The doubled burden of diabetic bone disease: hip fracture and post-hip fracture mortality.

OBJECTIVE: Patients with diabetes have an increased risk of osteoporosis and shorter life expectancy. Hip fracture (HF) is the most serious consequence of osteoporosis and is associated with increased mortality risk. We aimed to assess the association of antidiabetic medications with HF and the post-hip fracture mortality risk among diabetic patients ≥50 years. DESIGN: In this nationwide case-control study 53 992 HF cases and 112 144 age-, sex- and region-matched non-hip fracture controls were analyzed. A cohort of hip-fractured diabetic patients were followed-up for an all-cause mortality. METHODS: We defined three groups of diabetic patients based on a prescription of antidiabetic medications: group 1 treated with insulin monotherapy (G1DM), group 2 (G2DM) treated with blood glucose-lowering drugs (BGLD) only, group 3 on a combined BGLD and insulin therapy (G3DM). We applied logistic regression and Cox regression. RESULTS: We identified 2757 G1DM patients, 15 310 G2DM patients, 3775 G3DM patients and 144 294 patients without any antidiabetic treatment. All three groups of diabetic patients had increased odds of HF compared to controls. G1DM patients aged 50-64 years (aOR: 4.80, 95% CI: 3.22-7.17) and G3DM patients (aOR: 1.39, 95% CI: 1.02-1.88) showed the highest HF odds, whereas G2DM patients had 18% decrease in HF odds than their non-diabetic controls (aOR: 0.82, 95% CI: 0.69-0.99). All diabetic patients had increased post-hip fracture mortality risk compared to non-diabetic controls. The highest mortality hazard was observed in G1DM patients, being greater for women than men (HR: 1.71, 95% CI: 1.55-1.89 and HR: 1.44, 95% CI: 1.27-1.64, respectively). CONCLUSIONS: Antidiabetic medications increase the probability of HF. Diabetic patients, who sustained HF have a higher mortality risk than non-diabetic patients.

Is whole body low dose CT still necessary in the era of 18F-FDG PET/CT for the assessment of bone disease in multiple myeloma patients?

OBJECTIVE: Whole body low dose computed tomography (WBLDCT) is the first-choice imaging modality to identify bone involvement in multiple myeloma (MM). Because the unenhanced LDCT co-registered to positron emission tomography (PET) (LDCT/PET) has similar technical characteristics to WBLDCT, we aimed to assess its reliability in the detection of bone disease, for employing fluorine-18-fluorodeoxyglucose (18F-FDG) PET/CT as unique multimodality imaging method in MM patients. SUBJECTS AND METHODS: Thirty three consecutive MM patients were prospectively enrolled and evaluated with WBLDCT to assess bone involvement. In addition, patients underwent 18F-FDG PET/CT using a disease-tailored optimized LDCT protocol. To compare both methods, skeletal anatomical regions were identified and a per-region and per-patient analysis were performed using Cohen's k test. Low dose computed tomography/PET sensitivity, specificity and accuracy were also calculated. RESULTS: The two imaging modalities resulted highly concordant considering both patient-based (k=0.841) and region-based analysis; some discrepancies were observed in dorsal spine (k=0.809) and thorax (k=0.756). Low dose computed tomography/PET sensitivity, specificity and accuracy were 89.4%, 98.3% and 93.5%, respectively. CONCLUSION: Low dose computed tomography co-registered PET has comparable performance to WBLDCT. If confirmed on a lager sample, these encouraging results suggest the possibility to use this multimodal hybrid imaging as the only method for MM evaluation, rather than both exams, providing both morphologic and metabolic information in one session with impact on patient compliance, health care spending and especially radiation exposure.

Inflammation-Related Patterns in the Clinical Staging and Severity Assessment of Chronic Kidney Disease.

