Jenson C. S. Mak

Meta-analysis of the cardiovascular benefits of intensive lipid lowering with statins

Chan DKY, O’Rourke F, Shen Q, Mak JCS, Hung WT. Meta‐analysis of the cardiovascular benefits of intensive lipid lowering with statins.
Acta Neurol Scand: 2011: 124: 188–195.
© 2010 John Wiley & Sons A/S.

A Prospective Review of Hip Fracture Subtypes, Surgical Procedure, Cognitive Status, and Analgesia Use Across 4 Australian Hospitals:

Objectives: To correlate analgesia use among patients with hip fracture requiring surgery with hip fracture subtype, cognitive status, and type of surgery in the postacute period. Design and Participants: Prospective review of patients with hip fractures requiring surgical intervention. A total of 415 patients (mean age: 81.2 ± 9.1 years, 74.3% women) presented with 195 subcapital fractures (39 undisplaced, 156 displaced) and 220 trochanteric fractures (136 stable, 84 unstable) requiring surgery. Setting: Inpatient orthopedic units in 4 Australian hospitals. Measurements: The primary outcome measures were mean analgesia usage (oral morphine equivalent) for 4 defined time intervals and total amount 36 hours following surgery. Results: Patients with subtrochanteric fractures required more analgesia compared with displaced-subcapital, undisplaced-subcapital, basicervical, stable-pertrochanteric, and unstable-pertrochanteric fractures in the 24 to 36 hours following operation (24.7 vs 11.3 vs 8.8 vs 12.1 vs 7.6 vs 9.7, P = .001). Total analgesia requirements were higher in patients treated with an intramedullary nail, increasing by 1.3- to 3.3-fold in the 36 hours postsurgery. Patients with cognitive impairment utilized markedly less analgesia at all time periods measured. At 24 to 36 hours, higher levels of analgesia were noted in patients with higher premorbid level of mobility (P = .015) and activities of daily living function (P = .007). Conclusion: Important differences in utilization of analgesia following hip fracture across readily defined clinical groups exist. Proactive pain management for those with cognitive impairment, certain hip fracture subtypes, and surgical procedures may enable early functional mobility and other activities.

Acupuncture in osteoporosis: more evidence is needed

Osteoporosis is a term that encompasses both a risk factor for bone fragility (low bone density) and a condition of fragility (fractures).1 About a third of new fractures come to medical attention, suggesting that, in reality, most are either asymptomatic or have tolerable symptoms.2 These fractures, especially hip fractures, frequently result in a short- or long-term need for a higher level of care, and are associated with increased mortality.3 Evidence for a role of calcium and vitamin D in preventing fractures are mainly confined to those with hypovitaminosis D or from aged care homes, with strong evidence of mild anti-fracture efficacy.4 Given the adverse effects of prolonged oestrogen therapy, including an increased risk of myocardial infarction and breast cancer,5 and the rare but potentially serious side-effects of common osteoporosis medications (bisphosphonates, raloxifene, denosumab and teriparatide),6 the quest for alternative treatments to boost bone mineral density (BMD), and indeed to prevent fractures, have focused upon complementary treatments with a good safety profile, such as acupuncture. Worldwide, acupuncture is integral to everyday medical practice. In recent decades its practice has gained popularity in Western countries. With increasing evidence of its clinical efficacy, acupuncture is now a …

Improving mobility and reducing disability in older people through early high-dose vitamin d replacement following hip fracture: a protocol for a randomized controlled trial and economic evaluation.

