Recent insights on circulating catecholamines in hypertension.

Pheochromocytomas are neuroendocrine tumors that commonly lead to excess catecholamine secretion, resulting in elevated blood pressure. In addition to potentiating vasoconstriction, catecholamines promote endothelial dysfunction, as evidenced by elevated markers of endothelial dysfunction, ADMA and sVCAM-1, in patients with pheochromcytoma. Importantly, catecholamine-induced endothelial dysfunction and hypertension may not only be due to catecholamine production by neuroendocrine tumors, as vascular endothelial cells have now been demonstrated to synthesize and secrete catecholamines. This local vascular catecholamine release appears to be triggered by hypoxia. In fact, chronic intermittent hypoxia both in vitro and in vivo leads to stabilization of hypoxic-inducible factors that increase gene expression of catecholamine-synthesizing enzymes. In an effort to target catecholamines as a means of treating hypertension, novel therapeutic options are being explored, including the generation of pharmacophores that mimic the suppressive effects of catestatin on catecholamine release as well as the use of renalase enhancers to increase catecholamine metabolism.

The medical orthopaedic trauma service: an innovative multidisciplinary team model that decreases in-hospital complications in patients with hip fractures.

OBJECTIVES: The purpose of the study is to evaluate the influence of a multidisciplinary model of care on the incidence of postoperative complications after a hip fracture. DESIGN: Retrospective cohort series. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Three hundred six patients with pertrochanteric femur fracture (OTA classification: 31-B1, 31-B2, 31-B3, 31-A1, 31-A2, 31-B3, 32-A1, and 32-A2). INTERVENTION: A multidisciplinary, collaborative model of perioperative care: the Medical Orthopaedic Trauma Service (MOTS). MAIN OUTCOME MEASURES: Incidence of in-patient complications, length of in-patient hospitalization, readmission rate after hospital discharge, and postdischarge mortality at 90 days and 1 year. RESULTS: Although there was no change in length of hospitalization, there was a significantly decreased overall incidence of in-patient complications and a decreased incidences of new-onset urinary tract infection and arrhythmias in the MOTS cohort. These differences persisted after controlling for age, comorbidity, gender, ethnicity, type of fracture, and number of days from admission to surgery with a logistic regression model. Subgroup analysis of patients with an American Society of Anesthesiologists physical status classification of 1 or 2 revealed a significantly decreased 90 day readmission rate with the MOTS model, but this did not persist in a regression model (P = 0.07). CONCLUSIONS: A multidisciplinary, collaborative model of care for patients with hip fractures decreases the incidence of postoperative in-patient complications and may influence hospital readmission rates. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A fracture does not adversely affect bone mineral density responses after teriparatide treatment.

BACKGROUND: Fracture leads to local and systemic catabolic physiologic changes. As teriparatide is an agent used to treat osteoporosis in patients with fragility fractures, it is unclear whether teriparatide treatment alters bone mineral density (BMD) and bone markers when given to patients with fractures. QUESTIONS/PURPOSES: We asked whether BMD and bone marker responses would be blunted in patients with fractures placed on teriparatide after fracture compared with patients without fractures on teriparatide. PATIENTS AND METHODS: We retrospectively collected data from 141 patients treated with teriparatide for osteoporosis. Seventy-seven patients received teriparatide after fractures (fracture group), whereas 64 were treated for other indications (nonfracture group). We determined BMD at the lumbar spine and at the proximal femur before and 12 and 24 months posttreatment. Bone markers (urine N-telopeptide [urine NTX], bone-specific alkaline phosphatase [BALP]) were measured at baseline and 3, 12, and 24 months posttreatment. RESULTS: Mean lumbar spine and hip BMDs at last followup increased from baseline with no differences between groups to approximately 9% and 4% at 24 months, respectively. Both bone markers increased from baseline in the nonfracture group, peaking at 12 months. For the fracture group, only urine NTX increased at 3 and 12 months posttreatment. Although the peak levels of both bone markers in the nonfracture group were greater, there was no difference between the two groups. CONCLUSIONS: Fracture does not have a negative effect on the BMD and bone marker responses to teriparatide treatment. Clinicians should anticipate comparable BMD responses when treating patients with teriparatide for osteoporotic fractures and for other indications. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

The effect of long-term alendronate treatment on cortical thickness of the proximal femur.

