Absorptiometry and “osteoporosis”: problems

connecting the dots between diverse clinical and other matters and an updated bone physiology reveals relationships that could modify some ideas about the roles and uses of absorptiometry in osteoporosis work. Herein, absorptiometry means that part of clinical densitometry that depends on X-ray absorption by bone and other tissues, thus excluding ultrasound methods and magnetic resonance imaging. The modifications concern, in part, some limitations of bone mineral density data, the kinds of physiological information that absorptiometry can and cannot provide, the relative importance of bone mass and whole-bone strength, how to define and study bone health and osteoporosis, and two kinds of osteoporotic fractures. As those modifications concern important national health care issues, they deserve answers based on hard evidence. Identifying those modifications might help others to evaluate them.     

“Half and half” woven and knitted Dacron grafts in the aortoiliac and aortofemoral positions: Seven and one-half years follow-up

One-hundred fifty-eight patients received specially manufactured aortoiliac or aortofemoral bifurcated grafts with one limb woven, the other knitted from Dacron. During an observation period ranging from 1,567 to 2,555 days (average 2,130 days) no statistically significant difference was found in either platelet adherence (30 patients studied) or in clinical patency. According to the results of the study, the type of graft (woven or knitted) did not seem to influence either platelet adherence or patency rate in the aortoiliac or aortofemoral positions.     

Patient anxiety and experiences associated with an outpatient “one-stop” “see and treat” hysteroscopy clinic

Background One-stop outpatient hysteroscopy clinics have become well established for the investigation and treatment of women with abnormal uterine bleeding. However, the advantages of these clinics may be offset by patient factors such as anxiety, pain, and dissatisfaction. This study aimed to establish patients views and experiences of outpatient service delivery in the context of a one-stop diagnostic and therapeutic hysteroscopy clinic, to determine the amount of anxiety experienced by these women and compare this with other settings, and to determine any predictors for patient preferences.Methods The 20-item State–Trait Anxiety Inventory was given to 240 women attending a one-stop hysteroscopy clinic: to 73 consecutive women before their appointment in a general gynecology clinic and to 36 consecutive women attending a chronic pelvic pain clinic. The results were compared with published data for the normal female population, for women awaiting major surgery, and for women awaiting a colposcopy clinic appointment. In addition, a questionnaire designed to ascertain patients views and experiences was used. Logistic regression analysis was used to delineate the predictive values of diagnostic or therapeutic hysteroscopy, and to determine their effect on the preference of patients to have the procedure performed under general anesthesia in the future.Results Women attending the hysteroscopy clinic in this study reported significantly higher levels of anxiety than those attending the general gynecology clinic (median, 45 vs 39; p = 0.004), but the levels of anxiety were comparable with those of women attending the chronic pelvic pain clinic (median, 45 vs 46; p = 0.8). As compared with the data from the normal female population (mean, 35.7) and those reported for women awaiting major surgery (mean, 41.2), the levels of anxiety experienced before outpatient hysteroscopy clinic treatment were found to be higher (mean, 45.7). Only women awaiting colposcopy (6-item mean score, 51.1 ± 13.3) experienced significantly higher anxiety scores than the women awaiting outpatient hysteroscopy (6-item mean score, 47.3 ± 13.9; p = 0.002). Despite their anxiety, most women are satisfied with the outpatient hysteroscopy see and treat service. High levels of anxiety, particularly concerning pain but not operative intervention, were significant predictors of patients desiring a future procedure to be performed under general anesthesia.Conclusions Outpatient hysteroscopy is associated with significant anxiety, which increases the likelihood of intolerance for the outpatient procedure. However, among those undergoing operative therapeutic procedures, dissatisfaction was not associated with the outpatient setting.     

