The relationship of 25-hydroxyvitamin D values and risk of fracture: a population-based retrospective cohort study.

Our study investigates 25-hydroxyvitamin D levels and fracture risk using population-level data. 25-Hydroxyvitamin D values < 12, 12-19, and > 50 ng/mL were not associated with increased risk of fractures overall compared with values 20-50 ng/mL. Severely low levels may be associated with increased risk of osteoporotic fracture, particularly of the wrist. INTRODUCTION: Studies of the relationship between serum 25-hydroxyvitamin D (25(OH)D) levels and fracture risk have been inconsistent. We hypothesized that high 25(OH)D concentrations (> 50 ng/mL) would be associated with increased risk of fracture. METHODS: We identified all adult patients living in Olmsted County, Minnesota, between January 1, 2005 and December 31, 2011, who had at least one 25(OH)D measurement. Fracture outcomes were retrieved starting 30 days after 25(OH)D measurement and until patients' final clinical visit as an Olmsted County resident, December 31, 2014, or death. Data were analyzed using Cox proportional hazard regression. RESULTS: Of 11,002 individuals with a 25(OH)D measurement, 5.8% had a 25(OH)D value ˂ 12 ng/mL, and 5.1% had a value > 50 ng/mL. Compared with subjects with 25(OH)D values 20-50 ng/mL (reference group), values < 12, 12-19, and > 50 ng/mL displayed no association with overall fracture risk. After adjusting for a prior diagnosis of osteoporosis/osteopenia, only individuals with values ˂ 12 ng/mL had increased risk of any osteoporotic fracture (aHR = 1.41; 95% CI 1.05-1.89) and wrist fracture (aHR = 2.11; 95% CI 1.27-3.48) compared with the reference group. Compared with the reference group, values ˂ 12 ng/mL were associated with increased risk of any fracture (aHR = 1.35; 95% CI 1.01-1.80), osteoporotic fracture (aHR = 2.18; 95% CI 1.44-3.31), and wrist fracture (aHR = 2.39; 95% CI 1.19-4.81) in subjects without a prior diagnosis of osteoporosis/osteopenia, but not in those with a prior diagnosis of osteoporosis/osteopenia. CONCLUSION: Severely low 25(OH)D levels may be associated with increased risk of osteoporotic fracture, particularly of the wrist, but 25(OH)D values > 50 ng/mL were not associated with increased fracture risk.

The impact of Helicobacter pylori on the presence of Barrett's esophagus in Azerbaijan, a high-prevalence area of infection.

There is a strong evidence that Helicobacter pylori infection is inversely associated with Barrett's esophagus. In a high-prevalence region of H. pylori, low rates of esophageal cancer and its precursor BE may indicate its preventive effect. The aim of this study is to determine the impact of H. pylori on characteristics of Barrett's esophagus. A total of 3317 outpatient upper endoscopy reports from 2013 to 2015 from an urban center in Azerbaijan from all patients with dyspepsia were retrospectively analyzed for patients with Barrett's esophagus. This was matched in a 1:2 ratio to age and gender matched control patients without Barrett's esophagus. The prevalence of H. pylori on Barrett's esophagus and the randomly selected control group were compared. There were 83 patients with BE and 167 control group cases. Biopsy-proven BE was diagnosed in 83 patients: 39 (47%) females, with mean age 43.1 ± 13.3 years. Of these, 13 (15.7%) had long segment and 70 (84.3%) had short segment Barrett's esophagus. A control group included 167 patients: 78 (46.7%) females, with mean age (45.8 ± 13.9). All patients were Caucasians. The rates of gastric inflammation, the presence of atrophy, and intestinal metaplasia in gastric specimens did not differ in patients versus controls. The prevalence of H. pylori was determined as 63.2% in male and 61.5 in female groups (odd ratio (OR) = 0.99 95%CI 0.97, 1.01; P = 0.22). Inflammation of gastric mucosa was strongly associated with the infection (67% vs. 33%; OR = 4.46 95% CI: 2.01, 9.92, P < 0.001). Atrophy was noted in majority of H. pylori-positive cases (OR = 1.43, 95% CI: 0.36, 5.65; P = 0.61). Gastric intestinal metaplasia was observed in 55.6% of H. pylori-positive patients and in 44.4% of negative individuals (OR = 0.74, 95% CI: 0.28, 1.94; P = 0.54). There was not a significant difference in the prevalence of HP in BE and control groups; 63.9% were positive for infection in BE cases and 61.7% of controls (OR = 1.10, 95% CI: 0.64, 1.90; P = 0.74). We found that neither presence of erosive esophagitis, length of BE nor dysplasia (45.5% of H. pylori-positive group, whereas 54.5%) was associated with the presence of the H. pylori infection (Table 1). In a predominantly Caucasian nation with a high prevalence of H. pylori gastritis, the presence of H. pylori was not inversely associated with the presence of Barrett's esophagus. These data challenge the mechanistic implications of this association.

