Fracture liaison service improves care for patients with fragility fractures

Patients receiving FLS care have high rates of evaluation and treatment for osteoporosis, leading to improved bone quality and function, according to the follow-up study by Julio C. Fernandes, MD, FRCSC, Ph.D., MBA, and colleagues of Université de Montréal. "These results suggest that an intensive FLS model of care, with a systematic longitudinal follow-up, is effective," the researchers write.

New Data on Two-Year Outcomes of FLS Care for Fragility Fractures

Fragility fractures are those resulting from minimal trauma, such as a fall from standing height or less, and commonly occur in the hip, spine, or wrist. The FLS approach has emerged as a means to improve the identification and care of fragility fractures, including those related to osteoporosis.

Dr. Fernandes and colleagues report on their experience with FLS care in 532 patients. The average patient age was 63 years, and 86 percent were women. Rates of recommended evaluation and management of fragility fractures were analyzed, along with subsequent fractures and other key outcomes after a two-year follow-up.

Patients managed with use of FLS had high rates of recommended care. Eighty-nine percent of patients underwent measurement of bone mineral density, and 87 percent were started on treatment for osteoporosis. Overall, 84 percent of patients made at least one follow-up visit.

A total of 23 subsequent fractures occurred in 21 patients over nearly 900 person-years, with a rate of 2.6 percent per 100 person-years. That rate was lower than those suggested by past studies of patients with fragility fractures in the general population, which have ranged from 4 to 10 per 100 person-years.

Laboratory tests showed significant improvements bone metabolism during FLS care, including a slower rate of bone turnover. Standard measures of functional capacity and disability improved, while pain scores decreased.

Despite its growing popularity, there are still limited data on the effectiveness of the FLS approach. While previous "real world" studies of FLS care have reported high rates of testing and treatment, this new study is one of the first to include the results of systematic follow-up, including subsequent fracture rates.

The results suggest real benefits of FLS care for patients with fragility fractures, including testing, treatment, and follow-up participation rates over 80 percent. This study also suggests that FLS care is associated with a low rate of subsequent fractures, with reduced bone turnover and improved functional capacity.

Although this new analysis doesn't include a comparison group of patients not receiving FLS care, historical data from previous studies support their findings. "A randomized controlled trial with a larger sample and a longer follow-up period would better quantify the yield of improvement over the usual care," Dr. Fernandes and colleagues conclude.

'It's like you have a hand again': An ultra-precise mind-controlled prosthetic

In a major advance in mind-controlled prosthetics for amputees, University of Michigan researchers have tapped faint, latent signals from arm nerves and amplified them to enable real-time, intuitive, finger-level control of a robotic hand.To achieve this, the researchers developed a way to tame temperamental nerve endings, separate thick nerve bundles into smaller fibers that enable more precise control, and amplify the signals coming through those nerves. The approach involves tiny muscle grafts and machine learning algorithms borrowed from the brain-machine interface field.

"This is the biggest advance in motor control for people with amputations in many years," said Paul Cederna, who is the Robert Oneal Collegiate Professor of Plastic Surgery at the U-M Medical School, as well as a professor of biomedical engineering.

"We have developed a technique to provide individual finger control of prosthetic devices using the nerves in a patient's residual limb. With it, we have been able to provide some of the most advanced prosthetic control that the world has seen."

Cederna co-leads the research with Cindy Chestek, associate professor of biomedical engineering at the U-M College of Engineering. In a paper published March 4 in Science Translational Medicine, they describe results with four study participants using the Mobius Bionics LUKE arm.

Novel use of robotics for neuroendovascular procedures

Surgeons at the Sidney Kimmel Medical College at Thomas Jefferson University are pioneering the use of robotics in neuroendovascular procedures, which are performed via the blood vessels of the neck and brain.

