A comparison of bone mineral density in normal weight and obese adolescents with polycystic ovary syndrome.

STUDY OBJECTIVE: To evaluate whether there are any differences in bone mineral density (BMD) between normal weight and obese adolescents suffering from polycystic ovary syndrome (PCOS) with oligo/amenorrhea. DESIGN: Prospective cohort study. SETTING: Adolescent gynecology clinic in a general service hospital. PARTICIPANTS: Subjects consisted of adolescents between 16 to 18 years of age presenting with oligo/ amenorrhea with ultrasound morphology of polycystic ovaries ± evidence of hyperandrogenism over 24 months. Controls consisted of consecutive eumenorrheic patients within the same age group. INTERVENTIONS: All underwent full hormonal profile assessment, and dual energy X-ray absorptiometry and peripheral quantitative computed tomography scans. MAIN OUTCOME MEASURES: Areal and volumetric BMD parameters. RESULTS: Of 37 adolescents with PCOS, 12 (32%) were obese with BMI ≥25, of which 9/12 (75%) were hyperandrogenic. The control group consisted of 40 normal weight eumenorrheic girls. The PCOS group overall had lower lumbar spine BMD values as compared to the controls (0.91 vs 0.97 g/ cm(2), P = 0.033). The normal weight PCOS group had lower BMD at the spine (0.90 vs 0.97 g/ cm(2), P = 0.027), trochanter (0.66 vs 0.71 g/ cm(2), P = 0.039) as well as volumetric distal tibial core sites (268 vs 296 mg/ cm(3)) as compared to eumenorrheic controls, but there were no significant BMD differences between the obese PCOS group and the eumenorrheic controls. CONCLUSIONS: Normal weight PCOS adolescents with oligo/amenorrhea have marginally lower BMD values than controls, but obese PCOS adolescents have BMD values compatible with eumenorrheic adolescents.

Bone mineral density changes during pregnancy in actively exercising women as measured by quantitative ultrasound.

OBJECTIVE: To evaluate whether bone mineral density (BMD) changes in women engaged in active exercises during pregnancy would be different from non-exercising women. METHODS: Consecutive patients with singleton pregnancies who were engaged in active exercise training during pregnancy were prospectively recruited over a period of 6 months. Quantitative USG measurements of the os calcis BMD were performed at 14-20 weeks and at 36-38 weeks. These patients were compared to a control cohort of non-exercising low-risk women. RESULTS: A total of 24 physically active women undergoing active physical training of over 10 h per week at 20 weeks gestation and beyond (mean 13.1 h, SD 3.3) were compared to 94 non-exercising low-risk women. A marginal fall in BMD of 0.015 g/cm(2) (SD 0.034) was demonstrable from early to late gestation in the exercising women, which was significantly lower than that of non-exercising women (0.041 g/cm(2); SD 0.042; p = 0.005). Logistic regression models confirmed that active exercises in pregnancy were significantly associated with the absence of or less BMD loss in pregnancy. CONCLUSION: In women actively engaged in physical training during pregnancy, the physiological fall in BMD during pregnancy was apparently less compared to those who did not regularly exercise.

Changes in bone mineral density of the os calcis as measured by quantitative ultrasound during pregnancy and 24 months after delivery.

AIM: To evaluate the use of quantitative ultrasound measurement of the os calcis to monitor bone mineral density (BMD) changes in pregnancy and 24 months after delivery. METHODS: Low-risk patients booked before 20 weeks of gestation were recruited prospectively over a period of 12 months. BMD measurements of the os calcis were taken using quantitative ultrasound between 14 and 20 weeks and after 36 weeks using the Hologic Sahara system. Body weight and fat composition were also measured at each occasion. The measurements were repeated 24-28 months after the index delivery. Those who were delivered preterm or those diagnosed to have significant medical or antenatal complications were excluded. RESULTS: A total of 95 patients completed the study, of which 55 (57.8%) were primiparous and 40 (42%) were multiparous. A mean fall in BMD of 0.0389 g/cm(2) was demonstrable from early to late gestation. The mean BMD difference between the 2-year assessment and early pregnancy (Δ BMD) was -0.008 g/cm(2) . Δ BMD was negligible for multiparous women compared to a small loss in primiparous women (0.0006 vs. -0014 g/cm(2) , P = 0.026). There were no significant differences in Δ BMD between those who lactated for over 16 weeks (n=35) and those who did not (n=60). A logistic regression model showed that the extent of BMD loss during pregnancy and pregnancy weight gain were significant factors associated with BMD changes 24 months after delivery. CONCLUSION: Bone mineral density loss during pregnancy that was detectable by quantitative ultrasound at the os calcis has largely recovered at 24 months after delivery.

