Who are the French plastic surgeons?

Based on data from the national advice of the Conseil National de l'Ordre des Médecins (French Medical Board), the author found 654 plastic surgeons in France and classified them into five categories, demonstrating the increasing proportion of females in this specialty.     

Hypocitraturia: a risk factor for reduced bone mineral density in idiopathic hypercalciuria?

The association between idiopathic hypercalciuria (IH) and reduced bone mineral density (BMD) has been described in adults and children. Frequently, hypocitraturia (HC) is an associated condition. To determine the effect that HC may have on bone metabolism of these patients, we studied 88 children with IH at diagnosis, divided into the following groups: group 1 - 44 (50%) patients with associated HC; group 2 - 44 (50%) patients without HC; group 3 (29 subjects), a healthy control group. Urinary and blood electrolytes, as long as urinary N-telopeptide, were measured. Lumbar spine (L2–L4) and femoral neck bone mineral density (BMD) and bone mineral content (BMC) were measured by dual energy X-ray absorptiometry. There was no difference in age between the three groups (P=0.80), but weight, height, body mass index, and bone age were lower (P<0.01) and serum intact parathyroid hormone (iPTH) was higher (P<0.05) in group 1 than in groups 2 and 3. N-telopeptide, measured in urine, did not differ between groups. The following bone densitometry parameters: lumbar spine BMC, BMC adjusted for height (BMCh), BMC adjusted for width of vertebrae (BMCw) and BMD, as well as femoral neck BMD, were significantly lower in group 1 than in groups 2 and 3 (P<0.01). When we corrected densitometry parameters for height, BMC was lower in group 1 and not in group 2 when compared with controls. Conclusions: Children with IH and associated HC may have a higher risk of bone mass loss and consequent osteopenia. Further studies are needed to assess the role that hypocitraturia may have in this form of bone disease.     

Glucocorticoid-induced osteoporosis: is the bone density decrease the only explanation?

BACKGROUND: Glucocorticoids may increase bone fragility via mechanisms independent from their bone mass reducing effect. OBJECTIVE: To study relationships between osteoporotic fractures and bone mineral density in patients on long-term glucocorticoid therapy. PATIENTS AND METHODS: We studied 121 women with a mean age of 60.4 +/- 14.3 years on long-term glucocorticoid therapy (cumulative dose > or = 1 g of prednisone equivalent, duration > or = 6 months) for rheumatoid arthritis (n = 38), polymyalgia rheumatica or giant cell arteritis (n = 26), connective tissue disease (n = 15), asthma (n = 14), another inflammatory joint disease (n = 14), or another condition (n = 14). The control group was composed of 125 subjects who had the same mean age and met the same exclusion criteria as the case group. Bone mineral density was measured at the lumbar spine and femoral neck using a Hologic QDR 4500 unit. In subjects with back pain, radiographs of the thoracic and lumbar spine were obtained to look for fractures. RESULTS: The odds ratio for a bone mineral density decrease of one standard deviation at the femoral neck was 1.68 (1.20-2.35) in patients with a cumulative glucocorticoid dose of 10 g of prednisone equivalent and 1.67 (1.22-2.29) in those with a glucocorticoid therapy duration of 2 years. Sixty-eight fractures were recorded in 56 patients (46% of the overall patient group). Even after adjustment on age, glucocorticoid therapy duration, and dose, mean bone mineral density values at the lumbar spine and femoral neck were significantly lower in the subgroup of patients with fractures than in the subgroup without fractures. Sensitivity and specificity of bone mineral density at the femoral neck and/or lumbar spine for the diagnosis of vertebral fracture and/or peripheral fracture were 73% and 51%, respectively. In the stepwise logistic regression model, factors explaining the presence of fractures were as follows, in hierarchical order: age; absence of calcium/vitamin D supplementation, femoral neck T-score, and glucocorticoid dose. CONCLUSION: Our data are compelling evidence that bone mineral density is a major determinant of the fracture risk in patients with glucocorticoid-induced osteoporosis.     

What are the actual indications for a surgical parathiroidectomy?