Traditional and “new” cardiovascular risk markers and factors in pediatric dialysis patients

Cardiovascular disease (CVD) is the principal cause of mortality in patients with end-stage renal disease (ESRD). The aim of this study was to analyze carotid intima-media thickness (cIMT), endothelium-dependent dilatation (EDD), and left ventricular mass index (LVMI) as the cardiovascular risk markers and to investigate the independent risk factors of these markers in pediatric dialysis patients. This study included 39 children and adolescents undergoing dialysis (15 hemodialysis and 24 peritoneal dialysis) and 15 age- and gender-matched healthy subjects. The cIMT and EDD were assessed by high-resolution ultrasound, and LVMI was calculated from standard echocardiographic measurements. Compared with control subjects, cIMT standard deviation scores (SDS), LVMI, total homocysteine (tHcy), and high-sensitivity C-reactive protein (hs-CRP) values were significantly higher in patients, but EDD values did not differ. The mean hs-CRP level was significantly higher in hemodialysis (HD) patients than in peritoneal dialysis (PD) patients. The cIMT-SDS and LVMI were associated with several variables in univariate analysis. Stepwise linear regression analysis, indexed SBP (p = 0.017), and hemoglobin (p = 0.001) turned out to be independent variables for predicting LVMI, and a significant predictor of cIMT was indexed diastolic blood pressure (DBP) (p = 0.035). The causes of atherosclerosis and left ventricular hypertrophy are multifactorial in children and adolescents with ESRD. Better management of hypertension and anemia may be priorities for preventing or improving CVD in these patients.     

Spinal Cord Stimulation and Early Experimental Cerebral Spasm: The “Functional Monitoring” and the “Preventing Effect”

Summary  Background. Clinical and experimental data on cerebral blood flow (CBF) changes during spinal cord stimulation (SCS) were published since 1986. The aims of the present work are: 1. To find an experimental model of reliable, simple and in vivo monitoring of “early” basilar artery spasm after subarachnoid haemorrhage (SAH) and 2. To investigate the effects of cervical spinal cord stimulation (CSCS) on it. Vasospasm due to SAH is both “acute” and “recurrent”. Early spasm occurs within minutes of the SAH, its duration is approximately 1 hour. The need of different morphological and haemodynamic methods to evaluate experimental early spasm is reported. To overcome intracranial surgical manipulations and biological effects of contrast and fixation media we designed a model that allows “ in vivo” functional monitoring of basilar blood flow far away from the spasm without direct surgical and chemical interference. Subsequently we investigated the effects of CSCS on the new model of “functional monitoring” of the “early” cerebral vasospasm.  Method. 29 adult Burgundy rabbits were studied. Group 1: under homeostatic monitoring, “on-line” carotid blood flow (carotid BF) changes produced by SAH in cisterna magna of 12 (plus 5 sham treated) animals were studied from the common carotid artery after external carotid artery occlusion before, during SAH and up to the end of the experiments. All the animals underwent digital subtraction cerebral panangiography (CPA) after SAH obtaining a significant increase of carotid BF only when basilar vasospasm was shown by CPA. Carotid BF increase during basilar vasospasm was defined “functional monitoring” of early spasm. Group 2: Twelve animals wearing a cervical epidural electrode underwent carotid BF “functional monitoring” of early basilar spasm before and during CSCS.  Findings. Carotid BF changes during CSCS occurred in 10 animals. No carotid BF changes (i.e. no basilar vasospasm) occurred after SAH up to the end of the experiments in all the stimulated animals.  Interpretation. CSCS is able to prevent “early spasm” due to SAH in all the animals studied with the new model of “functional monitoring” described, independently from the occurrence and the sign for stimulation-induced carotid BF variations. The role and the limits of reversible functional sympathectomy in mediating the effect of CSCS on early vasospam are discussed.     

Efficacy and toxicity of CyberKnife re-irradiation and “dose dense” temozolomide for recurrent gliomas

Background  

Stereotactic radiosurgery (SRS) can be a useful adjunct to the treatment of recurrent glioblastoma multiforme (GBM). Its combination with chemotherapy is attractive for the possible radiosensitization effect and cytotoxicity on tumor cells in distant areas. The aim of this study was to evaluate the efficacy and toxicity of CyberKnife SRS alone and combined with a “dose-dense” administration of temozolomide (TMZ) for recurrent GBM.     

