The effectiveness of physical therapies for patients with base of thumb osteoarthritis: Systematic review and meta-analysis.

BACKGROUND: Trapeziometacarpal osteoarthritis (known as base of thumb OA) is a common condition causing pain and disability worldwide. OBJECTIVE: The purpose of this review was to evaluate the effectiveness of multimodal and unimodal physical therapies for base of thumb osteoarthritis (OA) compared with usual care, placebo or sham interventions. DESIGN: Systematic review and meta-analysis. METHOD: We searched MEDLINE (PubMed), CINAHL, Embase, AMED, PEDro, Cochrane Database of Systematic Review, Cochrane Register of Controlled Trials (CENTRAL) from inception to May 2017. Randomized controlled trials involving adults comparing physical therapy treatment for base of thumb OA with an inactive control (placebo or sham treatment) and reported pain, strength or functional outcomes were included. Meta-analyses were performed where possible. Methodological risk of bias was assessed with the Cochrane Risk of Bias tool. RESULTS: Five papers with low risk of bias were included. Meta-analyses of mean differences (MD) with 95% confidence intervals (95% CI), were calculated for between-group differences in point estimates at 4 weeks post-intervention. Multimodal and unimodal physical therapies resulted in clinically worthwhile improvements in pain intensity (MD 2.9 [95% CI 2.8 to 3.0]; MD 3.1 [95% CI 2.5 to 3.8] on a 0-10 scale, respectively). Hand function improved following unimodal treatments (MD 6.8 points [95% CI 1.7 to 11.9)] on a 0-100 scale) and after a multimodal treatment (MD 20.5 (95%CI -0.7 to 41.7). CONCLUSIONS: High quality evidence shows unimodal and multimodal physical therapy treatments can result in clinically worthwhile improvements in pain and function for patients with base of thumb OA.

Further evidence for specific IFIH1 mutation as a cause of Singleton-Merten syndrome with phenotypic heterogeneity.

Singleton-Merten syndrome (MIM 182250) is an autosomal dominant inherited disorder characterized by early onset periodontitis, root resorption, osteopenia, osteoporosis, and aortic valve or thoracic aorta calcification. The disorder can have significant intrafamilial phenotypic variability. Here, we present a mother and daughter with Singleton-Merten syndrome harboring a previously described pathogenic missense mutation, c.2465G>A p.(Arg822Gln), in IFIH1 (interferon induced with helicase C domain 1), encoding MDA5 (Melanoma Differentiation-Associated protein 5). These data confirm the pathogenicity of IFIH1 c.2465G>A p.(Arg822Gln) for Singleton-Merten syndrome and affirm the striking phenotypic heterogeneity of this disorder. In addition, we expand the Singleton-Merten phenotype by adding severe systemic lupus erythematosus (SLE) to the clinical picture. Investigations of known SLE genes as well as a single nucleotide polymorphism suggested to be involved in development of SLE were normal.

Open reduction and internal fixation for intraarticular fracture of metacarpal head.

Intraarticular fracture of the metacarpophalangeal (MP) joint presents complex problems related to the sophisticated functional aspects of the hand. Injury to the metacarpal head may have a severe effect on hand function but few studies have investigated the management of this condition. In this study, we applied open reduction and internal fixation for the displaced fracture of the metacarpal head and report the clinical and radiographic outcomes of our experience. Thirteen patients (12 men, 1 woman; mean age 21 years) were included in this study, and medical records and radiographs were reviewed retrospectively. The average follow-up period was 12.5 months. Range of motion (ROM) and Disabilities of the Arm, Shoulder, and Hand (DASH) scores were analyzed, and functional results and serial radiographs were investigated for the maintenance of articular congruity and fracture union. The injured fingers were 5 long, 4 small, 2 ring, and 2 index. Five cases were fixed with K­wires, 5 cases with headless screws, and 3 cases with screw and K­wire. The average range of injured MP joint motion was 89°, total active range of motion (TAM) was 265°, and the average DASH score was 3.8 at the last follow-up. All patients showed fracture union on the radiographs and no patient showed significant articular surface incongruence or degenerative change. Open reduction and internal fixation of the metacarpal head fracture had favorable outcomes in our study. The authors suggest accurate reduction and stable fixation for better functional results in metacarpal head fractures.

Clinical Inquiry: Does knuckle popping lead to arthritis?

