Episodes Of Fracturing Research Articles

Hydrothermal silicification along rift border faults in the Rio do Peixe basin, Brazil

This study investigates hydrothermal silicification along rift border faults in the Cretaceous Rio do Peixe Basin, Brazil, through field geology, petrography, mineralogy, and fluid inclusion microthermometry. We distinguish three main structural-diagenetic domains: (1) a non-silicified fault damage zone, (2) a silicified damage zone composed of deformation bands and centimeter-scale quartz veins in the hanging wall and footwall, respectively, and (3) a silicified fault core with meter-scale wide quartz veins and mosaic breccia textures. We recognize three main events of silicification in the fault zone. The first silicification event occurs after the widespread development of deformation bands in the hanging wall damage zone that may reach 270 m in width. During subsequent deformation events, multiple fracturing episodes were accompanied with precipitation of the second quartz generation in hydraulic mosaic breccias and the third quartz cement in vein stockworks. Shallow burial conditions of faulting (<2 km), combined with fluid inclusion homogenization temperatures of the second quartz generation, indicate that silicification occurred in a hydrothermal system characterized by fluid temperatures in the range of 71–391 °C (mean value of 141 °C). We conclude that hydrothermal silicification was imprinted during the late synrift stage, when the rift border faults were already established. This contribution has implications for understanding how structural processes may control the geometrical, petrographic and petrophysical attributes of hydrothermal products.

Acoustic emission and failure characteristics of coal and rock under single-free-face true triaxial loading

The airside roadway is frequently identified as the predominant site for dynamical disasters involving coal and rock. For the assurance of safety in mining zones, it becomes imperative to understand the mechanical response and energy characteristics of the coal and rock system within the airside roadway during mining processes. A triaxial static and dynamic load test system was used to conduct compression experiments on coal and rock samples under single-free-face true triaxial loading at different loading rates. The research findings are summarized as follows: (1) The damage and failure of the samples gradually propagate from the free face to the deeper sections of the samples and evident stage characteristics. Revealed that the damage mechanism was “microfracture localization – localized region development through – overall instability.” (2) A rising loading rate impedes the coal and rock's ability to make adaptive adjustments, thereby amplifying the sample's resistance against crack development, and playing a positive role in stimulating coal and rock failure, and the coal and rock system changed from progressive stable failure to sudden instability failure. The mesoscopic failure pattern gradually evolves into inadequacy and irregularity. (3) Throughout the entire failure episodes of coal and rock samples, the predominant mode of failure is tensile. However, influenced by the loading rate, the principal failure mechanism transitions from tensile to shear during the Ⅳ stage of failure. (4) There is noteworthy congruence between the macrofracture sites and the spatial positioning of high-energy fracture episodes. This furnishing pivotal insights for preempting and control deep impact disasters.

Ulnar carpal translation following palmar locking plate fixation for distal radius fractures: a retrospective analysis

BackgroundConcomitant injuries to the radiocarpal ligaments may occur during episodes of distal radius fractures, which may not cause acute subluxation or dislocation but can lead to radiocarpal instability and progress over time. This study aimed to analyze the occurrence of ulnar carpal translation (UCT) after open reduction and internal fixation of distal radius fractures and evaluate the associated factors of UCT.MethodsThe retrospective study has been done now and includes patients treated between 2010 and 2020 who had undergone reduction and locking plate fixation of distal radius fractures. We assessed radiographs taken immediately after the operation and at 3 months post-operation, enrolling patients with UCT for evaluation. In addition to demographic data, we evaluated radiographic parameters, including fracture pattern, fragment involvement, and ulnar variance. We also assessed the palmar tilt-lunate (PTL) angle to determine associated rotatory palmar subluxation of the lunate (RPSL).ResultsAmong the 1,086 wrists, 53 (4.9%) had UCT within 3 months post-operation. The majority of wrists with UCT exhibited normal to minus ulnar variance (49 wrists; mean: −1.1 mm), and 24 patients (45.3%) had concomitant RPSL. Fracture classification was as follows: 19 type A3 (35.8%), 5 type C1 (9.4%), 11 type C2 (20.8%), and 18 type C3 (34.0%). Radial styloid was involved in 20 wrists (37.7%), palmar rim in 18 wrists (34.0%), dorsal rim in 25 wrists (47.2%), and die-punch fractures in 3 wrists (5.7%). Concomitant ulnar styloid fractures were present in 29 wrists (54.7%).ConclusionThis study highlights the potential for UCT to occur following reduction and fixation of distal radius fractures, particularly in cases with a more severe fracture pattern and combined with ulnar minus variance. The high incidence of concomitant RPSL provides further evidence for the possibility of associated radiocarpal ligament insufficiency after distal radius fracture.

