Osteopathy modulates brain-heart interaction in chronic pain patients: an ASL study.

In this study we used a combination of measures including regional cerebral blood flow (rCBF) and heart rate variability (HRV) to investigate brain-heart correlates of longitudinal baseline changes of chronic low back pain (cLBP) after osteopathic manipulative treatment (OMT). Thirty-two right-handed patients were randomised and divided into 4 weekly session of OMT (N = 16) or Sham (N = 16). Participants aged 42.3 ± 7.3 (M/F: 20/12) with cLBP (duration: 14.6 ± 8.0 m). At the end of the study, patients receiving OMT showed decreased baseline rCBF within several regions belonging to the pain matrix (left posterior insula, left anterior cingulate cortex, left thalamus), sensory regions (left superior parietal lobe), middle frontal lobe and left cuneus. Conversely, rCBF was increased in right anterior insula, bilateral striatum, left posterior cingulate cortex, right prefrontal cortex, left cerebellum and right ventroposterior lateral thalamus in the OMT group as compared with Sham. OMT showed a statistically significant negative correlation between baseline High Frequency HRV changes and rCBF changes at T2 in the left posterior insula and bilateral lentiform nucleus. The same brain regions showed a positive correlation between rCBF changes and Low Frequency HRV baseline changes at T2. These findings suggest that OMT can play a significant role in regulating brain-heart interaction mechanisms.

The role of cystatin C as a proteasome inhibitor in multiple myeloma.

Objectives: Bone destruction and renal impairment are two frequent complications of multiple myeloma (MM). Cystatin C, an extracellular cysteine proteinase inhibitor, is encoded by the housekeeping gene CST3 and associated with human tumors. The role of cystatin C in multiple myeloma has been revealed recently. The purpose of this study was to explore the role of cystatin C as a proteasome inhibitor in multiple myeloma. Methods : A comprehensive literature review was conducted through Pubmed to summarize the published evidence on cystatin C in multiple myeloma. English literature sources since 1999 were searched, using the terms cystatin C, multiple myeloma. Results: cystatin C is a sensitive indicator for the diagnosis of myeloma nephropathy and has a dual role in myeloma bone disease. Also, cystatin C reflects tumor burden and is strongly associated with prognosis in patients with multiple myeloma. Conclusion: Cystatin C have great diagnostic and prognostic value in multiple myeloma. It can provide a new treatment direction for MM by designing and searching for antagonists of cystatin C or cysteine protease agonists using cystatin C as a therapeutic target.

Radiographic Value of the Lisfranc Diastasis in a Standardized Population.

Introduction. Injury to the Lisfranc's joint, in particular to the second metatarsal-medial cuneiform (second MMC) joint, can be difficult to evaluate, especially in subtle Lisfranc injuries. The purpose of this study was to determine the value of the Lisfranc joint width (diastasis) of the adult foot in a standardized population thereby establishing a potential reference range when investigating this area for potential injury. Methods. The 2nd MMC joint in 50 men and 50 women was evaluated. Individuals with a history of foot/ankle pain, previous foot/ankle operation or fracture, or a history of systemic disease were excluded from the study. Bilateral weightbearing digital anterior-posterior and lateral radiographs were taken using a standardized method. Results. The mean 2nd MMC diastasis in 200 feet was 5.6 mm (95% CI 5.39-5.81). In the female population, the mean 2nd MMC diastasis was 5.8 mm (95% CI 5.51-6.09) as compared with 5.6 mm (95% CI 5.31-5.89) in males. The mean distance between the fifth metatarsal base and first cuneiform in the entire study population was 16.3 mm (95% CI 15.57-17.03). Conclusion. This study helps define baseline measurements of the Lisfranc joint for the general population, which can provide a standard measurement against which suspected foot injuries can be compared.Level of Evidence: Level IV.

Impact of Diabetes Mellitus on Bone Health.