Association of mindfulness and stress with menopausal symptoms in midlife women.

Purpose: Midlife women frequently experience stress and menopausal symptoms. Mindfulness is thought to mitigate stress by avoiding emotional reactivity and ruminative thinking. We sought to assess the association of mindfulness and stress on menopausal symptoms among midlife women. Materials and methods: In this cross-sectional study, women aged 40-65 years completed questionnaires, including the Menopause Rating Scale (MRS), the Perceived Stress Scale-4 (PSS-4), and the Mindfulness Attention Awareness Scale (MAAS). Linear regression was used to assess the impact of mindfulness and stress on menopausal symptoms with use of univariate and multivariable analyses, adjusting for patient characteristics. Results: In this cohort of 1744 midlife women, higher mindfulness (MAAS) and lower stress (PSS-4) scores correlated independently with lower menopausal symptom (MRS) scores. On multivariable analysis, a significant interaction effect was observed between the MAAS and PSS-4 on the MRS, such that with higher PSS-4 scores, the magnitude of association between the MAAS and lower MRS scores was larger. Conclusion: Among midlife women, higher mindfulness and lower stress correlated with lower menopausal symptom scores independently. Among women experiencing more stress, the magnitude of association between mindfulness and lower menopausal symptom scores was greater, largely driven by psychological subdomain scores. Mindfulness may mitigate menopausal symptoms among midlife women.

Prediction of short-term surgical complications in women undergoing pelvic exenteration for gynecological malignancies.

OBJECTIVE: Pelvic exenteration (PE) is an extensive surgery associated with high rates of postoperative morbidity and mortality. The absence of well-defined preoperative selection criteria to identify patients eligible for PE prompted the assessment of pre-operative predictors of 30-day major surgical complications. METHODS: Demographics and surgical characteristics of patients undergoing PE for gynecologic cancer in a single institution between 01/2004-12/2016 were reviewed. Postoperative complications within 30 days following surgery were graded using the Accordion grading system. Logistic regression was used to analyze potential risk factors for severe postoperative complications. RESULTS: A total of 138 patients were included in the cohort. Forty-five patients underwent total PE, 52 anterior PE, and 41 posterior PE. Among the 137 patients with follow-up, a severe postoperative complication was experienced by 37 patients (27.0%) and 3 patients (2.2%) experienced death within 90 days. The most frequent grade 3 complications were complications of urinary reconstruction (n = 15), wound dehiscence (n = 9), and abdominal abscess requiring intervention with drain or return to the operating room (n = 6). On multivariable analysis, independent predictors of severe postoperative complications were anterior or total PE (adjusted odds ratio (aOR): 11.66, 95% CI 2.56-53.18), pre-operative hemoglobin ≤10 mg/dl (aOR 2.70, 95% CI 1.02-7.14) and presence of 3+ comorbidities (aOR: 2.76, 95% CI 1.07-7.10). CONCLUSIONS: Major complications after exenteration are common. Surgical complexity and patient selection play a considerable role in predicting complications. These data can be used to better risk stratify patients undergoing PE.