Therapeutic Prediction of Osteoporotic Vertebral Compression Fracture Using the AO Spine-DGOU Osteoporotic Fracture Classification and Classification-Based Score: A Single-Center Retrospective Observational Study.

The treatment of osteoporotic vertebral compression fractures (OVCFs) is based on their severity; however, an efficient prediction tool is lacking. We aimed to evaluate the validity of the osteoporotic fracture classification (OF classification) and scoring system (OF score) in predicting the treatment strategy for patients with OVCF, defined according to the Japanese criteria. We retrospectively investigated 487 consecutive patients diagnosed with vertebral body fractures between January 2018 and December 2022. Only patients with their fresh vertebral fracture episode during the study period were included. Patients were classified into 3 groups: conservative treatment, balloon kyphoplasty (BKP), and open surgery. OF classification and OF scores were assessed for each patient. A total of 237 patients with OVCF were included. There were 127, 81, and 29 patients in the conservative, BKP, and open surgery groups, respectively. The OF score was significantly higher in the BKP and open surgery groups than in the conservative group (p < 0.001). Multivariate logistic regression analysis showed that antiosteoporotic drug use, OF classification, progressive deformity, neurological symptoms and mobilization were independent risk factors for operative treatment (all p < 0.001). Receiver operating characteristic analysis showed that the cutoff OF score for operative indication was 5.5, with a sensitivity of 91.9%, specificity of 56.5%, and area under the curve of 0.820 (95% confidence interval, 0.769-0.871). The OF score identified patients who required operative treatment with a high degree of accuracy. This is especially important for ruling out patients who definitely require operative treatment.

Differential assessment of fracture frequency and risk in patients undergoing hemodialysis depending on the treatment of mineral and bone disorders: Prospective cohort study with historical control

The present study aimed to assess the incidence, risk, and timing of fractures in patients undergoing hemodialysis with secondary hyperparathyroidism (SHPT), following the correction of mineral and bone disorders (MBD).&#x0D; Methods. This prospective cohort open-label study involving 242 patients was conducted between 2019 and 2022. The patients were categorized into three groups based on MBD treatment. Group 1 (n=64) represented a historical cohort without modern treatment, while Group 2 (n=153) received contemporary MBD and SHPT correction. Group 3 (n=22) included patients prescribed selective vitamin D receptor activators in addition to modern therapy.Patients underwent regular assessments, including calcium, phosphorus, and parathyroid hormone measurements every three months, therapy adjustments, fracture diagnosis, and treatment over a 24-month follow-up period.&#x0D; Results. Our findings revealed a significantly higher cumulative proportion of patients without bone fractures in Group 2 compared to the historical control, with survival rates of 75.8% and 92.6%, respectively (p=0.0006). The average life expectancy before fractures in Group 2 was 695.77±10.19 days, significantly longer than the historical group (p &lt; 0.0001), and the risk of bone fractures decreased by more than four times (HR 0.2274, 95% CI: 0.0965 – 0.5358).&#x0D; Comparing Groups 1 and 3 showed even more positive outcomes. The cumulative proportion of patients without fractures at the end of the study was 75.8% in Group 1 and 95.5% in Group 3 (p = 0.0441), with a life expectancy before fractures of 630.88±24.29 days and 724.38±5.48 days, respectively (p &lt; 0.0001). The risk for bone fractures decreased by one-third in Group 3 (HR 0.3390, 95% CI: 0.0838 - 0.9058). The average life expectancy before fractures in Group 3 was significantly longer than in Group 2 (p &lt; 0.0001), although the cumulative proportion of patients without fractures did not differ significantly (95.5% vs. 92.6%, p &gt; 0.05).&#x0D; Conclusions. The study demonstrates that correcting SHPT and MBD with non-calcium phosphate binders, calcimimetics, and paricalcitol or vitamin D reduces fracture incidence and risk, and increases the treatment duration until a fracture episode occurs in patients undergoing hemodialysis.

Geothermal carbonate reservoirs and their sustainability: what can natural hydrothermal systems tell us?