Long-term exposure to a diabetic environment leads to changes in bone metabolism and impaired bone micro-architecture through a variety of mechanisms on molecular and structural levels. These changes predispose the bone to an increased fracture risk and impaired osseus healing. In a clinical practice, adequate control of diabetes mellitus is essential for preventing detrimental effects on bone health. Alternative fracture risk assessment tools may be needed to accurately determine fracture risk in patients living with diabetes mellitus. Currently, there is no conclusive model explaining the mechanism of action of diabetes mellitus on bone health, particularly in view of progenitor cells. In this review, the best available literature on the impact of diabetes mellitus on bone health in vitro and in vivo is summarised with an emphasis on future translational research opportunities in this field.

Undetected traumatic diastasis of cranial sutures: a case of child abuse.

Traumatic diastasis of cranial sutures is a type of bone fracture more common in children than in adults, but little attention has been paid to this skull damage. Differentiation between inflicted and accidental traumatic head injury is still a challenge in forensic pathology, particularly in pediatric population. In fact, diastasis of cranial sutures may occur with or without other skull fractures and may be the only evidence of an abusive head trauma (AHT). This is a case study dealing with undetected traumatic diastasis of cranial sutures in child abuse. The skeletonized juvenile remains were found inside a suitcase. A diastasis of the coronal and sagittal sutures was the only finding recorded at the autopsy with no other relevant bone defects. The diastasis was originally attributed by the medical examiner to a physiological unfused stage of the calvarial bones. Therefore, the cause of death was undetermined. Twelve years later an anthropological revision of the cold case showed that diastasis of the coronal and sagittal sutures was assessed as the evidence of an AHT. Analysis of skull fractures in child abuse can be challenging as normal skull suture variants mimicking intentional injury are reported. Diastasis of the cranial sutures can be also a post-mortem effect of burning or freezing. Therefore, a differential diagnosis between natural, accidental or inflicted skull defects is mandatory in death investigation. A multidisciplinary approach in such circumstances is strongly recommended in order to reduce the risk of misdiagnosis.

Heritable Skeletal Disorders Arising from Defects in Processing and Transport of Type I Procollagen from the ER: Perspectives on Possible Therapeutic Approaches.

Rare bone disorders are a heterogeneous group of diseases, initially associated with mutations in type I procollagen (PC) genes. Recent developments from dissection at the molecular and cellular level have expanded the list of disease-causing proteins, revealing that disruption of the machinery that handles protein secretion can lead to failure in PC secretion and in several cases result in skeletal dysplasia. In parallel, cell-based in vitro studies of PC trafficking pathways offer clues to the identification of new disease candidate genes. Together, this raises the prospect of heritable bone disorders as a paradigm for biosynthetic protein traffic-related diseases, and an avenue through which therapeutic strategies can be explored.Here, we focus on human syndromes linked to defects in type I PC secretion with respect to the landscape of biosynthetic and protein transport steps within the early secretory pathway. We provide a perspective on possible therapeutic interventions for associated heritable craniofacial and skeletal disorders, considering different orders of complexity, from the cellular level by manipulation of proteostasis pathways to higher levels involving cell-based therapies for bone repair and regeneration.

The Critical Role of Imaging in the Management of Multiple Myeloma.

Multiple myeloma (MM) is characterized by abnormal proliferation of plasma cells in the bone marrow leading to symptoms of anemia, renal failure, hypercalcemia, and bone lesions. Bone imaging is critical for the diagnosis, staging, assessment for the presence and extent of bone lesions, and initial treatment of MM. Skeletal survey is the preferred initial imaging modality due to its availability and low cost. However, it has poor sensitivity and patients with occult myeloma may escape detection, delaying their diagnosis and treatment. New cross-sectional imaging modalities such as low-dose whole body CT, MRI, and PET-CT have high sensitivity and specificity for detecting lytic lesions and extramedullary relapse in MM. The combined use of cross-sectional imaging may provide complimentary information for staging, prognosis, and disease monitoring. In this review, we will discuss commonly used imaging modalities and their advantages and disadvantages in the management of MM.