A study by Pascal Jabbour, MD, Chief of the Division of Neurovascular Surgery and Endovascular Neurosurgery, demonstrated that the use of these robots to aid surgeons during diagnostic cerebral angiograms and transradial carotid artery stenting was both safe and effective. The research was published March 1st in the Journal of NeuroInterventional Surgery.

"This technology could be groundbreaking, acting as a precursor for remote stroke interventions," Dr. Jabbour said.

When a patient suffers from a stroke, time is of the essence because the blocked vessel must be opened as quickly as possible to prevent permanent damage. Patients living in remote geographic areas have further to travel for stroke intervention, and, often, by time they arrive at a stroke center, it is too late, explains Dr. Jabbour.

Jefferson is the first center in the country to perform robotic transradial carotid stenting. Currently, robots are only approved by the FDA for use in certain general surgery procedures and in interventional cardiology procedures.

Use of robots in neuroendovascular procedures would give surgeons more precise control over the microcatheter and the microwire, two tools threaded through a patient's blood vessels during these procedures.

In addition, physicians who do these procedures regularly will have less exposure to radiation from the X-rays used during the procedure because they can operate the robot from a separate room just outside the surgical suite. Eliminating exposure to radiation would allow surgeons to forgo wearing the heavy personal protective equipment, such as lead aprons, that is typically needed during these procedures.

'Play, Dagmar, play': Violinist recalls tumour op performance

Emerging from the depths of slumber, Dagmar Turner had barely a chance to notice the hushed intensity of the operating theatre when someone thrust her violin into her hands. It was time to play the performance of her life.

As surgeons behind her removed a tumour from her brain, Turner took up her bow and played George Gershwin's aria "Summertime", ensuring she can still perform with her beloved violin after recovery.

"The last thing that comes to your mind is 'I would really like to play my violin now'," she told AFP about her virtuoso performance on the operating table.

The British-based violinist agreed to the unconventional concert to help avoid damage to her brain during surgery.

The 53-year-old German, who plays with the Isle of Wight Symphony Orchestra in southern England, was diagnosed in 2013 with a slow-growing tumour after suffering a seizure during a concert.

Turner told AFP how it felt to be woken from anaesthetic as surgeons operated on her brain.

"It was like being woken up from a really deep sleep," she said, adding that she was then handed her instrument.

"It started fine and the first thing I really remembered was when they put this violin in my face, like, 'now play, Dagmar, play'.

"I was like, 'let me sleep'. It's just horrible."

The amateur musician described being able to feel "somebody standing up behind my head... telling me 'Dagmar, we have just removed 95 percent of your tumour'.

"I was utterly in shock and speechless. You know the day before you have an inoperable tumour and then the next day they tell you 95 percent of that has been taken out," she explained.

What we learned after 5,000 non-surgical rhinoplasties

As patients continue to seek non-invasive treatments across the cosmetic spectrum, "liquid rhinoplasty" is emerging as the non-surgical alternative to the traditional nose job. Using dermal fillers to change the appearance of the nose, non-surgical rhinoplasty is gaining in popularity due to its relatively low cost, convenience, and short recovery time.

There has previously been debate regarding the safety and effectiveness of this procedure—especially in the absence of large-scale studies reporting on the patient outcomes. To address this gap, the March issue of Plastic and Reconstructive Surgery, the official medical journal of the American Society of Plastic Surgeons (ASPS), features a new study that includes an analysis of 5,000 non-surgical rhinoplasties performed between 2015 and 2019—the largest published experience of non-surgical rhinoplasty to date.

The study's lead author, Ayad Harb, FRCSPlast, is a London Consultant Plastic Surgeon and world authority on this increasingly popular procedure.

"We find this treatment an excellent alternative to surgical rhinoplasty in those patients who do not want, cannot have, or do not need surgery," writes Dr. Harb. "This study demonstrates high efficacy and safety, and relatively low complication rates in the hands of an experienced clinician."

The study outlines a safe and effective non-surgical rhinoplasty technique, which focuses on three critical aesthetic points of the nose—the radix, bridge and tip.