Minerals that make up carbonate rocks (i.e. calcite) have very high chemical reactivity, allowing for various types of porosity-altering deformation processes such as dissolution and recrystallization (e.g. dolomitization, silicification), that produce secondary porosity. Even though water enriched with CO2 may quickly equilibrate by dissolving calcite, carbonate is also very dynamic, and cemented veins may still act as planes of weakness compared to the host rock allowing fluids to open up and then seal these fractures again. Therefore, natural carbonate rocks often show not only the numerous deformation stages overprinting one another, but also the same veins opening up again and again forming crack-seal structures.Natural fossil hydrothermal systems were investigated within outcrops at Nowa Wioska, Czatkowice, Pomorzan, Trzebionka, Orzel Bialy mines, Dziura cave and Hucianski Klin crest in the south of Poland to evaluate the influence of hydrothermal activities on the rock pore evolution. We present in more detail the Triassic carbonate sequence near Nowa Wioska village in the Silesian-Kraków region, where hydrothermal water had been flowing through an open fault zone, forming various hydrothermal products: secondary intercrystalline pores, vugs, breccias, metal ore and mineral precipitates. The impact of these products on the permeability of the geothermal system was analyzed in comparison with the adjacent host rock unaffected by tectonic and hydrothermal processes. We observed that at least three successive episodes of fracturing occurred during the Tertiary demonstrating that fluids were introduced episodically in the Triassic rocks. Fracture- and vug-filling calcite, saddle dolomite, pyrite, sphalerite, galena, quartz and clays were preferentially observed on the downthrown side of the fault that underwent a more intense tectonic deformation that had a decisive influence on the migration of mineralizing hydrothermal solutions. Even though mineral and metal-ore precipitates, sediments and solution / collapse breccias fill most of these karsts and fractures, the porosity and permeability of the hydrothermally altered rocks remain quite high compared to the host rock. Moreover, secondary dissolution forming vugs increase this porosity and permeability even further. The studied examples suggest that once geothermal system has been active, it stays as a preferential zone for the following deformation events, making it sustainable for tens of thousands or even millions of years.

Validation of an algorithm to identify fractures among patients within the Veterans Health Administration.

To validate an algorithm that identifies fractures using billing codes from the International Classification of Diseases Ninth Revision (ICD-9) and Tenth Revision (ICD-10) for inpatient, outpatient, and emergency department visits in a population of patients. We identified and reviewed a random sample of 543 encounters for adults receiving care within a single Veterans Health Administration healthcare system and had a first fracture episode between 2010 and 2019. To determine if an encounter represented a true incident fracture, we performed chart abstraction and assessed the type of fracture and mechanism. We calculated the positive predictive value (PPV) for the overall algorithm and each component diagnosis code along with 95% confidence intervals. Inverse probabilities of selection sampling weights were used to reflect the underlying study population. The algorithm had an initial PPV of 73.5% (confidence interval [CI] 69.5, 77.1), with low performance when weighted to reflect the full population (PPV 66.3% [CI 58.8, 73.1]). The modified algorithm was restricted to diagnosis codes with PPVs > 50% and outpatient codes were restricted to the first outpatient position, with the exception of one high performing code. The resulting unweighted PPV improved to 90.1% (CI 86.2, 93.0) and weighted PPV of 91.3% (CI 86.8, 94.4). A confirmation sample demonstrated verified performance with PPV of 87.3% (76.0, 93.7). PPVs by location of care (inpatient, emergency department and outpatient) remained greater than 85% in the modified algorithm. The modified algorithm, which included primary billing codes for inpatient, outpatient, and emergency department visits, demonstrated excellent PPV for identification of fractures among a cohort of patients within the Veterans Health Administration system.

Canine appendicular osteosarcoma: Amputation and chemotherapy in cancer treatment

Osteosarcoma is a malignant bone neoplasm with a high incidence in adult and giant breed dogs, with the appendicular skeleton being the most affected compared to the axial one. The symptoms usually present are claudication, swelling and may or may not be associated with episodes of fractures. The diagnosis consists of imaging exams, and in many cases, confirmation is only possible through bone biopsy. Due to aggressiveness the prognosis is unfavorable, and the best treatment for this case is limb amputation, with the intention of removing the primary tumor. The dog, in this report, was diagnosed by bone biopsy, whose histopathological result was osteoblastic osteosarcoma. The tumor originated in the distal femur of the left pelvic limb and the patient was referred for amputation, the surgical technique used was coxofemoral disarticulation. As an adjuvant treatment, chemotherapy with carboplatin was instituted. There were fivw sessions in an interval of 21 in 21 days, without reaction or alterations in the complementary exams. Pulmonary macro metastases were not identified in the radiographic examination, and a disease-free interval was observed, guaranteeing quality of life for the patient, despite being a very aggressive tumor.

