John R. Hebel

Survival experience of aged hip fracture patients

Hip fracture has long been considered a major threat to survival in aged populations. This report describes the survival experience of 814 aged, community dwelling hip fracture patients treated in seven Baltimore hospitals between 1984 and 1986: 4.3 per cent died during hospitalization; 8.2, 12.6, and 17.4 per cent died within three, six, and 12 months after fracture, respectively. The mortality rate for the entire population approaches expected mortality approximately six months post-fracture, but varies by age and sex. The most important factors predicting mortality are presence of serious concomitant illness and marked delirium (in the absence of dementia) at the time of hospital admission. The authors suggest that medical factors that may contribute to patient disorientation be investigated and treated, when possible, in an effort to improve the survival status of hip fracture patients.

Loss of bone density and lean body mass after hip fracture.

Abstract: Few studies of bone loss have assessed the amount of loss directly after a hip fracture. The present prospective study was conducted to determine changes in bone mineral density (BMD) and muscle mass shortly after fracture and through 1 year to assess short-term loss and related factors. The setting was two acute care teaching hospitals in Baltimore, Maryland, and subjects were 205 community-dwelling women with a new fracture of the proximal femur between 1992 and 1995. Bone density of the nonfractured hip and whole-body and body composition were measured by dual-energy X-ray absorptiometry at 3 and 10 days and 2, 6 and 12 months after admission. Mean BMD of the femoral neck was 0.546 ± 0.007 g/cm2 at baseline. Average loss of femoral neck BMD from baseline was 2.1% at 2 months, 2.5% at 6 months and 4.6% at 12 months. The average loss of BMD in the intertrochanteric region was 2.1% at 12 months. Total lean body mass decreased by 6% while fat mass increased by 3.6% by 1 year after the fracture. These findings indicate that significant loss in BMD and lean body mass occur shortly after hip fracture while body fat increases. Continued loss was evident throughout the 1 year of follow-up. This loss of both bone density and muscle mass may lead to new fractures.

The association of Chlamydia trachomatis, Neisseria gonorrhoeae, and group B streptococci with preterm rupture of the membranes and pregnancy outcome

There is conflicting evidence regarding a possible causal role for Chlamydia trachomatis in the development of preterm premature rupture of the membranes. We investigated the relative prevalence of endocervical infection with C. trachomads and group B streptococci in patients with preterm premature rupture of membranes compared with a control group taken from the same obstetric population. C. trachomads was isolated from 23152 (44%) patients with preterm premature rupture of membranes versus 13184 (15%) women in the control group ( p Neisseria gonorrhoeae . Group B streptococci were isolated from 16% of the patients with preterm premature rupture of membranes versus 4% of the control population ( p C. trachomads and N. gonorrhoeae . Endocervical infection with C. trachomads did not significantly affect early maternal complication rates after delivery.

Carcinoma of the esophagus: A comparison of the results of transhiatal versus transthoracic resection

The cases of 78 patients with primary esophageal carcinoma treated from 1977 to mid-1987 were retrospectively analyzed. Fifty-two of the patients underwent transthoracic esophagogastrectomy (TTE) and 26, transhiatal esophagectomy (THE). The two groups were statistically similar in preoperative characteristics except that more of the THE group had received chemotherapy; this group had relatively more tumors of the upper esophagus; and 20 (77%) of the THE group, compared with 50 (96%) of the TTE group, had tumors in stages III and IV. The incidence of major postoperative complications did not differ significantly between the two groups. There were five (19%) anastomotic leaks in the THE group, but only one led to a prolongation of hospital stay by more than 14 days, whereas all three (6%) of the leaks in the TTE group caused hospital stay to be prolonged several weeks. Overall morbidity was high: 75% (39/52) for the TTE patients and 85% (22/26) for the THE patients (p greater than 0.10). Hospital mortality was 6% (3/52) in the TTE group and 8% (2/26) in the THE patients (p greater than 0.10). There was no significant difference in actuarial survival either between the two groups as a whole or between those patients in each group who had stage III or IV tumors. We conclude that THE, among the types of patients for whom we used the procedure, provides long-term survival comparable with that provided by TTE without causing a significant increase in hospital mortality or morbidity.(ABSTRACT TRUNCATED AT 250 WORDS)