Factores pronósticos de complicaciones postquirúrgicas en pacientes con infecciones óseas y seudoartrosis / Prognostic factors for post surgical complications in bone infection and pseudarthrosis

Resumen: La infección ósea y la seudoartrosis son las principales complicaciones ortopédicas en cuyo tratamiento intervienen múltiples factores en la tasa de falla al tratar de corregirlas. Conocer estos factores fue el problema que originó la investigación a través de un estudio longitudinal y prospectivo de una cohorte histórica de 83 pacientes de 43.3 ± 16.1 años de edad tratados por seudoartrosis asépticas y sépticas, osteomielitis, osteítis, consolidación viciosa o prótesis infectadas, el desenlace se relacionó con los factores pronósticos sistémicos y locales tomados del modelo de Cierny-Mader como factores que afectan la vigilancia inmunológica, el metabolismo y la vascularización local. Para el análisis bivariado se aplicó χ2 o el test exacto de Fisher; para el análisis multivariado se aplicó el modelo de regresión logística binaria no condicional con método de Wald hacia atrás para seleccionar los factores pronósticos significativos. El error alfa se fijó ≤ 0.05. Las complicaciones se presentaron en 51.8% de los casos. Los factores locales (linfedema, arteritis, insuficiencia venosa y pérdida de piel) con una OR de 5.0 (IC 95% 1.0-24.9, p = 0.03), las seudoartrosis sépticas con OR de 5.0 (IC 95% 1.9-13.0, p = 0.001) y fracturas segmentarias con OR de 3.2 (IC 95% 0.8-13.0, p = 0.07) fueron los factores pronósticos identificados en el análisis bivariado; sin embargo, la regresión logística sólo seleccionó como factor significativo a las seudoartrosis sépticas. Es necesario detectar y en su caso controlar o eliminar dichos factores que pueden incidir directamente en malos resultados postquirúrgicos.

Abstract: Bone infection and nonunion are the main orthopedic and traumatic complications whose treatment remains a challenge because multiple factors are involved in the rate of failures when you try to correct them. Knowing these factors were the problem that caused the research through a prospective longitudinal study of 83 patients of 43.3 ± 16.1 years old. They were treated for aseptic and septic nonunion, osteomyelitis, osteitis, malunion or infected joint replacement. The cases were classified with or without postoperative complications and outcome related to systemic and local factors taken prognostic model Cierny-Mader as factors affecting immune surveillance, metabolism and local vascularization. For bivariate analysis of data χ2 it was applied or where appropriate Fisher's exact test; for multivariate analysis model not conditional binary logistic regression method was applied Wald backward to select the significant prognostic factors. The alpha error was set ≤ 0.05. General complications occurred in 51.8% of cases. Local factors (lymphedema, arteritis, venous insufficiency, loss of skin) with an OR of 5.0 (95% CI 1.0-24.9, p = 0.03), septic nonunion with OR of 5.0 (95% CI 1.9-13.0, p = 0.001) and segmental fractures with an OR of 3.2 (95% CI 0.8-13.0, p = 0.07) were the prognostic factors identified in the bivariate analysis; however, the logistic regression only selected as the septic pseudoarthrosis as a significant factor. It is necessary to detect and if necessary control or eliminate those factors that can directly affect poor postoperative results.

Management of a 3-year-old with an unstable C6-C7 diastasis without quadriplegia.