Habitual knuckle popping, or cracking (over the course of several decades) isn't associated with clinical or radiographic evidence of osteoarthritis.

Rigideces metacarpofalángicas en extensión. ¿Un desafío para el cirujano de mano? / Metacarpophalangeal joint stiffness. Still a challenge for the hand surgeon?

Objetivo. Analizar los resultados obtenidos en el tratamiento quirúrgico de la rigidez metacarpofalángica en extensión mediante tenoartrólisis dorsal en nuestro centro y revisar la literatura al respecto. Material y método. Estudio retrospectivo de 21 rigideces metacarpofalángicas intervenidas. En todos los pacientes se realizó tenoartrólisis dorsal de forma ambulatoria, comenzando la rehabilitación a los diez días postoperatorios. Se registró etiología, variación de la movilidad activa tras la cirugía, complicaciones, cuestionario DASH y una encuesta de satisfacción con el resultado. Resultados. El seguimiento medio fue de 6,5 años y la edad media de 36,5 años. La causa más frecuente fue la fractura de un metacarpiano (52,4%) seguida de los traumatismos complejos de antebrazo (19%). A final del seguimiento la mejoría en la movilidad activa fue de 30,5° pese a obtener una movilidad intraoperatoria de 0-90° en más del 80% de los casos. En el cuestionario DASH la puntuación media fue de 36,9, calificando el resultado como excelente el 10% de nuestros pacientes, bueno el 30%, regular el 40% y malo el 20% restante. En el 9,5% de los casos se produjo un síndrome de dolor regional complejo y en el 14,3% lesión de la musculatura intrínseca. Conclusión. Por su difícil abordaje y pobres resultados, el tratamiento quirúrgico de la rigidez metacarpofalángica en extensión es de gran dificultad mostrándose la tenoartrólisis dorsal como una técnica reproducible en relación con nuestros resultados y a los resultados publicados en la literatura (AU)

Objectives. The aim of this study is to analyse the outcomes of the surgical treatment of metacarpophalangeal stiffness by dorsal teno-arthrolysis in our centre, and present a review the literature. Material and methods. This is a retrospective study of 21 cases of metacarpophalangeal stiffness treated surgically. Dorsal teno-arthrolysis was carried out on all patients. A rehabilitation programme was started ten days after surgery. An evaluation was performed on the aetiology, variation in pre- and post-operative active mobility, complications, DASH questionnaire, and a subjective satisfaction questionnaire. Results. The mean age of the patients was 36.5 years and the mean follow-up was 6.5 years. Of the 21 cases, the most common cause was a metacarpal fracture (52.4%), followed by complex trauma of the forearm (19%). Improvement in active mobility was 30.5°, despite obtaining an intra-operative mobility 0-90° in 80% of cases. Mean DASH questionnaire score was 36.9 points. The outcome was described as excellent in 10% of our patients, good in 30%, poor in 40%, and bad in the remaining 20%. There was a complex regional pain syndrome in 9.5% of cases, and intrinsic muscle injury in 14.3%. Conclusion. Because of its difficult management and poor outcomes, surgical treatment of metacarpophalangeal stiffness in extension is highly complex, with dorsal teno-arthrolysis being a reproducible technique according to our results, and the results reported in the literature (AU)

Long term clinical outcome of dental implants placed in a patient with Singleton-Merten syndrome.

PATIENTS: Singleton-Merten syndrome is an extremely rare autosomal dominant condition with less than 10 reported cases in the literature. It is characterized by abnormal aortic calcifications and dental abnormalities. The goal of this case report is to discuss the abnormal oral clinical features and the modified treatment protocol that was used in order to achieve osseointegration of dental implants in a patient having abnormal bone density and bone turnover associated with Singleton-Merten Syndrome. DISCUSSION: Following extraction of the remaining teeth, titanium implants (Friadent GmbH, Mannheim, Germany and Straumann(®), Basel, Switzerland) were placed in the upper and lower jaw of the patient. The upper jaw which was treated with dental implants, received a bar supported implant retained prosthesis and the lower jaw an implant retained telescopic prosthesis. The patient was regularly followed up for the past 13 years during which, clinical and radiological evaluation of osseointegration was undertaken. All the loaded implants showed clinical and radiographic evidence of osseointegration. With a follow up of 13 years after insertion of the first implant, the patient reported functioning well with no complications. CONCLUSION: The treatment with dental implants in the extremely rare Singleton-Merten syndrome patients is a reasonable treatment option to rehabilitate maxillofacial aesthetics and establish normal function of the jaws.