Bone mineral density changes in pregnancies with gestational hypertension: a longitudinal study using quantitative ultrasound measurements.

OBJECTIVE: To compare the maternal bone mineral density (BMD) changes in gestational hypertensive and normotensive pregnancies using quantitative ultrasound. METHODS: Consecutive patients were recruited from a general obstetric clinic over a period of 9 months. BMD measurements were performed at the os calcis in early pregnancy before 20 weeks and in the late third trimester after 36 weeks, using a Hologic Sahara Clinical Bone Sonometer system. These patients were followed up in accordance with standard antenatal protocol. The diagnosis of gestational hypertension (GH) was made based on a standard institutional protocol. The changes in BMD from early to late pregnancy were compared between those with/without GH. RESULTS: A total of 450 patients with complete data were analyzed. The overall incidence of GH was 4.8% (n = 22), of which 1.7% (n = 8) fulfilled the definitions of severe pre-eclampsia. A mean BMD loss of 0.0382 g/cm2 (around 6% of early pregnancy BMD) [corrected] was demonstrable from early to late gestation The hypertensive group has marginally higher mean BMD loss as compared to the normotensive group (0.052 vs. 0.037 g/cm²; P = 0.037). However, regression analysis models showed that early pregnancy BMD values, early pregnancy fat percentage and fat accumulation in pregnancy were significant factors affecting BMD loss during pregnancy, while GH was not in the equations. CONCLUSION: The development of gestational hypertensive disorders apparently does not have any significant impact on BMD changes during pregnancy.

Magnetic resonance imaging in adolescent painful flexible flatfoot.

BACKGROUND: The cause of navicular tuberosity pain in adolescents with flexible flatfeet is not well understood. We hypothesized that some of the navicular tuberosity pain may be related to insertional enthesopathy of the posterior tibial tendon at the navicular. Magnetic resonance imaging was performed to look for abnormal signal changes in a series of patients. MATERIAL AND METHOD: Consecutive adolescent patients presenting with flexible flatfeet and navicular tuberosity pain were prospectively recruited. A detailed foot examination and body fat analysis was performed. Standing radiographs and Tekscan pedobarograph of both feet were obtained. Magnetic resonance examinations were performed on a 1.5-T whole-body magnetic resonance imaging system utilizing a standard extremity coil. RESULTS: MRI abnormality was detected in 15 of the 36 feet in 18 adolescents examined. Abnormalities detected included thickening of the posterior tibial tendon insertion, marrow edema in the accessory navicular, marrow edema in the navicular tuberosity, and contrast enhancement at the posterior tibial tendon insertion site. Patients with MRI abnormalities were significantly taller, had a lower body mass index and a lower body fat percentage than those without MRI abnormality. Forward stepwise logistic regression analysis identified low body fat percentage and presence of an accessory navicular as independent predictors for abnormality on MRI. CONCLUSION: MRI abnormality was frequently detected in adolescents with painful flexible flatfeet. The MRI signal changes indicated an enthesopathy like process occurring at the posterior tibial tendon insertion to the navicular which could explain the origin of pain in flexible flatfeet patients without an accessory navicular. Early identification and appropriate treatment to prevent progression may be helpful.

Body fat composition and weight changes during pregnancy and 6-8 months post-partum in primiparous and multiparous women.

