCLUSION: The outcomes of older non-hip fracture patients are comparable to the poor outcomes of older hip fracture patients, and appear to be primarily related to comorbidities, pre-fracture function and nutritional status. The low rate of patients on osteoporosis medications likely reflects the insufficient recognition of the importance of osteoporosis assessment and treatment in non-hip fracture patients. Increased clinical and academic attention to non-hip fracture patients is needed.

Quantitative assessment of bladder cancer by nuclear texture analysis using automated high resolution image cytometry.

The aim of this study was to investigate the possibility of identifying urothelial neoplasia by nuclear chromatin texture feature analysis using high resolution image cytometry to improve the diagnostic accuracy of cytologic examination in the detection and monitoring of bladder cancer. Touch imprints of transurethral resection material of 56 control group (CG) cases of nonmalignant urothelium and 94 tumor group (TG) cases of bladder cancer were analyzed. The specimen collection was divided randomly into a training set and a test set. Cells were stained specifically for DNA by the Feulgen method. Only diploid cell nuclei were analyzed from both groups. A discriminator comprised of three nuclear texture features was derived from the training set of cases to separate CG from TG cases. This discriminator was then applied to the independent test set. CG cases were separated from TG cases with a sensitivity of 97% and a specificity of 95% on the independent test set of cases. When dividing TG cases into high-risk and low-risk groups, sensitivity in the low-risk group was 93%. None of the high-risk cases was misclassified (sensitivity, 100%). This retrospective investigation demonstrates that by high-resolution image cytometry it is possible to distinguish between urothelial neoplasia and normal urothelium with high reliability when examining diploid cell nuclei only. This method is superior to DNA ploidy analysis using image or flow cytometry and may become clinically relevant as a supplement to conventional cytologic examination. These promising results should be confirmed on cytologic preparations derived from bladder washings or voided urine.