Emergency department reorganisation introducing increased autonomy: A mixed effects approach to evaluate the effects of a national policy.

In 2007, a Danish national policy to future-proof emergency department (ED) performance was launched. The policy included several recommendations for the management and organisation of care that essentially introduced greater ED autonomy. In this study, we evaluate the effects of increased ED autonomy on readmission, mortality and episode costs for two large patient groups. A non-randomised stepped wedge study-design where all EDs gradually implemented the policy at different steps during the study period (2008-2016). The timing and extent of policy implementation was determined from a retrospective cross-sectional survey of all 21 Danish EDs. This was linked to all episodes of hip fracture (n = 79,697) and erysipelas (n = 39,900) identified in the Nation Patient Registry and with episode-level outcomes. Mixed effect models were specified for the outcomes of 30-day readmission, 30-day mortality and episode costs, and adjusted for relevant ED- and episode-level heterogeneity. Increased ED autonomy was associated with more readmissions (p<0.05) and higher episode costs (p<0.001) in hip fracture episodes. In erysipelas episodes, no general associations were found. When restricted to night-time admissions, increased ED autonomy was associated with poorer outcomes for erysipelas episodes and increased episode costs for both patient groups. The intended policy effects were not found for these two patient groups; in fact, reorganisation appeared to have harmed hip fracture patients and increased episode costs. Uncertainty remains regarding the longer-term consequences.

Proximal femoral fracture and female gender are risk factors for recurrent fracture: Cohort study of 292 patients over 75 years-old with iterative osteoporotic fractures

PurposeThe purpose of this study was to: 1/ describe the characteristics of a cohort of patients over 75 years of age hospitalized in perioperative geriatric units (UPOG) for iterative fractures; 2/ investigate the risks of institutionalization related to the first fracture; and 3/ search for potential risk factors for iterative fracture. MethodsThis is a retrospective single-center study analyzing patients over 75 years old, hospitalized in UPOG. ResultsOf the 3207 patients hospitalized, 292 patients had a refracture (9.1%), with a mean age of 85.4+/-5.8 years. Initial fractures were mainly intertrochanteric (43.2%) and the femoral neck (32.9%). Refractures occurred mainly in the first year (55.5%), with a median delay of 9.6 months. Refractures were mainly intertrochanteric (29.5%), peri‑implant (prosthesis, osteosynthesis) (28.8%), and femoral neck (26.7%). Dementia was the only factor for institutionalization after the first fracture episode (p = 0.0002).Proximal femoral fracture (PFF) and female gender were risk factors for iterative fracture (10.2% vs. 6.8%, p = 0.003; 10.7% vs. 6.8%, p = 0.005 respectively), but not age (85.4 vs. 85.8 years, p = 0.24). PFF were more likely to result in the same fracture type in the second episode (58.1% vs 7.1%, p<0.0001). The time to refracture was shorter in case of peri‑implant fracture (p = 0.0002), or discharge directly to home (p = 0.04). ConclusionPFF and female gender are risk factors for recurrent fracture, which is even more likely to occur early in case of home discharge or peri‑implant fracture.

PLASMA HIGH DENSITY LIPOPROTEIN CHOLESTEROL AND RISK OF FRACTURES IN OLDER ADULTS

Abstract The ASPirin in Reducing Events in the Elderly trial participants (ASPREE, aged &amp;gt;70-years Australians), for whom high-density lipoprotein cholesterol (HDL-C) levels were measured were included. Fractures included were confirmed by medical imaging and included both traumatic and pathological fractures. Fractures were confirmed by an expert review panel. Cox proportional hazards regression was used to calculate hazard ratio (HR) and 95% confidence interval (CI) for associations with fractures. Of the 16262 participants who had a plasma HDL-C measurement at baseline 1,659 experienced at least one episode of fracture over a median of 3.98 years (interquartile range, 0.02, 7.0 years). In the fully adjusted model, each mmol/L increment in HDL-C was associated with a 34% (HR 1.34, 95% CI 1.20–1.50) higher risk of fractures. The results remained similar when these analyses were stratified by sex. Sensitivity analyses demonstrated that these associations persisted when the analyses were repeated including only: 1) nontraumatic fractures, 2) participants not on osteoporotic medications, 3) participants who were never-smokers and reported that they did not drink alcohol, and 4) participants who walked outside less than 30 minutes and reported no participation in moderate/vigorous physical activity. No association was observed between non-HDL-C and fractures. This prospective observational study suggests that higher levels of HDL-C are associated with higher fracture risk. This association was independent of the common risk factors of fractures.