OBJECTIVE: To compare changes in maternal weight and body fat composition from early to late pregnancy and 6-8 months postnatally between primiparous and multiparous patients. METHODS: Maternal weight and body fat percentage were assessed in a cohort of low-risk uncomplicated women in a general antenatal clinic at 14-20 weeks gestation, after 36 weeks, and around six to eight months after delivery using a Tanita TBF 105 Fat Analyser. Maternal epidemiological and anthropometric data, as well as pregnancy characteristics and perinatal outcome, were derived from standard antenatal records after delivery. The cohort was stratified into primiparous and multiparous women for comparison. RESULTS: In a cohort of 104 women, 55 (52.8%) were primiparous and 49 (47.1%) were multiparous. A relatively good overall correlation between body fat percentage gain and weight gain was observed (correlation coefficient 0.33) from early to late pregnancy. Primiparous women had higher weight gain (12 kg) and higher body fat gain (7.7%) during the pregnancy compared to multiparous women (10.8 kg and 6%, respectively), and they also retained more of the fat accumulated during pregnancy (1.92% vs - 0.44%, P < 0.001) when assessed over six months after their delivery. CONCLUSION: The findings could represent more exaggerated physiological responses to the pregnant state in the primiparous woman as compared to multiparous women.

Back pain symptoms and bone mineral density changes in pregnancy as measured by quantitative ultrasound.

OBJECTIVE: To evaluate whether back pain symptoms in pregnancy are associated with bone mineral density (BMD) changes as measured by quantitative ultrasound at the os calcis. METHODS: Consecutive patients were recruited from a general obstetric clinic over 1 year. Quantitative ultrasonographic measurements of BMD were performed at the os calcis between weeks 14-20 and 36-38. They were then surveyed for back pain symptoms experienced during pregnancy in the early postpartum period, and these were subsequently correlated with BMD changes. RESULTS: Of a total of 463 patients, 231 (49.8%) reported one or more episodes of significant back pain during pregnancy. A mean fall in BMD of 0.0395 g/cm(2) was demonstrable from early to late gestation. Those with back pain symptoms have higher mean BMD loss at the os calcis during pregnancy compared to those without back pain (0.038 vs. 0.029 g/cm(2); p = 0.012). A logistic regression model showed that weight gain and BMD loss in pregnancy were significantly associated with back pain symptoms. CONCLUSION: Back pain symptoms in pregnancy were associated with a greater fall in BMD at the os calcis, supporting the hypothesis that BMD changes could have an etiological role in back pain during pregnancy.

Bone mineral density changes in gestational diabetic pregnancies-a longitudinal study using quantitative ultrasound measurements of the os calcis.

To compare the maternal bone mineral density (BMD) changes in gestational diabetic and non-diabetic pregnancies using quantitative ultrasound measurements of the os calcis, BMD measurements were performed at the os calcis in early pregnancy before 20 weeks and in the late third trimester after 36 weeks, using a Hologic Sahara Clinical Bone Sonometer system. Random glucose screening and direct oral glucose tolerance testing were used to diagnose gestational diabetes mellitus (GDM) according to World Health Organization criteria, which was then treated according to a standard protocol. In a cohort of 480 patients, there were 96 gestational diabetic patients (14 GDM and 82 with impaired glucose tolerance). The mean BMD loss was higher in diabetic patients compared with controls (0.038 vs. 0.025 g/cm2, p = 0.048). A regression model of all pregnancies showed that higher fat accumulation was related to lower BMD loss, but diabetic status was not in the equation. Within diabetic pregnancies, lower initial BMD values, higher fat accumulation and higher early-pregnancy body mass index were associated with lower BMD loss. While gestational diabetic women had higher BMD loss than non-diabetic women, this was apparently secondary to other anthropometric factors rather than due directly to the gestational diabetic state.

Limb salvage in extensive diabetic foot ulceration: an extended study using a herbal supplement.