Chronic kidney disease (CKD) is an irreversible loss of kidney function, and it represents a major global public health burden due to both its prevalence and its continuously increasing incidence. Mineral bone disorders (MBDs) constitute a hallmark of CKD, and alongside cardiovascular complications, they underlie a poor prognosis for these patients. Thus, our study focused on novel CKD biomarker patterns and their impact on the clinical staging of the disease. As a first testing approach, the relative expression levels of 105 proteins were assessed by the Proteome Profiler Cytokine Array Kit for pooled CKD stage 2-4 serum samples to establish an overall view regarding the proteins involved in CKD pathogenesis. Among the molecules that displayed significant dysregulation in the CKD stages, we further explored the involvement of Dickkopf-related protein 1 (Dkk-1), a recognised inhibitor of the Wnt signalling pathway, and its crosstalk with 1,25OH2D3 (calcitriol) as new players in renal bone and vascular disease. The serum levels of these two molecules were quantified by an ELISA (76 samples), and the results reveal decreasing circulating levels of Dkk-1 and calcitriol in advanced CKD stages, with their circulating expression showing a downward trend as the CKD develops. In the next step, we analysed the inflammation and MBD biomarkers' expression in CKD (by xMAP array). Our results show that the molecules involved in orchestrating the inflammatory response, interleukin-6 (IL-6) and tumour necrosis factor alpha (TNFα), as well as the mineral biomarkers osteoprotegerin (OPG), osteocalcin (OC), osteopontin (OPN), and fibroblast growth factor 23 (FGF-23), correlate with Dkk-1 and calcitriol, raising the possibility of them being potential useful CKD biomarkers. These results reveal the impact of different biomarker patterns in CKD staging and severity, thus opening up novel approaches to be explored in CKD clinical management.

Bone Mineralization and Fracture Risk Assessment in the Pediatric Population.

Identifying children most susceptible to clinically significant fragility fractures (low trauma fractures or vertebral compression fractures) or recurrent fractures is an important issue facing general pediatricians and subspecialists alike. Over the last decade, several imaging technologies, including dual-energy X-ray absorptiometry and peripheral quantitative computed tomography, have become useful to identify abnormal bone mineralization in children and in adolescents. This review aimed to summarize the latest literature on the utility of these modalities as they pertain to use in pediatrics. In addition, we review several disease states associated with poor bone health and increased fracture risk in children, and discuss the implications of low bone mineral density in these patients. Finally, we will highlight the gaps in knowledge with regard to pediatric bone health and make recommendations for future areas of research.

Assessment of bone turnover markers to predict mineral and bone disorder in men with pre-dialysis non-diabetic chronic kidney disease.

BACKGROUND: Chronic kidney disease (CKD) is commonly associated with disturbances in mineral metabolism and bone disease. Bone biopsy is the gold standard in diagnosing mineral bone disorder. Hence the search for non-invasive assessment of bone health gains importance. We undertook to assess the bone health in men with stage 4 and 5 chronic kidney Disease. METHODS: We recruited 32 male subjects with Stage 4 and 5 chronic kidney disease and 32 age-matched healthy male controls. 25-hydroxyvitamin D, intact parathyroid hormone, and bone-specific alkaline phosphatase were assayed. Bone mineral density (BMD) was estimated using dual-energy X-ray absorptiometry. RESULTS: CKD is associated with significantly higher levels of bone-specific alkaline phosphatase and intact parathyroid hormone and lower levels of 25-hydroxyvitamin D and bone mineral density, when compared to controls. In the multivariate linear regression model, bone-specific alkaline phosphatase emerged as an independent predictor of reduced BMD. Receiver Operator Characteristic analysis for prediction of reduced BMD in CKD showed both intact parathyroid hormone and bone-specific alkaline phosphatase have significant predicting power. CONCLUSION: The combination of bone-specific alkaline phosphatase and intact parathyroid hormone has more significant predicting power and is a more reliable index for non-invasive assessment of bone health in men with chronic kidney disease, than either marker when used alone.

Gaps in addressing problem drinking: overcoming primary care and alcohol treatment deficiencies.

Despite the high prevalence of problem drinking among Americans, primary care physicians often fail to address this major health threat. In addition, once alcohol use disorders are identified, patients often fail to receive coordinated medical and substance abuse treatment. This article reviews four types of barriers as well as potential facilitators to improving the prevention and management of problem drinking. First, primary care physicians are poorly trained about the clinical relevance of addressing alcohol problems in their daily patient care. Second, primary care physicians are concerned about the stigma and health insurance problems encountered by patients diagnosed with alcohol use disorders. Third, primary care practices have limited organizational and financial support to identify and address alcohol problems. Fourth, primary care and alcohol treatment settings communicate and collaborate poorly in delivering patient care. Opportunities to overcome these challenges are discussed and must be initiated to reduce the myriad of adverse outcomes resulting from problem drinking.