Sex differences in fitness and cardiac function during exercise in adolescents with chronic fatigue.

Females demonstrate less robust Frank-Starling mechanism with respect to cardiac preload than males at rest. We asked whether this phenomenon would also affect cardiac performance during exercise. We hypothesized that stroke volume (SV) response to exercise would be more limited in deconditioned females such that cardiac output would be mainly rate dependent, compared with males. We conducted a chart audit of clinical exercise tests performed by adolescents with chronic fatigue. Oxygen uptake (V˙O2) was measured breath-by-breath at rest and during cycle ergometry, while cardiac output was measured by acetylene rebreathing at rest plus 2-3 subthreshold workloads. SV response was analyzed in two ways: after normalization for body surface area (SV index, SVI) and as percentage change from resting values. Among 304 adolescents (78% females) with chronic fatigue, 189 (80%) of 236 females and 52 (76%) of 68 males were deconditioned (peakV˙O2 <90% predicted). Heart rate trajectory during exercise was steeper for unfit than fit females, 70 vs 61 beat·min-1 per L·min-1 V˙O2, (P=.003); but not for males, 47 vs 42 beat·min-1 per L·min-1 V˙O2 (P=.23). The highest measured SVI did not differ between unfit vs fit females (42.8 vs 41.5 mL·m-2 , P=.39) while fit males showed larger SV during exercise than their unfit peers (highest SVI 55.9 vs 48.0 mL·m-2 , P=.014). Both qualitative and quantitative sex differences exist in SV responses to exercise among chronically fatigued adolescents, suggesting volume loading may be more efficacious in girls.

The analysis of synovial fluid in total knee arthroplasties with flexion instability.

AIMS: Patients with flexion instability after total knee arthroplasty (TKA) often present with a recurrent effusion, which may be a haemarthrosis. While the radiographic factors contributing to flexion instability have been elucidated, the clinical diagnosis remains challenging. Our aim, in this study, was to determine the mean white cell count and differential profile in pre-operative aspirations of synovial fluid in a consecutive series of patients undergoing revision TKA for flexion instability. PATIENTS AND METHODS: Between 2000 and 2010, 60 patients undergoing aseptic revision TKA for flexion instability were identified. The results of the pre-operative aspiration of synovial fluid were available for 53 patients (88%). These patients were 1:2 matched to 106 patients who underwent aseptic TKA for indications other than flexion instability. The mean age of the patients at revision TKA was 65 years (44 to 82) and 55% were women. The mean follow-up was 4.3 years (2 to 10.2). RESULTS: In the flexion instability group, the median total cell count was 312 cells/µL (interquartile range (IQR) 104 to 624), with a mean distribution of 45% macrophages (2% to 90%), 30% lymphocytes (1% to 69%), 18% neutrophils (0% to 80%), 0.5% eosinophils (0% to 6%) and 7% other cells (0% to 42%; mainly synovial cells). There was no significant difference in the median total cell count (p = 0.14) or mean distribution of macrophages (p = 0.42), lymphocytes (p = 0.38), neutrophils (p = 0.19) and eosinophils (p = 0.89) between the flexion instability and control groups. There was a significant difference in the percentage of bloody serosanguineous aspirations which was 58% in the flexion instability group and 18% in the control group (odds ratio = 6.5; p = 0.0001). CONCLUSIONS: In the group of patients who underwent revision TKA for flexion instability, most had a mean cell count and differential similar to those who underwent revision for other aseptic indications. However, bloody serosanguineous aspirations were 6.5 times more common in those with flexion instability confirming that many of the recurrent effusions seen in this condition are haemarthroses. Cite this article: Bone Joint J 2017;99-B:1477-81.