Current Concepts of the Carpal Boss: Pathophysiology, Symptoms, Clinical or Imaging Diagnosis, and Management.

The carpal boss reflects an osseous protuberance at the level of the dorsal base of the second or third metacarpal, variably present in the general population. There are numerous theories as to the etiology of the bony excrescence; however, the exact cause remains uncertain. The abnormality can result in dorsal wrist pain and swelling. The diagnosis is typically established based on clinical examination and imaging, including radiography, ultrasound, nuclear medicine, computed tomography, and magnetic resonance imaging. We review the proposed theories of how the carpal boss develops, explain the clinical manifestations, demonstrate the imaging appearance, and address treatment strategies.

Investigation of the effect of conservative interventions in thumb carpometacarpal osteoarthritis: systematic review and meta-analysis.

PURPOSE: The purpose of this study was to conduct a current review of randomized controlled trials regarding the effect of conservative interventions on pain and function in people with thumb carpometacarpal (CMC) osteoarthritis (OA), perform a meta-analysis of the findings and summarize current knowledge. METHOD: Data were obtained from MEDLINE, CINAHL, Embase, PEDro and CENTRAL databases from their inception to May 2014. Reference lists of relevant literature reviews were also searched. All published randomized trials without restrictions to time of publication or language were considered for inclusion. Study subjects were symptomatic adults with thumb CMC OA. Two reviewers independently selected studies, conducted quality assessment and extracted results. Data were pooled in a meta-analysis, when possible, using a random-effects model. Quality of the body evidence was assessed using GRADE approach. RESULTS: Sixteen RCTs involving 1145 participants met the inclusion criteria. Twelve were of high quality (PEDro score > 6). We found moderate quality evidence that manual therapy and therapeutic exercise combined with manual therapy improve pain in thumb CMC OA at short- and intermediate-term follow-up, and from low to moderate quality evidences that magneto therapy improves pain and function at short-term follow-up. Orthoses (splints) were found to improve function at long-term follow-up and pinch strength at short-term follow-up. Finally, we found from very low to low-quality evidence that other conservative interventions provide no significant improvement in pain and in function at short- and long-term follow-up. CONCLUSIONS: Some of the commonly performed conservative interventions performed in therapy have evidence to support their use to improve hand function and decrease hand pain. Additional research is required to determine the efficacy of other therapeutic interventions that are performed with patients with thumb CMC OA. IMPLICATIONS FOR REHABILITATION: Manual therapy and exercise are an effective means of improving pain and function at short-term follow-up by patients with thumb CMC OA. Magneto therapy, manual therapy, manual therapy and exercise and Orthoses (splints) were found to have clinically significant results. Very few of the included studies showed a clinically significant effect size in favor of treatment.

Dynamic postures of the transverse metacarpal arch during typing.

The purpose of this paper is to describe the transverse metacarpal arch (TMA) during a dynamic typing task. Static/relaxed and dynamic typing TMA were collected from 36 right-handed females with musculoskeletal discomfort using a motion capture system. While the angle of right TMA static/relaxed posture (10.1° ± 5.5°) was significantly larger than the left (8.5° ± 5.6°) (P < .05), the right dynamic posture (10.6° ± 4.3°) was not significantly different from the left (10.3° ± 5.5°) (P = .66). Within both these mean scores, there was considerable individual variation, with some subjects demonstrating very flat TMA, and some very curved. The results indicate that TMA angular postures both for static/relaxed and dynamic typing are highly variable both between individuals and between individual hands.

Parenteral amino acid intakes: possible influences of higher intakes on growth and bone status in preterm infants.

OBJECTIVE: To study the possible influences of amino acid (AA) intakes on growth and bone status in preterms. STUDY DESIGN: Newborns, weighing <1250 g, received standard (S) or higher (H) parenteral AA intakes (3 or 4 g kg(-1) per day). Anthropometry, biochemistry and quantitative ultrasound (metacarpus bone transmission time (mcBTT), in µs) were measured prospectively. RESULT: A total of 55 patients in group S and 60 in group H were studied. Significantly better growth rate was found in the H group during the study without signs of intolerance. We found a significant decrease in mcBTT from birth to 21 days in the H group; nonetheless, mcBTT at 36 weeks of gestational age significantly positively correlated with early AA and energy intakes. A significant positive correlation between mcBTT and lower limb length (LLL) at 21 days was found. CONCLUSION: Early higher AA intakes improved growth without short-term AA intolerance. Nutritional parameters could influence bone growth. LLL was the anthropometric parameter that best correlated to bone status.