BACKGROUND: Caring for pediatric spine trauma patients places spine surgeons in situations that require unique solutions for complex problems. Recent case reports have highlighted a specific injury pattern to the lower cervical spine in very young children that is frequently associated with complete spinal cord injury. METHODS: This report describes the presentation and treatment of a C6-C7 dislocation in a 3-year-old patient with an incomplete spinal cord injury. The highly unstable cervical injury and the need to prevent neurologic decline added complexity to the case. RESULTS: A multi-surgeon team allowed for ample manpower to position the patient; with individuals with the requisite training and experience to safely move a patient with a highly unstable cervical spine. Initial closed reduction under close neurophysiologic monitoring, posterior fusion and immediate anterior stabilization lead to a successful patient outcome with preserved neurologic function. A traumatic cerebrospinal fluid leak, while a concern early on during the procedure, resolved without direct dural repair and did not complicate the patient's fusion healing. Additional anterior stabilization and fusion allowed long-term stability with bone healing that may not be achievable with posterior fixation and/or soft tissue healing alone. CONCLUSIONS: Familiarity with the challenges and solutions presented in the case may be useful to surgeons who could face a similar challenge in the future.

[Prognostic factors for post surgical complications in bone infection and pseudarthrosis]. / Factores pronósticos de complicaciones postquirúrgicas en pacientes con infecciones óseas y seudoartrosis.

Bone infection and nonunion are the main orthopedic and traumatic complications whose treatment remains a challenge because multiple factors are involved in the rate of failures when you try to correct them. Knowing these factors were the problem that caused the research through a prospective longitudinal study of 83 patients of 43.3 ± 16.1 years old. They were treated for aseptic and septic nonunion, osteomyelitis, osteitis, malunion or infected joint replacement. The cases were classified with or without postoperative complications and outcome related to systemic and local factors taken prognostic model Cierny-Mader as factors affecting immune surveillance, metabolism and local vascularization. For bivariate analysis of data Χ² it was applied or where appropriate Fishers exact test; for multivariate analysis model not conditional binary logistic regression method was applied Wald backward to select the significant prognostic factors. The alpha error was set 0.05. General complications occurred in 51.8% of cases. Local factors (lymphedema, arteritis, venous insufficiency, loss of skin) with an OR of 5.0 (95% CI 1.0-24.9, p = 0.03), septic nonunion with OR of 5.0 (95% CI 1.9-13.0, p = 0.001) and segmental fractures with an OR of 3.2 (95% CI 0.8-13.0, p = 0.07) were the prognostic factors identified in the bivariate analysis; however, the logistic regression only selected as the septic pseudoarthrosis as a significant factor. It is necessary to detect and if necessary control or eliminate those factors that can directly affect poor postoperative results.

La infección ósea y la seudoartrosis son las principales complicaciones ortopédicas en cuyo tratamiento intervienen múltiples factores en la tasa de falla al tratar de corregirlas. Conocer estos factores fue el problema que originó la investigación a través de un estudio longitudinal y prospectivo de una cohorte histórica de 83 pacientes de 43.3 ± 16.1 años de edad tratados por seudoartrosis asépticas y sépticas, osteomielitis, osteítis, consolidación viciosa o prótesis infectadas, el desenlace se relacionó con los factores pronósticos sistémicos y locales tomados del modelo de Cierny-Mader como factores que afectan la vigilancia inmunológica, el metabolismo y la vascularización local. Para el análisis bivariado se aplicó Χ² o el test exacto de Fisher; para el análisis multivariado se aplicó el modelo de regresión logística binaria no condicional con método de Wald hacia atrás para seleccionar los factores pronósticos significativos. El error alfa se fijó 0.05. Las complicaciones se presentaron en 51.8% de los casos. Los factores locales (linfedema, arteritis, insuficiencia venosa y pérdida de piel) con una OR de 5.0 (IC 95% 1.0-24.9, p = 0.03), las seudoartrosis sépticas con OR de 5.0 (IC 95% 1.9-13.0, p = 0.001) y fracturas segmentarias con OR de 3.2 (IC 95% 0.8-13.0, p = 0.07) fueron los factores pronósticos identificados en el análisis bivariado; sin embargo, la regresión logística sólo seleccionó como factor significativo a las seudoartrosis sépticas. Es necesario detectar y en su caso controlar o eliminar dichos factores que pueden incidir directamente en malos resultados postquirúrgicos.