A DIAGNOSTIC IN VITRO URINE ASSAY FOR INTERSTITIAL CYSTITIS

OBJECTIVES A low molecular weight urine factor that inhibits the proliferation of normal bladder epithelial cells in vitro was previously shown to be present significantly more often in the urine of patients with interstitial cystitis (IC) than in the urine of asymptomatic age-, race-, and sex-matched control subjects. We sought to determine the specificity of this finding for IC by determining whether the urine of patients with other urogenital inflammatory disorders also contains a factor that inhibits bladder epithelial cell proliferation. METHODS Urine was collected from women with IC, acute bacterial cystitis, or vulvovaginitis, as well as from asymptomatic control women. The proliferation of primary normal adult bladder epithelial cells was determined by measuring 3H-thymidine incorporation in vitro. RESULTS Osmolality- and pH-corrected urine specimens from 50 (86%) of 58 women with IC significantly inhibited human bladder epithelial cell proliferation compared with 3 (8%) of 36 asymptomatic control women, 7 (12%) of 58 women with bacterial cystitis, and 0 (0%) of 12 women with vulvovaginitis (P < 0.001 for the comparison of mean percent change in 3H-thymidine incorporation with IC urine versus urine from each of the control groups). Optimal sensitivity and specificity values of 91.4% and 90.6%, respectively, were achievable at a cutoff of 25% inhibition of 3H-thymidine incorporation, using all three control groups. CONCLUSIONS The measurement of urine antiproliferative activity may be a useful noninvasive means for diagnosing IC in women.

Acute pulmonary response in healthy, nonsmoking adults to inhalation of formaldehyde and carbon.

Formaldehyde (HCHO) is a common chemical found in occupational and residential environments and has been suggested as a cause of asthmalike symptoms in some individuals. Clinical and animal studies suggest that HCHO adsorbed on respirable particles may elicit a greater pulmonary physiologic and inflammatory effect than gaseous HCHO alone. The purpose of this study was to determine if respirable carbon particles have a synergistic effect on the acute symptomatic and pulmonary physiologic response to HCHO inhalation. We randomly exposed 24 normal, nonsmoking, methacholine-nonreactive subjects to 2 h each of clean air, 3 ppm formaldehyde, 0.5 mg/m3 respirable activated carbon aerosol, and the combination of 3 ppm formaldehyde plus activated carbon aerosol. The subjects engaged in intermittent heavy bicycle exercise (VE = 57 l/min) for 15 min each half hour. Measures of response included symptom questionnaires, spirometry, body plethysmography, and postexposure serial peak flows. Formaldehyde exposure was associated with significant increases in reported eye irritation, nasal irritation, throat irritation, headache, chest discomfort, and odor. We observed synergistic increases in cough, but not in other irritant respiratory tract symptoms, with inhalation of formaldehyde and carbon. Small (less than 5%) synergistic decreases in FVC and FEV3 were also seen. We observed no HCHO effect on FEV1; however, we did observe small (less than 10%) significant decreases in FEF25-75% and SGaw which may be indicative of increased airway tone. Overall, our results demonstrated synergism, but the effect is small and its clinical significance is uncertain.

Women with hip fracture experience greater loss of geometric strength in the contralateral hip during the year following fracture than age-matched controls.

SummaryThis study examined femur geometry underlying previously observed decline in BMD of the contralateral hip in older women the year following hip fracture compared to non-fractured controls. Compared to controls, these women experienced a greater decline in indices of bone structural strength, potentially increasing the risk of a second fracture.IntroductionThis study examined the femur geometry underlying previously observed decline in BMD of the contralateral hip in the year following hip fracture compared to non-fractured controls.MethodsGeometry was derived from dual-energy X-ray absorptiometry scan images using hip structural analysis from women in the third cohort of the Baltimore Hip Studies and from women in the Study of Osteoporotic Fractures. Change in BMD, section modulus (SM), cross-sectional area (CSA), outer diameter, and buckling ratio (BR) at the narrow neck (NN), intertrochanteric (IT), and shaft (S) regions of the hip were compared.ResultsWider bones and reduced CSA underlie the significantly lower BMD observed in women who fractured their hip resulting in more fragile bones expressed by a lower SM and higher BR. Compared to controls, these women experienced a significantly greater decline in CSA (−2.3% vs. −0.2%NN, −3.2% vs. −0.5%IT), SM (−2.1% vs. −0.2%NN, −3.9% vs. −0.6%IT), and BMD (−3.0% vs. −0.8%NN, −3.3% vs. −0.6%IT, −2.3% vs. −0.2%S) and a greater increase in BR (5.0% vs. 2.1%NN, 6.0% vs. 1.3%IT, 4.4% vs. 1.0%S) and shaft outer diameter (0.9% vs. 0.1%).ConclusionThe contralateral femur continued to weaken during the year following fracture, potentially increasing the risk of a second fracture.