BACKGROUND: One of the radiographic hallmarks in patients with atypical femoral insufficiency fractures after prolonged bisphosphonate treatment is generalized cortical hypertrophy. Whether cortical thickening in the proximal femur is caused by long-term alendronate therapy, however, remains unknown. QUESTIONS/PURPOSES: We asked whether long-term alendronate use of 5 years or more results in progressive thickening of the subtrochanteric femoral cortices. PATIENTS AND METHODS: We retrospectively evaluated changes in cortical thickness and cortical thickness ratio (ratio of cortical to femoral shaft diameter) at the subtrochanteric region of the proximal femur in baseline and latest hip dual-energy xray absorptiometry (DXA) scans of 131 patients. The mean followup was 7.3 years. Patients were divided into two groups: control (no history of alendronate, 45 patients) and alendronate (history of alendronate ≥ 5 years, 86 patients). We determined cortical thickness and cortical thickness ratio at 3.5 and 4.0 cm below the tip of the greater trochanter, representing the subtrochanteric region. RESULTS: After a minimum of 5 years followup, mean cortical thickness decreased approximately 3% in the alendronate and control groups. The cortical thickness at the subtrochanteric femoral region changed less than 1 mm in greater than 90% of the patients with long-term alendronate treatment. We observed no differences in mean changes of cortical thickness and percent changes of cortical thickness between the two groups. CONCLUSIONS: Long-term alendronate treatment did not appear to cause thickened femoral cortices within the detection limits of our method. This finding contrasts with the notion that long-term alendronate treatment leads to generalized cortical thickening.

Sex and gender considerations in male patients with osteoporosis.

BACKGROUND: Osteoporosis remains underrecognized and undertreated in both men and women, but men who sustain fragility fractures experience greater morbidity and mortality. While men exhibit advanced comorbidity at the time of hip fracture presentation, there are distinct sex- and gender-specific factors related to the pathophysiology and treatment of osteoporosis that further influence morbidity and mortality. QUESTIONS/PURPOSES: With a selective review of the literature, we evaluated sex- and gender-based differences contributing to increased morbidity and mortality in men with osteoporosis. WHERE ARE WE NOW?: Sex-specific differences in bone biology and morphology may affect the pathophysiology of osteoporosis, choice of pharmacotherapy, and surgical implant selection. Additionally, estrogen metabolism may play a key role in both fracture prevention and healing. Gender-based differences in recommendations for screening and prevention between men and women may influence the severity at which osteoporosis is recognized. Primary, secondary, and tertiary prevention efforts in men lag behind those of women. This may be due to a lack of consensus regarding screening guidelines for osteoporosis in men but may be attributed to lack of awareness in the physician and patient about osteoporosis and its potentially debilitating consequences. WHERE DO WE NEED TO GO?: These disparities are a call to action for healthcare providers to raise awareness for early prevention and treatment of this potentially debilitating disease, particularly in men. HOW DO WE GET THERE?: Continued prospective research on the differences between men and women diagnosed with osteoporosis is needed, as well as sex-specific stratification of data in all studies on osteoporosis.

Does a multidisciplinary team decrease complications in male patients with hip fractures?

BACKGROUND: Men with hip fractures are more likely to experience postoperative complications than women. The Medical Orthopaedic Trauma Service program at New York Presbyterian Hospital utilizes a multidisciplinary team approach to care for patients with hip fractures. The service is comanaged by an attending hospitalist and orthopaedic surgeon, with daily walking rounds attended by the hospitalist, orthopaedic resident, physical therapist, social worker, and a dedicated Medical Orthopaedic Trauma Service physician assistant. QUESTIONS/PURPOSES: We asked whether a multidisciplinary service for patients with hip fracture decreases (1) the incidence of inpatient complications in men, (2) the length of hospitalization, and (3) 90-day and 1-year mortality. PATIENTS AND METHODS: We retrospectively reviewed the charts of 74 men who had surgery for a nonperiprosthetic femoral neck, intertrochanteric, or subtrochanteric fracture for two 7-month periods before and after implementation of the Medical Orthopaedic Trauma Service. Age, ethnicity, comorbidity status, time to surgery, and postoperative complication data were collected. Regression modeling was used to evaluate the likelihood of postoperative complications, length of hospitalization, and 90-day and 1-year mortality while controlling for age, Charlson Comorbidity Index score, fracture type, and time from admission to surgery. RESULTS: We observed a decrease in the likelihood of experiencing at least one inpatient complication in male patients after implementation of the Medical Orthopaedic Trauma Service (odds ratio = 0.264). There was no difference in length of hospitalization, 90-day mortality, or 1-year mortality. CONCLUSIONS: Multidisciplinary collaboration for patients with hip fractures can decrease the likelihood of experiencing inpatient complications in male patients. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.