“Physiological osteoporosis” and “osteoblast insufficiency” in old age

Summary To investigate the expectation of general insufficiency of osteoblasts with increasing age, we studied autotopsy material from 105 deceased persons of both sexes who had died between 16 and 91 years and in whom clinically manifest diseases of the bone had been excluded. Quantitative morphometric examination of the structure of the spongy bone of the 3rd–5th lumbar vertebral bodies (LVBs) and of the 5th–7th cervical vertebral bodies (CVBs) was carried out in frontal and saggital planes, the parameters analysed being volumetric density (V_v), surface density (S_v) and specific surface area (S/V), and the results were subjected to statistical evaluation. The results showed that in the three LVBs, V_v, S_v and S/V behave in a similar manner, V_v and S_v decreasing after the age of 50 years by more than one-third while S/V remains constant throughout life. The three lower CVBs had higher values than the LVBs for all three structural parameters. In the 7th CVB somewhat lower V_v and S_v values and higher S/V values were found than in the 5th and 6th. The age-related changes, by contrast, were very small. This differing behavior of the spongy bone in the two regions of the spinal column is an expression of the different characteristic loading forces in each regions: LVB loading is predominantly static, CVB loading mainly dynamic. Thus, from the functional point of view, what is known as physiological osteoporosis due to ageing is nothing more than adaptation by an ageing bone to physical activity, reflecting —like the bone of the young adult — the current loading of the cancellous bone by the actions of the musculoskeletal system. Since such physical activity is often age-related, the performance of the osteoblasts does not depend upon age per se, but merely on the remaining functional adaptive capacities of the ageing organism as whole.Dedicated to Prof. Dr. Heinz Wagner on the occasion of his 60th birthday     

Electrocardiographic “pacemaker pseudospikes” and radio frequency interference

Purpose

To present a case of apparent interference of an ECG monitor by radiofrequency interference (RFI) and to provide a bnef review of RFI issues relevant to critical care medicine.

Clinical features

A 74-yr-old woman, with an implanted pacemaker, underwent major spinal surgery. In the post-anaesthesia care unit, the cardiac monitor demonstrated graphic evidence of pacemaker malfunction but there was no apparent effect on the patient. Investigation by the hospital’s biomedical personnel led to the conclusion that RFI was being interpreted by the monitor as abnormal pacemaker activity.     

“Marsupial cava” and ruptured abdominal aortic aneurysm

A patient with a ruptured abdominal aortic aneurysm underwent an emergency operation. A rare anomaly of inferior vena cava, known as “marsupial cava,” was found. The iliac vein confluence crossed anteriorly (rather then posteriorly) the right common iliac artery. Even though the patient had undergone a computed tomography scan, this rare anomaly had not been detected and therefore was unexpected by the surgeon. The aim of this report is to describe the technical details required to perform the aortic reconstruction and to stress the importance of routine computed tomography scans and their careful reading in the case of stable patients before retroperitoneal operation. This is, to our knowledge, the first report of an aortic prosthetic grafting for ruptured aortic aneurysm in association with a marsupial cava. (J Vasc Surg 1998;28:719-22.)     

New “sutureless” technique of ileostomy and colostomy

Background Brooke ileostomy and colostomy are associated with infection in the stomal and/or main wounds, leading to complications. The source of infection is feces from the open lumen. The objective of the present study was to find a way to prevent infection and subsequent complications. It was started in 1986 by serendipity after discovery that if wound contamination from intestinal contents is stopped in the immediate postoperative period, by a complete small/large intestinal obstruction, infection and complications are prevented. This study was based on the principle of delayed-primary wound closure. Methods and procedures Following its initial discovery for a Brooke ileostomy, the procedure was used for both ileostomy and colostomy. The stapled stoma was fixed to the opening in rectus sheath. It was covered with an appliance that has a transparent pouch, allowing daily inspection. During the period of postoperative ileus, there is angiogenesis on the serosal surface, making it refractory to infection. The stoma tends to bulge with the appearance of peristalsis. Stoma was then opened with electrocautery in a bedside procedure. The mucosal cuff protrudes, everts, advances with peristalsis, and “grafts” itself on angiogenesis on the surface of a single layer of serosa. The advancing margin of the mucosal cuff fuses with the circumference of the opening in dermis. The maturation of the stoma is natural and automatic. Absence of sutures reduced the tissue trauma and foreign body reaction, resulting in better wound healing. This new procedure was named “delayed-primary self-maturation” (DPSM). Results Thirty seven colostomies and nine ileostomies were performed using DPSM. Infection in the stomal and/or main wound and subsequent complications were prevented. Conclusions Delayed-primary self-maturation is technically easier and more scientific than a conventional ileostomy or colostomy and is recommended for all types of stomas. An erratum to this article can be found at     

An odd and serious “disc bulging”!