Petrosal cholesteatoma: management considerations for minimizing morbidity.

OBJECTIVE: This study aimed to analyze the surgical treatment of patients presenting with petrosal cholesteatoma. STUDY DESIGN: The study design was a retrospective case review. SETTING: The study was conducted at a tertiary referral center. PATIENTS: Patients were referred to the University Department of Otolaryngology, Manchester Royal Infirmary, with surgically confirmed petrosal cholesteatoma. INTERVENTION: Interventions were diagnostic and therapeutic. MAIN OUTCOME MEASURES: Postoperative facial function, hearing loss, recurrent cholesteatoma, and petrous cavity morbidity in relation to preoperative signs, intraoperative findings, and surgical techniques were measured. RESULTS: Twenty-five patients were treated between 1979 and 1997. Complete preoperative facial paralysis was always associated with bony erosion around the geniculate ganglion, and facial nerve ischemia was thought to be an important factor. Resection of the ischemic nerve segment and end-to-end anastomosis over the posterior fossa dura allowed full removal of cholesteatoma matrix and reinnervation along a healthy and vascularized nerve. In five of the seven cases with recurrent disease, cholesteatoma was localized to the intrapetrous carotid or geniculate ganglion. The introduction of endoscopic techniques has allowed assessment of the full extent of disease and removal of cholesteatoma matrix missed using conventional microscopic visualization. Bipolar diathermy to areas of cholesteatoma, densely adherent to dura, is effective in destroying squamous epithelium. Patients with cavity obliteration and blind sac closure had minimal postoperative morbidity, and current magnetic resonance imaging techniques are effective in diagnosing and delineating recurrence. CONCLUSIONS: This study illustrates a gradual change in the treatment of patients with petrosal cholesteatoma. By defining the main areas of patient morbidity and using both recent technical advances and alternative surgical techniques, further improvement in patient outcome is envisaged.

Radionuclide bone scanning in routine clinical practice.

Bone scintigraphy (scanning) is a quick and cost-effective method for evaluating potential bone lesions not visualized on plain radiography. Uses include evaluation of primary and metastatic bone tumors, treatment of bone pain due to tumor invasion, detection of occult fractures and stress injury, evaluation of postprosthesis joint pain, evaluation of metabolic bone disorders, and diagnosis of osteomyelitis. The main advantage of bone scanning is the ability to evaluate the entire skeleton rapidly with high sensitivity.

Roentgenographic assessment of acromial morphologic condition in rotator cuff impingement syndrome.

Patients with an isolated diagnosis of rotator cuff impingement syndrome were prospectively entered into the study. Each of the 23 subjects was refractory to conservative therapy, had preoperative roentgenograms, and underwent an open acromioplasty. The roentgenograms included anteroposterior, axillary, 30 degrees caudal tilt, and supraspinatus outlet views. The roentgenograms were measured by four independent readers. The separate views were then scored for reliability, and the correlation of the measurements with intraoperative acromial measurements was assessed. Interobserver reliability was highest for the caudal tilt view (0.84) and lowest for the axillary view (0.09). The supraspinatus and caudal tilt views correlated significantly with distinct intraoperative measurements of acromial spur size. We continue to advocate the evaluation of both views for preoperative assessment of the acromial spur in the rotator cuff impingement syndrome.

Skeletal problems in poultry: estimated annual cost and descriptions.

This introductory, review presentation is a prologue to four full-length symposium presentations. Estimates of the annual cost of skeletal problems in poultry and definitions of noninfectious skeletal diseases in poultry are the focus of this article. Losses due to skeletal problems in poultry are caused by an increase in mortality and the number of cull birds, increased condemnations from septicemia-toxemia, and more downgrading from the trimming of breasts and legs. Reduced feed conversion and rate of gain also occur. Estimated annual losses in the United States due to skeletal problems are $80 to $120 million in broilers, and $32 to $40 million in turkeys. Eleven skeletal problems in poultry are described, and synonyms, symptoms, and possible causes of each are presented. These diseases include long bone distortion, tibial dyschondroplasia, rickets, spondylolisthesis, degeneration of the femoral head, spraddled legs, chondrodystrophy, osteomyelitis and synovitis, Mycoplasma synoviae infection, viral arthritis, and footpad dermatitis.