Secondary hyperparathyroidism (HPTH-II) is a major complication of chronic renal insufficiency (CRI). It affects more than 300,000 dialyzed CRI patients in the world and probably more than 3 million as yet non-dialyzed CRI patients. It results from an imbalance in the interaction between calcium, phosphorus, vitamin D and parathyroid hormone (PTH). In fact, CRI is accompanied by phosphorus retention and this accumulation of phosphorus induces an increased synthesis of FGF-23 (Fibroblast Growth Factor-23) which inhibits the activity of lalpha-hydroxylase and the synthesis of calcitriol. Moreover, the hyperphosphaturia induced by PTH and its stimulant effect on calcitriol synthesis and tubular calcium reabsorption are compromised by the reduction in the expression of the renal PTH receptor. All these changes lead to a negative calcium balance and a reduction in calcium-sensitive receptors and vitamin D receptors in parathyroid cells (CaR), thereby releasing the secretion of PTH and the proliferation of parathyroid cells. The chronic stimulation of PTH by these anomalies causes progressive hyperplasia of the parathyroid cells which may be transformed into a benign tumor with a monoclonal appearance. The usual medical treatment of HPTH-II consists in the correction of hypocalcemia by calcium salts and vitamin D and its derivatives, hyperphosphatemia by lifestyle and dietary changes and intestinal phosphorus chelating agents and metabolic acidosis. Very recently, this treatment armamentarium has been expanded by the advent of the calcimimetic agent, cinacalcet HCl. This product increases the calcium sensitivity of CaR in parathyroid cells leading to a rapid and sustained decrease in PTH secretion. However, it is still necessary to resort to surgical parathyroidectomy (PTX) when these treatments prove to be ineffective or involve risks because of adverse effects and in particular an increase in the calcium-phosphorus ion product and the occurrence or worsening of cardiovascular calcifications. The purpose of this article is to revise the current indications of PTX and to discuss changes and the current and future trends for treatment of HPTH-II by surgery alone or combined.     

Should COPD patients be routinely evaluated for bone mineral density?

 There are many factors that increase the risk of osteoporosis, including smoking, malnutrition, vitamin D deficiency, hypogonadism, limited physical activity due to chronic disease, and corticosteroid therapy in chronic obstructive pulmonary disease (COPD). The aim of this study was to investigate bone mineral density (BMD) in COPD outpatients receiving regular therapy in order to clarify whether they were suitable candidates for bone mass screening. Twenty-eight male, clinically stable COPD patients (mean age, 63 ± 9 years) and 20 male volunteer subjects with normal pulmonary function, as a control group (mean age, 63 ± 5 years) were admitted to the study. The BMD of the COPD patients and control subjects was measured by dual X-ray absorptiometry (Hologic QDR-4000). Pulmonary function tests and arterial blood gas analyses of COPD patients revealed moderate-degree airway obstruction with mild hypoxemia and normal pH. Rates of 42% and 67% for lumbar and femoral osteopenia, respectively, and 35%, and 10% for lumbar and femoral osteoporosis, respectively, were detected in the COPD patients; whereas the rates of lumbar and femoral osteopenia were 40% and 50%, respectively, and the rates of lumbar and femoral osteoporosis were 40% and 15%, respectively, in the control subjects. There was no statistically significant difference between the BMD values of the COPD and control groups. Lumbar BMD was 0.871 g/cm² in the COPD patients and 0.853 g/cm² in the control group (P = 0.682); femoral BMD was 0.790 g/cm² in the COPD patients and 0.795 g/cm² in the control group (P = 0.909). Bone density was correlated with the degree of airway obstruction and arterial blood pH. In conclusion, the BMD values of COPD patients were not different from those of control subjects of the same age group. We conclude that the risk of osteoporosis is not increased in appropriately treated patients with moderate-degree COPD, and there is no indication for bone mass screening in this group. Received: June 13, 2002/Accepted: December 12, 2002 RID="*" ID="*" Offprint requests to: F. Karadag     

Is dissociation a multidimensional construct? Data from the Multiscale Dissociation Inventory

The dimensionality of dissociation was examined in a combined sample of 1,326 general population, clinical, and university participants who completed the Multiscale Dissociation Inventory (MDI). Principal components analysis identified five moderately intercorrelated factors (mean r = .39): Disengagement, Identity Dissociation, Emotional Constriction, Memory Disturbance, and Depersonalization/Derealization. Differential relationships were found between individual MDI factors and demographics, trauma history, clinical status, posttraumatic stress, and scores on other dissociation measures. Surprisingly, after controlling for sex and age, trauma exposure accounted for only 3 to 7% of the variance in MDI factors. The notion of dissociation as a general trait was not supported. Instead, dissociation may represent a variety of phenomenologically distinct and only moderately related symptom clusters whose ultimate commonality is more theoretical than empirical.     