Percutaneous distraction lengthening in brachymetacarpia.

Brachymetacarpia is a condition manifesting a shortened metacarpal that is caused by early closure of the epiphyseal plate and believed to arise idiopathically. The correction for brachymetacarpia is usually for cosmetic reasons as brachymetacarpia does not impair function. The literature indicates several different approaches to lengthening digits, including single-stage lengthening and rapid distraction lengthening with a bone graft. However, gradual distraction is the preferred method due to excellent cosmetic outcomes and few postoperative complications. This article reports a case of brachymetacarpia treated with distraction lengthening using a minimally invasive, percutaneous approach. A 16-year-old girl presented with a shortened left ring finger and underwent surgery to correct the deformity. The left ring finger measured 12 mm shorter than her right ring finger; however, there was normal mobility at the joints. In the operating room, an external fixator was attached using 4 self-drilling, self-tapping pins through several 3-mm skin incisions. The total fixation time was 14 weeks; however, the achieved length of 12 mm was achieved 6 weeks postoperatively. The healing index of the fixation period was 81 days/cm. The postoperative course and fixation period were uneventful, with no complications except for 2 pin infections that were treated with oral antibiotics. The method of gradual distraction lengthening in this case successfully achieved the desired length and yielded an excellent cosmetic result.

Adaptación de unos dedos biónicos en una paciente con doble amputación de extremidades superiores / Adaptation of bionic fingers in a patient with double amputation of upper limbs

El objetivo de nuestro artículo es describir el grado de mejora de las actividades diarias en una paciente con doble amputación de las extremidades superiores. Se trata de una paciente de 42 años, pianista de profesión, que a raíz de una sepsis neumocócica (2003) sufrió necrosis distal de las 4 extremidades con amputación parcial de las mismas. Fue protetizada la amputación infracondilea de la extremidad superior izquierda (ESI) con una prótesis mioeléctrica. En la amputación transmetacarpiana de la extremidad superior derecha se realizó una neocomisura entre el 1.° y 2.° metacarpo que utilizaba para prensión de pequeños objetos. Posteriormente, se protetiza con dedos biónicos. La adaptación de los dedos biónicos ha mejorado la funcionalidad de la paciente en las tareas bimanuales y ha aumentado su independencia en las actividades de la vida diaria (AVD)(AU)

A case report of bilateral upper limb amputees describing improvement in basic activities of daily living is presented. A 42-year-old female pianist suffered distal necrosis of all limbs and partial amputation of them due to pneumococcal sepsis in 2003. Her left upper limb was prosthetized with a myoelectric prosthesis (infracondilean amputation). In the transmetacarpal amputation of the right upper limb, a neocommissure between the 1st and 2nd metacarpal was performed, used to grip small objects. After, it was prosthetized with bionic fingers. The adaptation of bionic fingers has improved her functionality in bimanual tasks and has increased her independence for the basic activities of daily living(AU)

Inflammatory pain in the rabbit: a new, efficient method for measuring mechanical hyperalgesia in the hind paw.

The discovery of novel analgesic compounds that target some receptors can be challenging due to species differences in ligand pharmacology. If a putative analgesic compound has markedly lower affinity for rodent versus other mammalian orthologs of a receptor, the evaluation of antinociceptive efficacy in non-rodent species becomes necessary. Here, we describe a new, efficient method for measuring inflammation-associated nociception in conscious rabbits. An electronic von Frey device is used, consisting of a rigid plastic tip connected to a force transducer in a hand-held probe. The plastic tip is applied to the plantar surface of a hind paw with increasing force until a withdrawal response is observed. The maximum force (g) tolerated by the rabbit (i.e., withdrawal threshold) is recorded. In young, conscious rabbits (500-700 g), baseline hind paw withdrawal thresholds typically fell within the 60-80 g range. Three hours after injection of the inflammatory agent carrageenan (3%, 200 microL, intra-plantar), withdrawal thresholds dropped by approximately 30-40 g, indicating the presence of punctate mechanical hyperalgesia. The development of hyperalgesia was dose dependently prevented by the NSAID indomethacin (ED50=2.56 mg/kg, p.o.) or the bradykinin B2 receptor peptide antagonist HOE 140 (intra-paw administration). An established hyperalgesia was dose dependently reversed by morphine sulfate (ED50=0.096 mg/kg, s.c.) or the bradykinin B1 receptor peptide antagonist [des-Arg10, Leu9]-kallidin (ED50=0.45 mg/kg, s.c.). Rabbits treated with the novel B(1) receptor small molecule antagonist compound A also showed dose-dependent reversal of hyperalgesia (ED50=20.19 mg/kg, s.c.) and analysis of plasma samples taken from these rabbits showed that, unlike other rabbit pain models, the current method permits the evaluation of pharmacokinetic-pharmacodynamic (PK-PD) relationships (compound A plasma EC50=402.6 nM). We conclude that the Electrovonfrey method can be used in rabbits with inflammatory pain to generate reliable dose- and plasma concentration-effect curves for different classes of analgesics.