Association of constipation with neurologic diseases.

To investigate possible etiologic influences on the development of constipation, the present study examines the concordant occurrence of constipation with other diseases. Using 8.8 million Medicare patients hospitalized in the United States during 1987, the frequency distribution of all three-digit International Classification of Diseases (ICD) codes was compared in constipated patients and patients without constipation. Most associations and the closest associations were observed between constipation and neurologic diseases, the majority of which resulted from damage to the central nervous system. Associations between constipation and disorders of the spine also involved neuronal damage. The influence of potential confounding factors such as immobility or pain on the development of constipation was assessed and found to be minimal. The frequent association of constipation with disorders involving neuronal malfunction suggests that disruption of the neural modulation of colonic motility may play an important role in the development of constipation.

Thermography--its current diagnostic status in musculoskeletal medicine.

OBJECTIVE: To evaluate the currently perceived status of thermography in the diagnosis of musculoskeletal disorders. DATA SOURCES: Medical and legal journals published from 1956 onwards; report of the United States Office of Health Technology Assessment and personal communication with the author of that report. STUDY SELECTION: Confined to application of thermography to musculoskeletal and neurological medicine. DATA EXTRACTION AND SYNTHESIS: Weighted towards prospective and controlled studies. CONCLUSION: Little evidence exists of any application of thermography in which it is unequivocally superior to conventional diagnostic imaging methods.

Young adults with special health care needs: prevalence, severity, and access to health services.

Health care needs of disabled young adults and access to care are analyzed using the 1984 National Health Interview Survey, a nationally representative sample of 10,394 randomly selected noninstitutionalized young adults aged 19 to 24. In 1984, 1.4 million young adults (almost 6%) suffered from disabilities. The leading cause of disability was diseases of the musculoskeletal system and connective tissue. Young adults living in poverty, in households where the family reference person had less than a high school education, and who were male were at elevated risk of disability. Disabled young adults made almost three times as many physician contacts and were hospitalized for close to six times as many days as nondisabled young adults. One of every 5 disabled young adults was uninsured in 1984. Forty-one percent of disabled Hispanic 19- to 24-year-olds and 51% of disabled young adults of other races were uninsured compared with 19% of whites and blacks. Research and financing policy implications are discussed.

Valoracion nutricional en el paciente ortopedico / Nutritional evaluation in the orthopaedic patient

En la practica ortopedica no se ha enfatizado la prevencion, elreconocimiento y el tratamiento de los estados de depresion nutricional o hipermetabobicos que aumentan la morbilidad de los pacientes. De acuerdo a estudios en otros campos de la medicina, has el 50 por ciento de los pacientes hospitalizados para cirugia tienen algun grado de desnutricion, no infrecuente dado el contexto socioeconomico de nuestra poblacion, que se agrava frente al stress de la enfermedad, el trauma quirurgico y la infeccion. Se sintetizan los conceptos teoricos sobre nutricion del paciente quirurgico: composicion corporal, absorcion y metabolismo de nutrientes, respuesta metabolica al estres, evaluacion nutricional en trauma y alimentacion del enfermo. Se analizan 33 pacientes admitidos por urgencias por politraumatismo y Fx de huesos largos o Fx multiples, que fueron evaluados por el equipo de soporte nutricional en los 3 primeros dias despues de su ingreso y se siguieron durante el postoperatorio inmediato, los resultados de la valoracion nutricional se estudiaron estadisticamente y no se encontraron diferencias significativas con los parametros normales. De los 29 pacentes bien nutridos, 8 (12.6 por ciento ) sufrieron complicaciones como sepsis, infeccion de la herida quirurgica o retardo en la consolidacion de la fractura. En 4 pacientes cuyo estado nutricional se describio como marasmo, el 100 por ciento sufrio complicaciones en el curso del tratamiento