OBJECTIVE: To further study the clinical value of a herbal supplement in the treatment of chronic foot ulcers in diabetic patients. DESIGN: Double-blind randomised, placebo-control trial. SETTING: Two general hospitals in Hong Kong. PATIENTS: Eighty patients were recruited according to strict selection criteria. INTERVENTIONS: Clinical measures included standard antidiabetic treatment, daily wound care including antiseptic bath, debridement, toe removal for gangrene when necessary, and the daily consumption of a herbal drink or placebo. MAIN OUTCOME MEASURES: The primary outcome was limb salvage. Secondary outcomes included: granulation maturation, local temperature and circulatory changes, tumour necrosis factor-alpha levels, and adverse events. RESULTS: Limb salvage was achieved in 85% of the patients. Among the early failures, three each came from the treatment and placebo groups. After shifting to herbal treatment (without unblinding of the original treatment), all were rescued in those initially assigned to herbal concoction (6 out of 6) while only 50% (6 out of 12) were rescued from among those initially assigned to placebo. The speed of granulation maturation, and decline in tumour necrosis factor-alpha levels indicating control of inflammation, were also more favourable with the herbal group. No serious adverse events were observed. CONCLUSION: The herbal adjuvant therapy was effective in helping the healing of chronic diabetic ulcers.

Comparison of quality of life scores among non-exercising adolescent females and adolescent dancers with oligomenorrhea and amenorrhea.

STUDY OBJECTIVE: To evaluate whether oligomenorrhea and amenorrhea in adolescent females would have a negative effect on the standard quality of life (QOL) scores as compared to eumenorrheic adolescents, and whether such scoring would differ between those with exercise related oligo/amenorrhea or those with hypothalamic/ovarian causes. DESIGN: Prospective cross-sectional observational survey. METHODS: Young dancers were recruited from the Sports Clinic of a collegial School of Dance, and non-dancers were recruited from a hospital-based adolescent gynecology clinic. All subjects completed a structured self-answering questionnaire recording epidemiological data and a 36-item Short Form Health Survey (SF-36). All subjects had a full hormonal profile and pelvic ultrasound to study ovarian morphology. RESULTS: Sixty-six dancers (19 with exercise-related oligo/amenorrhea and 47 eumenorrhoeic) and 90 non-dancers (45 eumenorrhoeic and 45 oligo/amenorrheic) were analyzed, all 16-20 years of age. There was no difference in the scoring between eumenorrheic dancers and non-dancers. Oligo/amenorrheic dancers did not score lower than eumenorrheic dancers. Compared with eumenorrheic subjects or to oligo/amenorrheic dancers, oligo/amenorrheic non-dancers had significantly lower QOL scores in the domains of physical functioning (PF) and general health (GH) and vitality (VT). CONCLUSION: Compared with eumenorrheic adolescents, QOL scores were lower in non-exercising adolescents with oligo-amenorrhea, but not those with exercise related oligo/amenorrhea. The negative effects of oligomenorrhea and amenorrhea on quality of life were apparently attenuated if the menstrual dysfunction was related to physical training.

Bone mineral density differences between adolescent dancers and non-exercising adolescent females.