Background and importanceCauda equina syndrome is a common acute medical condition, usually caused by large degenerative disc herniation or metastatic lumbar disease. We describe a patient who presented with a lesion featuring both discal and tumoral characteristics.Clinical presentationA 41-year-old woman presented with ongoing back pain, progressive lower-limb weakness and sphincter disorder. Magnetic resonance imaging showed a very odd-looking large anterior epidural lesion originating from the L3-L4 space and severely compressing the roots of the cauda equina. Partial surgical decompression was performed in emergency. At a later time, redo surgery was performed to maximize resection, and was unfortunately followed by several complications. After 6 surgical procedures including a ventriculo-peritoneal shunt insertion and intensive rehabilitation, the patient could walk independently with the aid of one crutch. Following collegial review, the diagnosis of low-grade chondrosarcoma of the intervertebral disc was suggested.ConclusionWe report on a very unusual and therapeutically challenging spinal tumor diagnosed as low-grade chondrosarcoma of discal origin, an entity never previously described.     

Tissue-engineered airway and “in situ tissue engineering”

Since the 1980s, tissue engineering has become one of the major areas of endeavor in medical research, applying the principles of biology and engineering to the development of functional substitutes for damaged tissue. Using this technology, various attempts have been made to create and apply a tissue-engineered prosthetic trachea, or airway. In addition to the conventional tissue engineering approach, a new substantially different concept has been advocated in Japan since 2000. This is “in situ tissue engineering,” where a tissue is created not in vitro but in vivo, exploiting the potential of the living body for wound healing. An artificial trachea created by in situ tissue engineering has already been applied in human patients for reconstruction of airway defects, and promising results have been obtained. This article reviews recent progress in the relatively new field of airway reconstruction employing tissue engineering.     

The “mirror image” and “two-thirds” types of hemispherical spondylosclerosis

Summary Clinical and radiological examination of 167 hemispherical spondylosclerosis (HSS) patients (56 male, 111 female) revealed a total of 186 cases of HSS with multiple incidences occurring in 18 patients. Radiologically these HSS cases were characterized by erosion and new bone formation at the inferior and upper end plate of the vertebra below, periosteal bone apposition or ossification of the anterior longitudinal ligament, spondylophytes, and signs of degenerative alteration of the vertebra and disc. In addition, the size and location (anterior, middle, posterior third) of each HSS in the lateral view was investigated. The cases were also investigated for reflection phenomenon between supra- and infradiscal sclerosis and for kyphotic angulation of the two adjacent vertebrae. The results showed that in 105 cases (56.5%) the HSS filled out the entire vertebral area; 97 cases (52.2%) showed a mirror-image type HSS; while in 8 cases (4.3%), the infradiscal sclerosis was polymorphic. In 81 cases (43.5%), the sclerosis was limited to the anterior two-thirds; this is termed two-thirds type. All 81 of these cases of HSS showed a kyphotic angulation of at least 4°. Of these, 61 (32.8% of the total) showed reflection phenomenon while 20 (10.7% of the total) had polymorphic infradiscal sclerosis. Overall, 158 cases of HSS (85%) exhibited the reflection phenomenon between supra- and infradiscal sclerosis. whereas 28 cases (15%) revealed polymorphic sclerosis of the subadjacent vertebra. Kyphotic angulation was completely absent when HSS was visible in the entire vertebra. A dorsal gap of the disc space was seen in 36 cases (19.4%). A biomechanical classification of HSS is presented in order to help differentiate between centric and eccentric segmental load transfer.