Is the negative relationship between obesity and bone mineral content greater for older women?

Obesity and osteoporosis are two important body composition problems with increasing prevalences in aged populations. Traditionally, obesity has been regarded as being beneficial to bone health. However, the protective effect of obesity on osteoporosis has been questioned. In some recent studies, obesity, as defined by percentage body fat, was regarded as a risk factor for osteoporosis. The purpose of this study was to (1) evaluate the effect of waist circumference, a surrogate measure for abdominal obesity, on bone mineral content (BMC) and (2) examine whether the effect of waist circumference increases with advancing age. The study population is made up of women aged over 45 years who completed the body composition and bone mineral density examinations in the fifth Korea National Health and Nutrition Examination Survey in 2010. Subjects who take estrogen or are under medical treatment for osteoporosis were excluded. Stroke patients are also excluded. Femoral neck, total-hip, and whole-body BMC were measured by dual-energy X-ray absorptiometry. A total of 1,434 subjects were included in the analysis. Waist circumference was negatively associated with BMC in all tested regions after correction for weight, menopausal status, smoking, drinking, and exercise. In addition, the negative association between waist circumference and BMC in the femoral neck and total hip increases with age, after correction for confounding factors, showing an interaction effect between waist circumference and age on BMC. In conclusion, this study shows that the negative relationship between waist circumference and BMC in the femoral neck and total hip is greater for older women.     

Interradicular trabecular bone density of the lateral maxilla for temporary anchorage devices – a histomorphometric study

Objective

To analyze the interradicular trabecular bone density of the lateral maxilla regarding the insertion of temporary anchorage devices (TADs).

Material and methods

The material consisted of tissue blocks of autopsy material from 20 subjects (17 male, 3 female, 16 - 63y). The specimens comprised the dentated alveolar bone of the lateral maxilla. The interradicular areas (IRA) from canine to distally of the second molar (IRA 3–4, 4–5, 5–6, 6–7, 7d) were histomorphometrically measured with respect to the hard tissue fraction of the trabecular bone (HTFTB, %) and statistically analyzed.

Results

Histomorphometric measurements showed the following results: Mean HTFTB of IRA 3–4 was 44.08%, of IRA 4–5 31.07%, of IRA 5–6 33.96%, of IRA 6–7 36.33% and of IRA 7d 25.40%. Only the difference between the HTFTB of IRA 3–4 and the other IRAs was statistically significant (p < 0.05). Regarding the minimum and maximum HTFTB value of each IRA, there was a great amount of difference, especially for IRA 3–4: minimum HTFTB was 17.20% and maximum 67.03%.

Conclusion

Apart from the IRA between canine and first premolar, the HTFTB in the IRAs of the lateral maxilla have to be classified as low or even moderate. IRA 3–4 should also be considered cautious regarding its minimum values. Thus, it seems that the interradicular trabecular bone density of the lateral maxilla is unfavorable to achieve a good primary stability of TADs.     

Should older patients be selectively referred to high-volume centers for abdominal aortic surgery?

The objective of the current study was to determine the effect of hospital volume on outcomes of abdominal aortic surgery for patients older than and younger than 65 years. In order to perform this investigation, information on all adult patients who underwent abdominal aortic surgery in Maryland from 1994 to 1996 (N = 2,987 patients) in 45 acute care hospitals was obtained. Hospitals were designated as low (< 20/year), medium (20 to 36/year), or high (> 36/year) volume according to the annual number of procedures performed. The relationship of hospital volume and mortality was determined for patients less than or greater than 65 years old. Two separate multiple logistic regression models were used to adjust for patient case-mix in each age category. Of the 2,987 patients, 2,067 (69%) were older than 65 years and 920 (31%) were younger. The crude in-hospital mortality rates according to hospital volume were 2.7% (low), 2.1% (medium), and 2.7% (high) for patients younger than 65 years old (p = .8). For patients older than 65 years, in-hospital mortality rates were 11.9% (low), 9.9% (medium), and 6.9% (high) (p = .005). After adjusting for patient case-mix in a multivariate analysis, high hospital volume was associated with a decreased risk of in-hospital mortality for patients older than 65 years (OR 0.57; 95% CI 0.37 to 0.86; p = .008) but not for patients under 65 years old. In conclusion, hospital volume was associated with decreased in-hospital mortality after abdominal aortic surgery only for patients greater than 65 years old. Because of this differential effect, targeting elderly patients for regionalization would achieve most potentially avoidable deaths for this common high-risk surgical procedure.     