Polypharmacy Predicts Onset and Transition of Frailty, Malnutrition, and Adverse Outcomes in Peritoneal Dialysis Patient.

Polypharmacy, frailty and malnutrition are known predictors of adverse outcomes in dialysis patients. Little has reported about their interaction and composite prognostic values. We aimed to describe the interaction between polypharmacy, frailty, nutrition, hospitalization, and survival in peritoneal dialysis patients. In this prospective cohort study, we recruited 573 peritoneal dialysis patients. Drug burden was measured by medication number and daily pill load. Frailty and nutrition were assessed by the validated Frailty Score (FQ) and Subjective Global Assessment (SGA) respectively. All patients were followed for two years. Primary outcome was all-cause mortality. Secondary outcomes were fall and fracture episodes, hospitalization, change in FQ and SGA. At baseline, each patient took 7.5 ± 2.6 medications with 15.5 ± 8.5 tablets per day. Medication number, but not daily pill load predicted baseline FQ (p = 0.004) and SGA (p = 0.03). Over 2 years, there were 69 fall and 1,606 hospitalization episodes. In addition, 148 (25.8%) patients died, while FQ and SGA changed by 0.73 ± 4.23 and -0.07 ± 1.06 respectively in survivors. Medication number (hospitalization: p = 0.02, survival: p = 0.005), FQ (hospitalization: p < 0.001; survival: p = 0.01) predicted hospitalization and survival. Medication number also predicted fall episodes (p = 0.02) and frailty progression (p = 0.002). Daily pill load did not predict any of these outcomes. Drug burden is high in peritoneal dialysis patients, and it carries important prognostic implication. Medication number but not pill load significantly predicted onset and progression of frailty, malnutrition, fall, hospitalization, and mortality.

Comparing the rates and modes of failure of two third generation cephalomedullary nail systems in the treatment of intertrochanteric hip fractures

IntroductionCephalomedullary (CMN) implants are commonly used to address elderly intertrochanteric hip fractures. Multiple CMN implant systems exist with subtle variation between manufacturers. Multiple modes of CMN failure have been described in the literature. The present study assessed the local modes and rates of construct failure (nail fracture, cut-out and non-union) of two such implants, after a change in implant supply provided the opportunity for retrospective comparison. Additional investigation was undertaken to assess whether any predictors of failure could be identified based on common radiographic measurement parameters. MethodsBased on local implant records, all consecutive patients who suffered an intertrochanteric fracture, treated at a tertiary care hospital with a cephalomedullary nail from January 2014 to January 2018 were included. Patients were excluded if they received a CMN for pathologic fracture. Within the collection period all patients received either a Synthes Trochanteric Fixation Nail (TFN) or Zimmer Natural Nail (ZNN). Patients were retrospectively assessed for fracture reduction and implant technique parameters at the time of initial surgery. Radiographic data were assessed at minimum two years post-operatively to assess for union. Patient demographic data was followed to assess rate and mode of failure. ResultsSix hundred and sixty-two patients were included in the study, from which a propensity matched cohort was derived. Comparing across equivalent cohorts, no differences in the rate or mode of construct failure were identified between the TFN and ZNN.When assessing the entire cohort we observed 39 construct failures (5.9%), which included 31 instances of nail cutout (4.7%), 4 episodes of nail fracture (0.6%) and 4 failures related to non-union (0.6%). Tip to apex distance, sagittal malalignment and Cleveland zone were identified as significant predictors of nail failure. ConclusionNo difference in rates or modes of failure were identified between the TFN and ZNN constructs. Similar to previous reports we again identified the impact of tip to apex distance on construct failure and further identified Cleveland zone and sagittal malalignment as significant risks for failure.

MO538: Lower Serum Levels of Magnesium are Associated With Higher Risk of Fractures in Haemodialysis Patients