Cytolethality of hemolytic Escherichia coli to primary human renal proximal tubular cell cultures obtained from different donors

OBJECTIVES In earlier experiments, we confirmed epidemiologic studies demonstrating the prominence in acute pyelonephritis of Escherichia coli expressing P fimbriae and hemolysin, produced the disease with pyelonephritogenic strains in an animal model, and developed in vitro assays using human renal proximal tubular cells that demonstrated bacterial adherence by P fimbriae and killing of the renal cells by hemolysin. In the present series of experiments, we sought to determine whether P-fimbriated hemolytic E coli killed human renal proximal tubular epithelial cells obtained from different human donors. METHODS Human renal proximal tubular cells, putative target cells for bacteria causing acute pyelonephritis, were cultured from 9 donors and cell death was measured by two methods. RESULTS We showed that the E coli strain was significantly more cytolethal for renal cells of all donors than its hemolysin-negative mutant. CONCLUSIONS This work suggests that the pathogenesis of acute pyelonephritis by P-fimbriated hemolytic E coli, characteristics of the causative organism in about 50% of human cases, may be at least in part through killing of human renal epithelial cells by hemolysin.

Hamster tracheal organ culture in serum-free media: A quantitative comparison of in vitro epithelial morphology with that of in vivo controls

SummaryThe epithelial morphology of the hamster trachea in serum-free organ culture was compared with that of age-matched in vivo control tissues by collecting and statistically analyzing several quantifiable parameters. By this technique it was possible to detect both subtle and dramatic epithelial alterations. Midtracheal tissues from 6-wk-old male Syrian golden hamsters were used as the explants. Explants were placed on Gelfoam sponges and cultured for 1, 2, and 3 wk in CMRL 1066 alone and in CMRL 1066 to which seven factors were added: insulin and transferrin (5 μg/ml); hydrocortisone (5×10−7M); epidermal growth facotr (5 ng/ml); bovine pituitary extract (0.5%); and phosphoethanolamine and ethanolamine (5×10−5M). The following data were collected and statistically analyzed for each tracheal ring: number of epithelial cells; proportion and number of each cell type; basement membrane length; linear density of epithelial cells; epithelial height; and mitotic index.Compared to controls, ciliated cells decreased by 52% during washes in Leibovitz (L15) medium and tissue manipulation performed before culture and this loss persisted after cutlure for 1 wk. Explants culturedwithout the factors showed marked changes after 2 and 3 wk including epithelial thickening and folding, which was associated with increased linear density. Many cells in these specimens could not be categorized by type (22% were unidentifiable after 3 wk). Epithelial migration onto the outside of the explant was inhibited. In contrast, explants culturedwith the factors maintained a morphology similar to controls at 2 and 3 wk and epithelial migration onto the outside of the explant was supported. This study shows that explants in CMRL 1066 with the seven factors provide a useful biological model for the in vitro study of the mucociliary respiratory epithelium.

Measurement of Distal Forearm Bone Mineral Density: Can Different Forearm Segments Be Used Interchangeably?

Many different forearm sites have been used for the measurement of bone mineral density (BMD) and prediction of risk of future fracture among community dwelling populations. In populations where bone densitometry of peripheral sites may be the most cost effective and practical means of measuring BMD, such as the nursing home population, knowing the characteristics of forearm BMD measures would be beneficial. The purpose of this study was to assess the relationship of four common commercially available measures to each other and to estimate the inter- and intrarater reliability of the measures in a sample of nursing home residents as a first step toward identifying appropriate forearm measurement sites. These sites were the distal radius, the distal ulna, a composite of the distal radius and distal ulna, and the ultra distal radius. BMD measurements on 48 nursing home patients were obtained using single X-ray absorptiometry. Inter- and intrarater reliability was excellent at all four sites (interclass correlation coefficients > 0. 85). Moderate to high correlations (0.84-0.91) between the distal radius and ultra distal radius sites of the forearm suggest that these measures may be interchangeable. Although not directly assessed here, differences in bone composition among forearm sites may partially explain moderate rather than high correlations between sites and may affect the ability of each site to predict future fractures. Thus, different forearm sites may be used interchangeably for diagnostic purposes; however, the prognostic value of each site remains unknown.