The role of radioisotopes for the palliation of bone pain from bone metastases

Bone metastasis occurs as a result of a complex pathophysiologic process between host and tumor cells leading to cellular invasion, migration adhesion, and stimulation of osteoclastic and osteoblastic activity. Several sequences occur as a result of osseous metastases and resulting bone pain can lead to significant debilitation. Pain associated with osseous metastasis is thought to be distinct from neuropathic or inflammatory pain. Several mechanisms, such as invasion of tumor cells, spinal cord astrogliosis, and sensitization of nervous system, have been postulated to cause pain. Pharmaceutical therapy of bone pain includes nonsteroidal analgesics and opiates. These drugs are associated with side effects, and tolerance to these agents necessitates treatment with other modalities. Bisphosphonates act by inhibiting osteoclast-mediated resorption and have been increasingly used in treatment of painful bone metastasis. While external beam radiation therapy remains the mainstay of pain palliation of solitary lesions, bone-seeking radiopharmaceuticals have entered the therapeutic armamentarium for the treatment of multiple painful osseous lesions. ^32p has been used for over 3 decades in the treatment of multiple osseous metastases. The myelosuppression caused by this agent has led to the development of other bone-seeking radiopharmaceuticals, including ^89SrCl, and ^153Sm-ethylenediaminetetramethylene phosphonic acid （^153Sm-EDTMP）. ^89Sr is a bone-seeking radionuclide, whereas ^153Sm-EDTMP is a bone-seeking tetraphosphonate; both have been approved by the Food and Drug Administration for the treatment of painful osseous metastases. While both agents have been shown to have efficacy in the treatment of painful osseous metastases from prostate cancer, they may also have utility in the treatment of painful osseous metastases from breast cancer and perhaps from non-small cell lung cancer. This article illustrates the salient features of these radiopharmaceuticals, including the approved dose, method of administration, and indications for use.     

National Practitioner Data Bank: Who can open the vault?

The National Provider Data Bank (NPDB) was created to restrict physicians from practicing “anonymously” across state lines. But a recent Government Accounting Office report stated that the NPDB is flawed because of underreporting, incorrect reporting, and limited access. For example, a private settlement between a physician and patient is not a reportable event because physicians are not defined as “eligible entities” under the law. The author discusses measures for improving the accuracy of Data Bank information and alternatives providing limited public access to physician information. (Aesthetic Surg J 2001;21:277-278.)     

Osteocyte morphology in human tibiae of different bone pathologies with different bone mineral density — Is there a role for mechanosensing?

Matrix strains due to external loading are different in bones of different pathologies with different bone mineral density (BMD), and are likely sensed by the osteocytes, the putative bone mechanosensors. The mechanosensitivity of osteocytes appears to be strongly influenced by their morphology. In this study, we explored the possibility that osteocyte morphology might play a role in various bone pathologies with different BMD.Confocal laser scanning microscopy and nano-CT were used to quantitatively determine 3D morphology and alignment of osteocytes and osteocyte lacunae in human proximal tibial bone with relatively low (osteopenic), medium (osteoarthritic), and high (osteopetrotic) BMD.Osteopenic osteocytes were relatively large and round (lengths 8.9:15.6:13.4 μm), osteopetrotic osteocytes were small and discoid shaped (lengths 5.5:11.1:10.8 μm), and osteoarthritic osteocytes were large and elongated (lengths 8.4:17.3:12.2 μm). Osteopenic osteocyte lacunae showed 3.5 fold larger volume and 2.2 fold larger surface area than osteoarthritic lacunae, whereas osteopetrotic lacunae were 1.9 fold larger and showed 1.5 fold larger surface area than osteoarthritic lacunae. Osteopetrotic osteocyte lacunae had lower alignment than osteopenic and osteoarthritic lacunae as indicated by their lower degree of anisotropy.The differences in 3D morphology of osteocytes and their lacunae in long bones of different pathologies with different BMD might reflect an adaptation to matrix strain due to different external loading conditions. Moreover, since direct mechanosensing of matrix strain likely occurs by the cell bodies, the differences in osteocyte morphology and their lacunae might indicate differences in osteocyte mechanosensitivity. The exact relationship between osteocyte morphology and bone architecture, however, is complex and deserves further study.     