Abstract BACKGROUND AND AIMS Magnesium (Mg) deficiency is associated with altered bone metabolism, However, the relationship between Mg and the risk of fragility fractures haemodialysis (HD) patients is still unclear. The aim of this study was to evaluate the association between pre-dialysis Mg serum levels and the risk of incident bone fractures in a cohort of prevalent HD patients. METHOD We performed a prospective study of 206 prevalent HD patients followed from 2009 until 2021. Demographic, clinical and biochemical parameters were evaluated. RESULTS A total of 37 episodes of fragility fractures were identified with a median HD vintage of 42 months, which corresponds to an incidence rate of 29/1000 person-years. The mean age of the studied population was 68.3 ± 13.1 years, 121 (59%) were male and the median follow-up time on HD was 58 months. Patients with incident fractures showed significantly lower Mg levels compared with those without fractures (2.3 ± 0.3 versus 2.8 ± 0.4 mg/dL, P &amp;lt; 0.001). In a multivariable analysis, lower Mg levels (P = 0.02) were independently associated with increased risk of fracture, in a model adjusted to age, female gender, albumin and dialysis vintage. Patients with a Mg serum level &amp;lt; 2.2 mg/dL (lowest quartile) had a 1.32-fold higher risk for fragility fractures than those in the highest quartile [95% confidence interval (95% CI), 1.15–1.48; P &amp;lt; 0.001]. CONCLUSION This study shows that the incidence of bone fragility fractures in HD patients is high and significantly associated with lower pre-dialysis Mg levels. Management of fracture risk in HD patients and assessment of its risk factors requires further study.

How fluid-mediated rock transformations can mimic hydro-fracturing patterns in hydrothermal dolomite

Numerous studies of hydrothermal dolomite bodies describe brecciated rocks characterized by dark angular fragments of dolomicrite bounded together by saddle dolomite crystals forming veins. Often associated with ore deposits, these hydrothermal dolomite breccia (HDB) patterns are usually interpreted as related to hydro-fracturing and so are considered as univocal markers of fluid overpressure. In this contribution we report an occurrence of typical HDB pattern in a dolomitized sedimentary breccia related to Mesozoic hyper-extension located in the Northern Pyrenees (France). We propose a model that accounts for the textural and crystallographic patterns of a HDB, without any fluid overpressure. The following observations lead us to propose that this HDB results from texturally controlled, hydrothermal fluid-initiated recrystallization of the initial sedimentary breccia by grain boundary migration: (1) the occurrence of rough contacts between the dolomite crystals and an initial dolomitized sedimentary breccia structure; (2) the crystallographic pattern of the hydrothermal dolomite; (3) the different grain size distribution in HDB texture and initial breccia structure; (4) the spatial distribution of oxide particles. Our alternate interpretation was further tested by 2D numerical simulations of the replacement process using the ‘ELLE’ modelling toolbox. Simulations confirm that advection of hot fluids along porous zones can locally trigger recrystallization by grain boundary migration, a replacement of the initial breccia texture and a preservation of larger, less permeable and cold fragments. We propose key features in textural evidence to assess whether HDB texture is pinpointing towards episodes of fluid overpressure and fracturing in carbonates, or if it rather is related to fluid-mediated rock recrystallization.

Bone Safety Profile of Steroidal Aromatase Inhibitor in Comparison to Nonsteroidal Aromatase Inhibitors in Postmenopausal Women with Breast Cancer: A Network Meta-Analysis

Background and Objectives: Aromatase inhibitors (AIs) provide an alternative to tamoxifen as an adjuvant therapy for postmenopausal patients with breast cancer (BC). Large trials resulted better outcomes with AIs. Adjuvant therapy with AIs reduced the risk of relapse compared with tamoxifen. Systemic therapies for BC can interfere with bone turnover, either by affecting gonadal steroid hormone production or by inhibiting peripheral aromatization into estrogen. We aimed to evaluate the safety profile of bone-related events by comparing 3 AIs with tamoxifen and a placebo. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were used for network meta-analyses (NMAs). Searches were performed using PubMed, Embase/Medline, Cochrane, and Ovid databases. Randomized controlled trials comparing tamoxifen and placebo or other AIs to steroidal or nonsteroidal AIs in patients with BC reporting bone-related safety events were included in NMA. NMA in a Bayesian approach was performed using R software (ver 3.2), Gemtc package. Results: Seventeen studies reporting 4 different bone-related endpoints were included. Although there was no statistical significance, treatment with exemestane lowered the incidence of bone pain (odds ratio [OR] vs. anastrozole and letrozole: 0.63, 0.54), fracture episodes (OR vs. anastrozole and letrozole: 0.84, 0.80), and osteoporosis (OR vs. anastrozole and letrozole: 0.85, 0.73) compared with letrozole and anastrozole. Reduction in bone mineral density was lesser in exemestane than in anastrozole (mean reduction in hip: 1.05; lumbar spine: 1.25). Treatment ranking with the surface under the cumulative ranking curve showed that exemestane was found to reduce the incidence of bone-related adverse events. Conclusion: A lower incidence of bone-related safety events was observed in patients treated with exemestane.