STUDY OBJECTIVE: To compare the bone mineral density (BMD) of the axial and appendicular skeleton between regularly exercising collegiate dancers and age matched non-exercising young females between the age of 17 and 19 to assess the impact of weight-bearing exercises and menstrual status on BMD. DESIGN: Prospective observational cohort. SETTING: Sports clinic in a collegiate school of dance and a hospital-based adolescent clinic. PARTICIPANTS: The adolescent dancers consisted of full-time collegiate dance students from a tertiary Performing Arts Institute (n = 35). The non-exercising controls consisted of eumenorrhoeic patients of the same age presenting to the Adolescent Clinic (n = 35). INTERVENTIONS: All subjects had a full hormonal profile, bio-impedance estimation of body fat, and dual energy X-ray absorptiometry and quantitative peripheral CT scans (pQCT) to determine bone density. MAIN OUTCOME MEASURES: Comparison of the mean bone mineral density in the axial and appendicular skeleton between the two groups. RESULTS: The incidence of oligo/amenorrhoea in the dancers was 20%. The lumbar spine BMD (1.006 g/cm(2) vs. 0.938, P = 0.048) and hip BMD (neck of femur 0.978 g/cm(2) vs. 0.838, P < 0.001; Ward's triangle 0.816 g/cm(2) vs. 0.720, P = 0.003; trochanter 0.777 g/cm(2) vs. 0.682; P < 0.001) were significantly higher in the eumenorrhoeic dancers as compared to controls. The radial BMD as measured by pQCT did not differ between the two groups, but the core trabecular tibial BMD was also higher in the dancers (321 mg/cm(3) vs. 286, P = 0.006). When only oligo/amenorrhoeic dancers (n = 7) were compared with the controls, the same differences in BMD values were no longer observed. CONCLUSION: Young women undergoing regular intensive weight-bearing exercises as in the collegiate dancers here studied have higher BMD in the axial and appendicular skeleton as compared to non-exercising females of the same age if they remain eumenorrhoeic during their training. This advantage was apparently lost when they developed oligo/amenorrhoea.

Bone morphogenetic protein 13 stimulates cell proliferation and production of collagen in human patellar tendon fibroblasts.

BACKGROUND: Recombinant human (rh) bone morphogenetic protein 13 (BMP13) has been shown to induce the formation of tendon and ligament tissues in animal experiments. The role of BMP13 in tissue regeneration in human tendons remains unexplored, however. MATERIAL AND METHODS: We collected healthy human patellar tendon samples for histological examination and tendon fibroblast culture. The cultured cells were incubated in the presence and absence of rhBMP13 and the effect of the protein on cell proliferation was measured using 5-bromo-2'-deoxyuridine uptake. RESULTS: BMP13 was detectable by immunohistochemical staining in healthy patellar tendon samples, and was located exclusively in active tenoblasts and perivascular mesenchymal cells but not in interstitial tenocytes. The expression of proliferating cell nuclear antigen (PCNA) and pro-collagen type I showed a similar distribution. In vitro studies showed that rhBMP13 can increase proliferation of tendon fibroblasts and increase the gene expression of pro-collagen type I in tendon fibroblast culture. INTERPRETATION: Our findings indicate that BMP13 may be involved in the matrix remodeling process in adult tendon, and that it may play a role in tissue regeneration in tendons.

A comparison of bone mineral density in oligomenorrhoeic adolescents with polycystic ovaries and normal ovaries.

We evaluated whether the presence of polycystic ovaries in adolescent girls as a cause of oligomenorrhoea and amenorrhoea would pose any protective effect against osteoporosis or low bone mineral density (BMD) compared with girls having similar menstrual dysfunction but normal ovaries. A cross-sectional observational study was done in consecutive girls, aged between 16 and 19 years, presenting to the adolescent gynaecology clinic with oligomenorrhoea or amenorrhoea. All patients underwent full hormonal profile assessment, pelvic ultrasound for ovarian morphology, bio-impedance estimation of body fat, and dual-energy X-ray absorptiometry and quantitative peripheral computed tomography scans to determine BMD in axial and appendicular skeletal sites. Polycystic ovaries were diagnosed according to ultrasound morphology. These were then compared with an age-matched eumenorrhoeic control group that had undergone the same evaluation. Of 45 patients with oligomenorrhoea or amenorrhoea, 14 (31%) were diagnosed to have polycystic ovaries, while the other 31 had normal ovaries. The control group consisted of 45 age-matched eumenorrhoeic girls. The group with normal ovaries had lower BMD at the lumbar spine and hip, as well as lower total tibial volumetric BMD, than the eumenorrhoeic controls, but there were no significant differences between the group with polycystic ovaries and eumenorrhoeic controls. We conclude that adolescents with oligomenorrhoea and amenorrhoea with normal ovaries had lower BMD than eumenorrhoeic ones, but those with polycystic ovaries had BMD values comparable to those of eumenorrhoeic controls despite their menstrual dysfunction.