Hypovitaminosis D is particularly common among older people with a proximal femoral (hip) fracture and has been linked with poorer lower extremity functioning, falls, and fractures. There is evidence that disability severity and fall rates may be reduced by adequate vitamin D replacement. However, the ideal regimen for vitamin D administration to have these benefits in older people who have been in the hospital has not been established. This randomized controlled trial will investigate the effects of an oral vitamin D loading dose with maintenance oral vitamin D and calcium on lower extremity function (gait velocity), correction of hypovitaminosis D, falls, and fractures among older people after hip fracture surgery. The cost-effectiveness of the REVITAHIP program from the health and community service provider’s perspective will also be established, as will predictors of adherence with the treatment. A total of 450 older people who have recently had a hip fracture requiring surgical intervention will be screened to achieve 250 participants for the study. Participants will have no medical contraindications to vitamin D replacement. The primary outcome measure will be mobility-related disability as measured with the 2.4-m gait velocity test. Secondary measures will be 25-hydroxyvitamin D (25-OHD) levels at 2, 4, and 26 weeks, number of falls and fractures, and additional measures of mobility, disability, quality of life, health system and community–service contact, adherence to the intervention, and adverse events. After surgical fixation and being deemed medically stable, participants will be randomly allocated to an intervention or placebo-control group. Participants of the intervention group will receive initial oral 250 000 IU (5 × 50 000 IU) vitamin D3 tablets. Both groups will receive oral maintenance vitamin D3 and calcium and will follow the usual hip fracture rehabilitation pathway. The study will determine the impact of a vitamin D loading dose on mobility-related disability in older people following hip fracture and will discuss the efficacy and cost-effectiveness of a loading dose vitamin D replacement more generally. The results will have direct implications for future use of vitamin D therapy for this high-risk group.

ORAL VITAMIN D REPLACEMENT AFTER HIP FRACTURE: A COMPARATIVE REVIEW

To the Editor: Hip fracture is a commonly encountered clinical problem, with an annual estimated prevalence of 512,000 in the United States by 2040, at a cost of

RELATIONSHIP BETWEEN HIP FRACTURE SUBTYPES AND ANALGESIA USE

16 billion. Hypovitaminosis D is commonly associated with hip fracture in older adults and is caused by multiple factors, such as decreased sun exposure with reduced skin production of vitamin D and low dietary D2/D3. This problem may result in proximal muscle weakness, pain, poorer dynamic balance, and slower performance speed, affecting rehabilitation during the acute postoperative and initial rehabilitation periods. Furthermore, symptomatic hypocalcemia may occur with intravenous bisphosphonate use, exacerbated by hypovitaminosis D, and may be life threatening and require hospitalization. In Australia, vitamin D supplementation is generally available only in an oral formulation at a dose of 1,000 IU (25 mg). The optimal dose and mode of replacement in vitamin D–deficient adults after hip fracture are not known. This study aimed to investigate the effectiveness of moderate-dose oral vitamin D replacement in improving 25-hydroxyvitamin D (25OHD) levels and rehabilitation outcomes after hip fracture surgery.

RELATIONSHIP BETWEEN HIP FRACTURE SUBTYPES, SURGICAL PROCEDURE, AND ANALGESIA USE

dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. N Engl J Med 2001;344: 3–10. 7. Appel LJ, Espeland MA, Easter L et al. Effects of reduced sodium intake on hypertension control in older individuals: Results from the Trial of Nonpharmacologic Interventions in the Elderly (TONE). Arch Intern Med 2001;161: 685–693. 8. Appel LJ, Espeland M, Whelton PK et al. Trial of Nonpharmacologic Intervention in the Elderly (TONE). Design and rationale of a blood pressure control trial. Ann Epidemiol 1995;5:119–129.