Organisational determinants and consequences of diagnostic discrepancy in two large patient groups in the emergency departments: a national study of consecutive episodes between 2008 and 2016

BackgroundDiagnostic discrepancy (DD) is a common phenomenon in healthcare, but little is known about its organisational determinants and consequences. Thus, the aim of the study was to evaluate this among selected emergency department (ED) patients.MethodWe conducted an observational study including all consecutive ED patients (hip fracture or erysipelas) in the Danish healthcare sector admitted between 2008 and 2016. DD was defined as a discrepancy between discharge and admission diagnoses. Episode and department statistics were retrieved from Danish registers. We conducted a survey among all 21 Danish EDs to gather information about organisational determinants. To estimate the results while adjusting for episode- and department-level heterogeneity, we used mixed effect models of ED organisational determinants and 30-day readmission, 30-day mortality and episode costs (2018-DKK) of DDs.ResultsDD was observed in 2308 (3.3%) of 69,928 hip fracture episodes and 3206 (8.5%) of 37,558 erysipelas episodes. The main organisational determinant of DD was senior physicians (nonspecific medical specialty) being employed at the ED (hip fracture: odds ratio (OR) 2.74, 95% confidence interval (CI) 2.15–3.51; erysipelas: OR 3.29, 95% CI 2.65–4.07). However, 24-h presence of senior physicians (nonspecific medical specialty) (hip fracture) and availability of external senior physicians (specific medical specialty) (both groups) were negatively associated with DD. DD was associated with increased 30-day readmission (hip fracture, mean 9.45% vs 13.76%, OR 1.46, 95% CI 1.28–1.66, p < 0.001) and episode costs (hip fracture, 61,681 DKK vs 109,860 DKK, log cost 0.58, 95% CI 0.53–0.63, p < 0.001; erysipelas, mean 20,818 DKK vs 56,329 DKK, log cost 0.97, 95% CI 0.92–1.02, p < 0.001) compared with episodes without DD.ConclusionDD was found to have a negative impact on two out of three study outcomes, and particular organisational characteristics seem to be associated with DD. Yet, the complexity of organisations and settings warrant further studies into these associations.

The effect of lockdown during SARS-CoV-2 pandemic on maxillofacial injuries in a level I trauma centre: a comparative study.

IntroductionThe SARS-CoV-2 pandemic forced many governments to impose nation-wide lockdowns. Government legislation forced limited travel on the population with restrictions on the normal way of life to limit spread of the SARS-CoV-2 virus. The aim of this study is to explore the effects of lockdown on the presentation of maxillofacial trauma in a level I trauma centre.MethodsComparative analysis was carried out using prospective and retrospective review of all consecutive patients admitted with any maxillofacial fracture in the lockdown period between 15th March and 15th June 2020 with the same period in 2019 to a Regional Trauma Maxillofacial Surgery Unit. Data included basic demographics and mechanism of injury including alcohol/drug influence, polytrauma, site of injury and treatment modality including escalation of care.ResultsAcross both periods, there were a total of one hundred and five (n = 105) recorded episodes of traumatic fractures with fifty-three (n = 53) in the pre-lockdown cohort and fifty-two (n = 52) in the lockdown. Included patients were significantly (p = 0.024) older during lockdown (mean age 41.44 years SD 20.70, range 5–96) with no differences in gender distribution between cohorts (p = 0.270). Patients in lockdown were more likely to be involved in polytrauma (p < 0.05) and have sustained their injury by cycling/running or any outdoor related activity (p = 0.013). Lockdown saw a significant reduction in alcohol and drug related violence (p < 0.05). Significantly more patients required operative management (p = 0.038).ConclusionLocal lockdowns form part of the governments public health strategy for managing future outbreaks of SARS-CoV-2. Our study showed no significant reduction in volume of trauma during lockdown. It is vital that hospitals maintain trauma capacity to ensure that patients are treated in a timely manner.