Modeling of biodynamic responses distributed at the fingers and the palm of the human hand-arm system.

The objective of this study is to develop analytical models for simulating driving-point biodynamic responses distributed at the fingers and palm of the hand under vibration along the forearm direction (z(h)-axis). Two different clamp-like model structures are formulated to analyze the distributed responses at the fingers-handle and palm-handle interfaces, as opposed to the single driving point invariably considered in the reported models. The parameters of the proposed four- and five degrees-of-freedom models are identified through minimization of an rms error function of the model and measured responses under different hand actions, namely, fingers pull, push only, grip only, and combined push and grip. The results show that the responses predicted from both models agree reasonably well with the measured data in terms of distributed as well total impedance magnitude and phase. The variations in the identified model parameters under different hand actions are further discussed in view of the biological system behavior. The proposed models are considered to serve as useful tools for design and assessment of vibration isolation methods, and for developing a hand-arm simulator for vibration analysis of power tools.

Suspensionplasty with the abductor pollicis longus tendon for osteoarthritis in the carpometacarpal joint of the thumb.

PURPOSE: Many surgical procedures have been described for treating painful osteoarthritis at the carpometacarpal joint of the thumb. This article reports our clinical and radiographic results in performing suspensionplasty using the abductor pollicis longus (APL) tendon without tendon interposition after a complete trapeziectomy for patients with painful osteoarthritis in the carpometacarpal joint of the thumb. METHODS: Eighteen patients (2 men, 16 women), including 21 thumbs with advanced arthritis of the first carpometacarpal joint, who were treated by suspensionplasty using the APL tendon after a complete trapeziectomy were evaluated both clinically and radiographically. Ten thumbs were classified as stage III and 11 were classified as stage IV (Eaton's classification). The average follow-up period was 33.3 months. RESULTS: All patients (18 patients, 21 thumbs) reported pain with daily use before surgery; after surgery 13 of the 21 thumbs had no pain, 5 thumbs had mild pain with strenuous activity, and the remaining 3 thumbs had mild pain with light work. At the final follow-up evaluation the radial and palmar abductions each were 56 degrees +/- 9 degrees and 56 degrees +/- 6 degrees. The grip and key-pinch strengths were 16 +/- 6 kg and 4 +/- 1 kg, respectively. The first metacarpal subsidence at rest was 15% and the additional subsidence when performing a 2-kg key pinch was 6% in the final follow-up radiographic findings. CONCLUSIONS: This study showed that the APL suspensionplasty has a favorable outcome for painful osteoarthritis in the carpometacarpal joint of the thumb and that the APL tendon can be removed as a deforming force without any abduction weakness. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.

Up-regulation of site-specific remodeling without accumulation of microcracking and loss of osteocytes.