RELATIONSHIP BETWEEN HIP FRACTURE SUBTYPES AND ANALGESIA USE: LETTERS TO THE EDITOR

tation), hypothyroidism, and osteoporosis. His medications include carvedilol, valsartan, dusteride, hydralazine, risedronate, calcium, and vitamin D. Physical examination showed a Caucasian man who used a walker for ambulation and in no acute cardiopulmonary distress. Vital signs were within normal limits, and his body mass index was 21.3 kg/m. No craniofacial abnormalities were detected, and examination of the heart and lungs was normal. On neurological examination, the patient was slow in responding to questions but oriented to time, place, and person. Examination of the cranial nerves was within normal limits, and no lateralizing signs were observed in the examination of the motor system. To confirm the diagnosis of sleep apnea, the patient underwent an overnight sleep study and was found to have severe OSAH (respiratory disturbance index 430 events/h of sleep), with significant oxygen desaturations and a hypoxic burden of 7%. CPAP titration resulted in a significant reduction in respiratory events at a CPAP pressure of 12 cm. During follow-up, the patient stated that he used his CPAP every night and that his nighttime sleep and daytime activities had improved significantly. He was waking up from sleep at night two or three times only and felt rested in the morning when he got out of bed. He was able to read his papers, watch television, carry on a conversation with friends, and engage in activities at the assisted living facility without dozing off, and he stated that these changes had significantly improved his quality of life. Patient is now 92 years old and has been using his CPAP for more than 1 year. This report illustrates successful treatment of OSAH with CPAP in a nonagenarian. Despite the patient’s numerous contacts with the healthcare system in previous years and his long-standing symptoms of snoring and daytime sleepiness, he was referred for evaluation of his sleeprelated problem only a year ago. This indicates missed opportunities for screening and earlier diagnosis of sleep apnea and may be representative of the current state of affairs regarding sleep apnea, especially in older adults. Another important point that this report demonstrates is that age should not be a factor when considering CPAP for treatment of sleep apnea. Average nightly CPAP use of 4.8 hours by older adults with OSAH has been reported previously, and the current case report reinforces this previous finding. Although the primary objective of treatment of sleep apnea in individuals in the oldest-old age group should be to improve functional status and improve quality of life, future studies should focus on the effect of CPAP treatment in older adults with OSAH on healthcare utilization and expenditure. In conclusion, improvement in nighttime sleep, daytime activities, and overall quality of life was achieved after treatment of sleep-disordered breathing with CPAP in a nonagenarian, and this case illustrates that successful CPAP treatment of OSAH in individuals in the oldest-old age group is possible.

Contemporary Pain Management in Elderly Patients after Hip Fracture Surgery: Cross sectional analyses at Baseline of a Randomised Controlled Trial

dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. N Engl J Med 2001;344: 3–10. 7. Appel LJ, Espeland MA, Easter L et al. Effects of reduced sodium intake on hypertension control in older individuals: Results from the Trial of Nonpharmacologic Interventions in the Elderly (TONE). Arch Intern Med 2001;161: 685–693. 8. Appel LJ, Espeland M, Whelton PK et al. Trial of Nonpharmacologic Intervention in the Elderly (TONE). Design and rationale of a blood pressure control trial. Ann Epidemiol 1995;5:119–129.

Improving the osteoporosis care gap in elderly patients following hip fractures: For the ICHIBAN initiative.

Background:Adequate pain management following hip fracture surgery reduces length of stay, reduces incidence of delirium, promotes recovery, and improves mobility. Previous research suggests that hip fracture pain is undertreated in some patient subgroups, and that hypovitaminosis D can further aggravate pain which could hinder active rehabilitation. We provide a cross-sectional analysis of the baseline characteristics of participants in the REVITAHIP study with the aim of documenting pain intensity and its associations after hip fracture and to explore the characteristics of people who report higher levels of pain. Method:We analyzed the baseline characteristics with a focus on pain scores in patients admitted with a hip fracture (undergoing surgery) to 3 teaching hospitals over New South Wales, Australia, between January 2011 and April 2013. Patients were evaluated using the Verbal Rating Scale (VRS). Secondary measures including 25-hydroxyvitamin D levels at baseline, hip fracture subtype, type of surgical intervention, quality of life score, and cognitive and mobility status were correlated with the VRS using the Pearson correlation, ANOVA, and regression analysis. Results:The 218 participants had a mean age of 83.9±7.2 years and 77.1% were women of whom 16.0% had a Mini Mental State Examination score of ⩽23 of 30. The mean and SD VRS pain score was 3.5±2.3. More than half (61.9%, n=113) had VRS≥3 and 18.1% (n=52) had VRS≥5. Using the EuroQOL pain subscore, 78.1% had moderate pain or discomfort and 7.9% had extreme pain or discomfort. Using a multivariate regression model, postoperative VRS was significantly higher in persons with a higher comorbidity count, those previously living independently alone, and surgical fixative modality with hemiarthroplasty. Conclusions:Overall, the levels of pain reported by this cohort are acceptable although approximately 10% to 15% had higher than reasonable levels of pain. This study provides an insight into pain assessment and management by identifying certain patient subtypes who are vulnerable to undertreatment of pain.