"The injections are carried out at the radix and move caudally with a micro-droplet technique. Boluses of no more than 0.1 mL at any one point," writes Dr. Harb. "Frequently, and especially nearer the tip, deposits of filler can be as small as 0.02 mL per site. With each injection point, the gel implant is massaged into place and can be maneuverer to produce a smooth and symmetrical surface. The injections continue in the midline until the tip is reached. The tip is injected perpendicular to the skin to improve projection and definition."

Opinion: New liver organ policy will adversely affect patients in rural US

A rushed proposal that became federal policy across the country this month will increase the cost and decrease access to life-saving care for patients in dire need of a liver transplant across much of the South and Midwest.Here's what is happening and what is at stake for Kentucky:

On Feb. 4, the Organ Procurement and Transplantation Network (OPTN)—based on a recommendation from the United Network for Organ Sharing (UNOS)—implemented a new policy for how livers are allocated around the country for potential transplant. The OPTN sets transplantation policy at the direction of the U.S. Department of Health and Human Services (HHS).

The basic framework of this policy would mean more organs in rural states, like Kentucky, would be sent to larger inner-city medical centers that have higher populations. The idea was to create a policy that ensured more critically ill patients (within 500 nautical miles) received access to livers, rather than the patients in closer proximity.

While the transplant policy is well-intentioned, the fact is the governing board creating and directing the policy is dominated by officials from large urban, coastal areas. The resulting policy benefits those areas.

The process creating this program was rushed and the policy is deeply flawed.

Even the framers of it concede there will be nearly a 30 percent drop in liver transplant volume in Kentucky as a result of this policy. We believe the drop will be even more significant, on the order of 40 percent.

Kentucky, as so many of us know, has a higher mortality rate for chronic liver disease such as cirrhosis than the national average. In rural areas of our state, the rate is even higher as access to care is more limited.

Several things—all negative—will occur in Kentucky and other rural areas of the country:

• This new policy will decrease access to livers for transplant even further.
• It will increase costs, the result of a more inefficient system because of rising costs for flights, fuel and transportation for Kentuckians and others who will have to travel farther to receive transplantation services.
• It will result in longer waiting periods and poorer health outcomes for Kentuckians and others who have to wait longer for donated livers.
• Others, who have to wait and who don't have time, will be more likely to die.

We stand with a network of academic medical centers throughout the South and Midwest—Emory University, the University of Kansas, Indiana University, the University of Michigan, Vanderbilt University, the University of Virginia, Virginia Commonwealth University and Washington University in St. Louis—that have filed a federal lawsuit, asking to prohibit the federal government from implementing the policy.

Looking for clues to improve the life of a transplanted organ

The long-term outcomes following solid organ transplantation in lung, heart, and kidney have not changed in over 20 years. "Transplantation remains a treatment, not a cure, especially in the pediatric population," says David Briscoe, MD, director of the Transplant Research Program at Boston Children's Hospital. "From a discovery perspective, we are trying to understand the molecules, the events, and how the entire process is coordinated to either promote or inhibit rejection following transplantation so that we can improve the outcomes for our pediatric patients."

With its new initiative, TxRP hopes to translate their discoveries into transformative care as the current monitors of organ stability after transplantation are outdated. To better identify patients at risk for post-transplantation organ failure, they are developing precision diagnostic tools that have a high potential to detect signs of organ failure sooner without the need for biopsy.

Understanding the molecular environment

From a discovery perspective, Briscoe and colleagues at Boston Children's have demonstrated that the transplanted organ itself may provide important clues as to why it may eventually fail even in the best of circumstances.

He and his colleagues are examining the molecular processes within the endothelial cells of a transplanted organ that support regulation of the surrounding immune system environment. They are examining how the graft microenvironment may interface with subsets of T-cells of the immune system to either keep the immune response quiet or to trigger a path towards organ failure over time.