Incremental biomarker and clinical outcomes after switch from enzyme therapy to eliglustat substrate reduction therapy in Gaucher disease

In Gaucher disease (GD), genetic deficiency of acid β-glucosidase leads to accumulation of its substrate glucosylceramide (GlcCer) and glucosylsphingosine (GlcSph). Lipid-laden cells, most prominently seen as macrophages engorged with GlcCer and GlcSph-laden lysosomes, trigger chronic metabolic inflammation and multisystemic phenotypes. Among the pleiotropic effects of inflammatory cascades, the induction of glucosylceramide synthase accentuates the primary metabolic defect. First-line therapies for adults with GD type 1 include Enzyme Replacement Therapy (ERT) and eliglustat Substrate Reduction Therapy (SRT). The ENCORE phase 3 clinical trial of eliglustat demonstrated non-inferiority compared to ERT. It is not known whether switching stable patients from long-term ERT to SRT results in the incremental reversal of the disease phenotype and its surrogate indicators. Herein, we report real-world experience from a single tertiary referral center of 38 adult GD type 1 patients, stable on long-term ERT (mean 13.3 years), who switched to eliglustat SRT (mean 3.1 years). After switch to SRT, there was significant reduction in spleen volume (P = 0.003) while liver volume, which was normal at baseline, remained unchanged. Platelet counts increased significantly (P = 0.026). Concomitantly, there was reduction of three validated biomarkers of Gaucher disease activity: plasma GlcSph decreased from 63.7 ng/ml (95% CI, 37.6-89.8) to 26.1 ng/ml (95% CI, 15.7-36.6) (P < 0.0001); chitotriosidase fell from 1136.6 nmol/ml/h (95% CI, 144.7-2128.6) to 466.9 nmol/ml/h (95% CI, 209.9-723.9) (P = 0.002); and glycoprotein non-metastatic melanoma B (gpNMB) decreased from 59.3 ng/ml (95% CI, 39.7-78.9) to 43.6 ng/ml (95% CI, 30.7-56.6) (P = 0.0006). There were no episodes of avascular necrosis or fractures in patients on SRT. Patients reported favorable experiences of switching from alternate week infusions to oral therapy. Collectively, these results demonstrate that the switch to eliglustat SRT from ERT leads to incremental response, even in stable patients after long-term ERT.

Gender Disparities in Osteoporosis Screening and Management Among Older Adults.

One in two women and one in four men experience an osteoporosis-related fracture in their lifetime. Related morbidity and mortality rates are higher in men versus women. Current guidelines are inconsistent in the screening recommendations for osteoporosis in men. Examination of gender disparities in the management of osteoporosis-related fractures among Medicare enrollees is currently lacking. In this retrospective cohort study using 5% National Medicare claims data from January1, 2012 through December31, 2016, eligible patients who were at least 65years of age on the date of a new fracture episode were classified into two mutually exclusive cohorts on the basis of whether they received testing and/or treatment for osteoporosis in the 6-month period after the new fracture episode. The cohorts were defined on the basis of the National Committee for Quality Assurance (NCQA) quality measure "osteoporosis management in women who had a fracture." Patients were followed to identify the occurrence of subsequent fracture, all-cause mortality, and a composite outcome-defined as the first occurrence of either subsequent fracture or mortality. Logistic regression models were carried out to identify predictors of testing and/or treatment and time-varying survival analysis to identify the relationship between the presence of testing and/or treatment and patient outcomes. Of the 35,774 eligible patients, only 10.2% (12.1% women and 5.7% men) received osteoporosis testing and/or treatment within 6months after a fracture. The interaction between gender and fragility fracture was significant (P < 0.0001). Fragility fracture had greater adjusted odds of testing and/or treatment among men (adjusted odds ratio [AOR] 3.47; 95% CI 2.94-4.10) than women (AOR 1.65; 95% CI 1.53-1.79). Of patients who were eligible for the outcome assessment, 27.5% experienced a subsequent fracture, 23.2% died, and 44.3% experienced a composite outcome during follow-up. Patients who received testing and/or treatment had a significantly lower hazard of all-cause mortality (hazard ratio [HR] 0.57; 95% CI 0.50-0.65; P < 0.0001) and the composite outcome (HR 0.42; 95% CI 0.39-0.45; P < 0.0001), but no difference in the risk of subsequent fracture (HR 1.02; 95% CI 0.94-1.11; P = 0.6083). Men were found to have a significantly lower hazard of subsequent fracture (HR 0.69; 95% CI 0.64-0.73; P < 0.0001), all-cause mortality (HR 0.67; 95% CI 0.61-0.72; P < 0.0001), and the composite outcome (HR 0.69; 95% CI 0.65-0.73; P < 0.0001). Testing and/or treatment for osteoporosis among older adults with a fracture is poor in the Medicare fee-for-service population overall and worse for men compared to women. Receiving appropriate testing and/or treatment was associated with reduced mortality and the risk of composite outcome. Improving osteoporosis testing and/or treatment and reducing health disparities are essential for managing the clinical and economic burden of osteoporosis in the USA.