Congenital hip dysplasia and bone mineral density of the hip--a new risk factor for osteoporotic fracture?

Decreased bone mineral density (BMD) at the hip is an important risk factor for hip fractures, which are a major socioeconomic problem in the elderly. The incidence of congenital hip dysplasia (CHD) is about 7-13% in the Middle European population. We assessed the question of whether a conservatively treated CHD may be a risk factor for low BMD at the hip in adult women. We evaluated prospectively 240 premenopausal women (33 +/- 7 years). Past medical history was recorded including the presence or absence of CHD. Lumbar and femoral BMD using dual-energy X-ray absorptiometry (DXA) and biochemical parameters of bone metabolism were measured. X-rays of the pelvis were performed in CHD patients. Thirty-one (12.9%) of the patients had a history of conservatively treated CHD, four (1.2%) had undergone surgery; all other patients served as control group. Patients and controls were comparable for anthropometric data, lifestyle factors, and hip axis length. BMD in CHD patients was significantly lower at the hip (difference by 1 STD) but comparable at the spine. OC was significantly higher in patients with CHD than in controls. In a logistic regression model, CHD was associated with a 6.3-fold increased risk for low BMD at the hip. We therefore conclude that a history of conservatively treated CHD may be a major risk factor for low BMD at the hip in about 1 out of 10 women. Whether this translates into an increased risk for future hip fractures will have to be assessed in further prospective studies.     

Internal fixation for displaced fractures of the femoral neck. Does bone density affect clinical outcome?

The results of meta-analysis show a revision rate of 33% for internal fixation of displaced fractures of the femoral neck, mostly because of nonunion. Osteopenia and osteoporosis are highly prevalent in elderly patients. Bone density has been shown to correlate with the intrinsic stability of the fixation of the fracture in cadaver and retrospective studies. We aimed to confirm or refute this finding in a clinical setting. We performed a prospective, multicentre study of 111 active patients over 60 years of age with a displaced fracture of the femoral neck which was eligible for internal fixation. The bone density of the femoral neck was measured pre-operatively by dual-energy x-ray absorptiometry (DEXA). The patients were divided into two groups namely, those with osteopenia (66%, mean T-score -1.6) and those with osteoporosis (34%, mean T-score -3.0). Age (p = 0.47), gender (p = 0.67), delay to surgery (p = 0.07), the angle of the fracture (p = 0.33) and the type of implant (p = 0.48) were similar in both groups. Revision to arthroplasty was performed in 41% of osteopenic and 42% of osteoporotic patients (p = 0.87). Morbidity (p = 0.60) and mortality were similar in both groups (p = 0.65). Our findings show that the clinical outcome of internal fixation for displaced fractures of the femoral neck does not depend on bone density and that pre-operative DEXA is not useful.     

Is severe atherosclerosis in the aortoiliac region a contraindication for kidney transplantation?

Background

Atherosclerosis is common in end-stage renal disease patients on dialysis. However, it has previously been considered to be a relative contraindication to kidney transplantation. Currently, patients with extended indications are accepted onto the waiting list, including those with severe atherosclerosis. These patients require vascular procedures before or during kidney transplantation. The aim of this study was to present our experience with vascular reconstruction before kidney transplantation.

Material and Methods

Twelve atherosclerotic, uremic patients referred to be candidates for kidney transplantation were refused because of occlusive lesions of the iliac arteries or the distal aorta. The 10 males and 2 females had an age range of 45 to 68 years. Preoperative assessments consisted of a Doppler ultrasound and an angio computed tomography scan. The reconstructions were performed with aorto-biliac, aorto-bifemoral, or ilio-femoral dacron grafts in 7, 4, and 1 patient, respectively, under general anesthesia.

Results

There were no major postoperative complications; the patients were discharged and placed on a special waiting list. Eight patients received kidney allografts, including one living-related transplantation. All procedures were performed with arterial anastomosis of the transplanted kidney to the side of the prosthesis. No patient developed signs of arterial graft infection. In the postoperative period, there were no arterial or transplanted kidney-related complications, except for delayed graft function in four cases. The remaining four patients are still on the waiting list.

Conclusion

In end-stage renal disease patients with severe atherosclerosis in the aortoiliac region, vascular reconstruction allows kidney transplantation.