Engineered allogeneic chondrocyte pellet for reconstruction of fibrocartilage zone at bone-tendon junction--a preliminary histological observation.

This study examined histologically the potential of using allogeneic cultured chondrocyte pellet (CCP) in enhancing bone-tendon junction (BTJ) healing using a rabbit partial patellectomy model. Chondrocytes isolated from the cartilaginous ribs of 6-week-old New Zealand white rabbits were cultured for 14 days to form CCP. Partial patellectomy was performed on 30 18-week-old rabbits. After removal of the distal third patella, the BTJ gap was repaired surgically with or without CCP interposition. Four samples of patella-patellar tendon complexes (PPTC) for each group were harvested each at 8, 12, and 16 weeks; and two additional PPTC for each group were harvested at 2, 4, and 6 weeks for early observation of fibrocartilage zone regeneration, histologically. Results showed that CCP interposition demonstrated earlier structural integration at the BTJ after 8, 12, and 16 weeks of healing, and formation of a fibrocartilage zone like structure, compared with control specimens. In addition, no immune rejection was observed in CCP experimental group. The results suggested that CCP had a stimulatory effect on BTJ healing. This bioengineering approach might have potential clinical application in treatment of difficult BTJ healing. However, systemic histomorphometric, immunological tests, and biomechanical evaluations are needed before any clinical trials.

Eccrine poroma: a differential diagnosis in chronic foot lesions.

Eccrine poroma is a benign tumor which arises from the intraepidermal portion of the eccrine sweat glands. It usually occurs as a solitary lesion in the extremity, with the foot and sole as a common site. It may present as a foot mass, ulcerative lesion, bleeding lesion, or suspected melanoma. The clinical diagnosis is often delayed or inaccurate. Three cases of eccrine poroma on the foot are presented. The clinical and histological features, problem in diagnosis, chance of recurrence, and potential transformation to eccrine porocarcinoma are discussed. It is emphasized that eccrine poroma should be considered in the differential diagnosis of chronic foot lesions. Complete excision prevents recurrence, excludes dysplastic change, and prevents future malignant change.

Relationship between bone mineral density changes in pregnancy and maternal and pregnancy characteristics: a longitudinal study.

OBJECTIVE: The study aims to verify whether a progressive fall in bone mineral density (BMD) values can be demonstrated using quantitative ultrasound measurements of the os calcis. The BMD change during the pregnancy was then correlated with other maternal and pregnancy characteristics to identify any high-risk factors for bone loss in pregnancy. METHODS: Consecutive patients were recruited from a low-risk obstetric clinic over a period of 9 months. BMD measurements were performed at the os calcis before 18 weeks, between 28 and 32 weeks, and at 36-38 weeks using a Hologic Sahara Clinical Bone Sonometer system. A computer-derived BMD value was obtained with each measurement. Body fat composition was also measured using a Tanita 501 bioimpedance assay system. RESULTS: In a cohort of 780 patients, a mean fall in BMD of 0.040 g/cm2 was demonstrable across the trimesters. The difference in BMD across the three serial measurements was highly significant (p < 0.001). Univariate analysis showed that those with a low initial BMD, glucose intolerance and high body fat accumulation weight gain during the pregnancy had lower BMD loss, while gestational hypertension and obesity had no impact on the degree of BMD loss. Entering these parameters in a logistic regression analysis showed that the impact of glucose intolerance was lost, but that the other factors remained significant. A linear regression model of quantitative variables showed that only fat accumulation (p = 0.03) and early pregnancy BMD values (p < 0.001) remained significant factors associated with BMD loss. CONCLUSION: A gradual fall in BMD was demonstrable using ultrasound measurement of the os calcis from early to late pregnancy. Of the various parameters identified as significant factors affecting BMD loss in pregnancy, a low initial BMD in early pregnancy and high body fat accumulation during pregnancy appeared to be related to lower BMD loss.