Functional adaptation of bone normally protects the skeleton from fracture during daily activity. Accumulation of microcracking and loss of osteocytes have been implicated in the regulation and initiation of targeted (reparative) remodeling of bone and, in certain situations, the development of fatigue or stress fracture. We performed a histologic study of the dorsal cortex of the mid-diaphysis of the third metacarpal (Mc-III) bone of Thoroughbred racehorses after bones were bulk-stained in basic fuchsin and transverse calcified sections were prepared. The Thoroughbred racehorse is an extreme athlete whose Mc-III bone experiences particularly high cyclic strains during training and racing. A group of non-athletic horses was also included in the experiment. The following variables were quantified: activation frequency (Ac.f); bone formation rate (BFR); resorption space density (Rs.N/T.Ar); microcrack density (Cr.Dn); microcrack mean length (Cr.Le); microcrack surface density (Cr.S.Dn); osteocyte density (Ot.N/T.Ar; Ot.N/B.Ar); and bone volume fraction (B.Ar/T.Ar). Ac.f and BFR were estimated using a mathematical algorithm. Using confocal microscopy, bones were examined for fine microcracks, diffuse matrix injury, and disruption of the osteocyte syncytium. Low values for Cr.Dn (#/mm2) were found in both groups (0.022+/-0.008 and 0.013+/-0.006 for racing Thoroughbreds and non-athletic horses, respectively). There was no significant relationship between Cr.Dn and Ot.N/T.Ar; Ot.N/B.Ar, B.Ar/T.Ar, and Ot.N/T.Ar; Ot.N/B.Ar, and remodeling (Ac.f, Rs.N/T.Ar) and Ot.N/T.Ar; Ot.N/B.Ar. Intense remodeling of the Mc-III dorsal cortex was found in the racing Thoroughbreds (Ac.f 12.8+/-7.4 #/mm2/year; BFR 31.5+/-15.6%; Rs.N/T.Ar 0.19+/-0.09 #/mm2) and was significantly increased compared with non-athletic horses. Overall, remodeling was weakly correlated with Cr.Dn (r2=0.15, P<0.05). Subtle matrix injury, not detectable by bright-field microscopy, was particularly evident adjacent to resorption spaces in Thoroughbred bone. In non-athletic horses, disruption of the dendritic cell processes of osteocytes associated with cement lines and interstitial fragments was more evident. Taken together, these findings suggest that site-specific (targeted) induction of remodeling during functional adaptation of bone in a high-strain skeletal site is not dependent on accumulation of microcracking or loss of osteocytes. We hypothesize that athleticism can directly influence bone turnover in this extreme athlete through pathways that do not involve classical linear microcracks.

[Study of bone mass in Turner syndrome]. / Estudio de la masa ósea en el síndrome de Turner.

OBJECTIVES: To evaluate bone mass in patients with Turner syndrome by measuring metacarpal cortical thickness and bone diameter before and after treatment with oxandrolone, growth hormone (GH) and estrogens. PATIENTS AND METHODS: We studied 42 girls with Turner syndrome divided into the following groups: group I: 31 patients aged between 3 and 15 years who were not treated before the study; group II: 15 patients treated with GH at start ages of between 5.2-14.8 years; group III: 17 patients treated with oxandrolone at start ages of between 5.3 and 15.2 years; group IV: 17 patients treated with estrogens and divided in different subgroups: IVa: seven patients treated with GH and estrogens at start ages of between 6.1 and 12.9 years; IVb: five patients treated with oxandrolone and estrogens at start ages of between 13.4 and 17.4 years, and IVc: five patients treated with oxandrolone, GH and estrogens at start ages of between 10.3 and 16.1 years. Bone mass was evaluated by a radiogrammetric method that measures the cortical thickness and bone diameter of three metacarpal bones with a magnifying glass. The results are expressed in SD according to Spanish longitudinal reference standards (Andrea Prader Center of Growth and Development) from 0.5 to 9 years of age and to Swiss standards from the age of 10 years onwards. Statistical significance was set at p < 0.05. RESULTS: Group I (spontaneous development): cortical development was below the mean and was significantly diminished at the ages of 9, 13 and 14 years; bone diameter was decreased in relation to controls throughout the study period; group II (impact of GH treatment): cortical thickness showed a nonsignificant increase of 0.6 SD from baseline to years 3-4 of treatment and diameter increased by 0.5 SD from baseline to year 4 of treatment; group III (impact of oxandrolone): cortical thickness increased from -0.8 SD before treatment to 0.0 SD at years 2 and 3 of treatment; bone diameter increased from -1.5 SD at baseline to -1 SD at 3 years of treatment; group IV (impact of treatment with estrogens); IVa: cortical thickness and bone diameter increased; IVb: cortical thickness increased but bone diameter was unchanged; IVc: both cortical thickness and bone diameter increased. CONCLUSIONS: The results of this study show that cortical thickness and bone diameter are decreased in untreated girls with Turner syndrome; cortical thickness was significantly decreased at the ages of 9, 13 and 14 years, while bone diameter was diminished at all ages, suggesting the presence of osteopenia in these patients. GH treatment produced a nonsignificant increase in cortical thickness and bone diameter. Oxandrolone treatment showed a positive effect on bone mass during the first few years of therapy. Because of the small number of patients, conclusions cannot be reached on the effectiveness of estrogens.

Estudio de la masa ósea en el síndrome de Turner / Study of bone mass in Turner syndrome

Los cuidados paliativos son esenciales en las unidades de cuidados intensivos pediátricos (UCIP). Dada la frecuencia de la muerte en las UCIP y la presencia de condiciones médicas que amenazan la vida del niño mientras este está ingresado, existe una necesidad de que el pediatra esté preparado para proporcionar cuidados paliativos, con independencia de los tratamientos curativos. En este artículo se revisan algunos temas, como el proceso de toma de decisiones en la UCIP, las necesidades psicosociales del personal sanitario y la vulnerabilidad al burnout, y los sentimientos y actitudes del personal sanitario ante la muerte del niño. Se proporcionan recomendaciones sobre cómo actuar cuando un niño muere, para concertar reuniones post mortem con los padres y para llevar a cabo el seguimiento del duelo, y se sugieren estrategias que pueden ayudar a afrontar las múltiples pérdidas que experimenta el pediatra de la UCIP

Palliative care is essential in the pediatric intensive care unit (PICU). Because of the mortality rates and the presence of life-threatening conditions in children admitted to the PICU, pediatricians must be prepared to provide palliative care independently of cure-directed therapies. The present article reviews certain issues, including the decision- making process in the PICU, psychosocial needs and susceptibility to burnout among PICU staff, and the emotions and attitudes of the staff when a child dies. We provide some guidelines on how to act when a child dies, how to meet with parents after the child’s death and how to follow- up parental bereavement. Strategies that can help PICU pediatricians to cope with the numerous loses they experience are suggested

Hand workload and the metacarpal cortical index. a study of middle-aged teachers and dentists.

We studied load-related predictors (handedness, occupation and workload history) of cortical bone mass as estimated by the metacarpal cortical index (MCI). After being randomly selected from trade-union registers, 295 female dentists and 248 teachers, aged 45-63 years (mean 54 years), participated in the study. The MCI was defined from the second metacarpal of both hands by analogue radiographs. Data regarding anthropometric measures, handedness, occupational exposure, number of pregnancies, hormonal therapy and contraceptive use, the presence of chronic diseases, dietary factors, smoking and leisure time physical activity were collected by questionnaire. Weight was measured. The dentists' workload was assessed in detail in 10-year periods. Multivariate methods were used in the statistical analysis. The metacarpal index averaged 0.62 in the right hand and 0.61 in the left hand (P = 0.02) among the right-handed subjects, while no differences by hand were observed among the left-handed or mixed-handed. The MCI of the teachers and dentists did not differ from each other, when we controlled for potential confounders. The MCI decreased similarly by age in both occupational groups. Among the dentists, workload history was inversely associated with the MCI in multivariate analyses by age group. Computer use was a positive predictor for MCI among dentists aged 55-63 years. Occupational factors seem to have contradictory effects on the MCI. Too heavy or one-sided manual work may be deleterious for cortical bone mass.

An assessment of equine cartilage degeneration.

Millions of Americans suffer from osteoarthritis, a joint disease characterized by cartilage degradation and subchondral bone sclerosis. However, little is known about its pathology. It remains to be discovered which comes first in the progression of osteoarthritis: subchondral bone remodeling or cartilage degeneration. This study assessed equine cartilage degeneration, based upon measurements of cartilage thickness and Indian ink stain uptake. By gaining a greater understanding of the determining factors in cartilage degeneration, we may be able to better understand the pathomechanics of osteoarthritis. In seven horses, joint regions of interest were harvested bilaterally and isolated into planar osteochondral samples using a band saw and stored at -20 degrees C. After thawing, the samples' articular surfaces were dyed using an Indian ink stain to highlight articular cartilage degeneration. Digital images of the samples were taken before and after the staining, and mean pixel values for the pre- and post-ink images were measured using image analysis software. Reflectance Score (RS) was calculated using mean pixel values normalized between grayscale calibration standards. Articular cartilage thickness was measured at five random locations on each sample from images taken in the transverse orientation. Statistical analysis found no significant effect of limb side for either RS values or thickness, allowing data from right and left limbs to be grouped for analysis. There is a statistically significant correlation between joint region and thickness, as well as between joint region and RS; however, there was no statistical correlation between thickness and RS.