Bone Mineral Density, Hip Axis Length and Risk of Hip Fracture in Men: Results from the Cornwall Hip Fracture Study

Bone mineral density (BMD) and hip axis length (HAL) are important determinants of fracture risk in women. There are, however, few data concerning their predictive risk in men. The aim of this study was to determine the relationship between BMD, HAL and the risk of hip fracture in men. A case–control design was used. Cases were men aged 50 years and over with a minimal-trauma hip fracture admitted to the Royal Cornwall Hospital, Truro, during 1995–1997. Controls were recruited from a large general practice within the catchment area of the hospital. Subjects were invited for assessment of BMD at the lumbar spine and proximal femur, using dual-energy X-ray absorptiometry. HAL was assessed using machine software. Data concerning BMD were available in 62 fracture cases and 100 controls. After adjusting for age, height and weight, a reduction in BMD was associated with a significant increase in the risk of hip fracture [odds ratio (OR) 1.8–4.0 per standard deviation (SD) reduction, depending on site]. HAL was similar in both fracture and control groups (12.0 cm vs 12.0 cm). After adjusting for height, there was no association between HAL and the risk of hip fracture (OR per 1 SD increase in HAL = 0.9; 95% confidence interval 0.6, 1.3). Compared with those with a cervical fracture (n= 31), those with an intertrochanteric fracture (n= 31) had lower BMD at all skeletal sites, though this was significant for the trochanteric site only. It is concluded that BMD though not hip axis length is a risk factor for low-trauma hip fracture in Caucasian men. Received: 28 September 1999 / Accepted: 21 April 2000     

Catastrophic payments for health care in Asia

Out-of-pocket (OOP) payments are the principal means of financing health care throughout much of Asia. We estimate the magnitude and distribution of OOP payments for health care in fourteen countries and territories accounting for 81% of the Asian population. We focus on payments that are catastrophic, in the sense of severely disrupting household living standards, and approximate such payments by those absorbing a large fraction of household resources. Bangladesh, China, India, Nepal and Vietnam rely most heavily on OOP financing and have the highest incidence of catastrophic payments. Sri Lanka, Thailand and Malaysia stand out as low to middle income countries that have constrained both the OOP share of health financing and the catastrophic impact of direct payments. In most low/middle-income countries, the better-off are more likely to spend a large fraction of total household resources on health care. This may reflect the inability of the poorest of the poor to divert resources from other basic needs and possibly the protection of the poor from user charges offered in some countries. But in China, Kyrgyz and Vietnam, where there are no exemptions of the poor from charges, they are as, or even more, likely to incur catastrophic payments.     

A calcified central venous fibrin sheath mimicking a fractured catheter

A 75-year-old female with end stage kidney failure had her tunneled central venous dialysis catheter (CVC) removed. A subsequent computed tomopgraphy (CT) scan of the chest reported a filling defect in the central vein that appeared to represent a fractured remnant of the CVC. The catheter had been retained for culture and was available for direct visualization, which showed it to be entirely intact. A subsequent venogram confirmed that the CT findings represented a retained calcified central venous fibrin sheath. As retained CVC fragments may require intervention, this diagnosis should be established carefully. A calcified fibrin sheath associated with a chronic CVC is a known, although rare, complication and should be considered in the differential diagnosis of an apparent CVC fracture prior to further interventions.     

A Seminoma in a Monorchid Guinea Fowl (Numida meleagris)

A case of seminoma in a monorchid adult guinea fowl (Numida meleagris) is described. Grossly, a right enlarged testis, which was soft in consistency, and white to pale in colour with few spots of haemorrhages was observed. Histologically, the testicle revealed diffusely spread sheets of tumour cells. The cells were large pleomorphic with eccentrically placed hyperchromic nuclei. Mitotic figures were evident. A scanty fibrous stroma, containing lymphocytes and histiocytes, separating the groups of tumour cells, along with few areas of haemorrhages were observed. Occurrence of seminoma in guinea fowl is unusual and hence reported.     

Malignant pheochromocytoma.

We present an interesting case of paroxysmal hypertension in a young male caused by malignant pheochromocytoma. This patient, who had history of paroxysms of abdominal pain with severe hypertension, developed osseous metastasis in the first lumbar vertebra resulting in collapse of the vertebra and it caused paraplegia. The diagnosis of pheochromocytoma was confirmed on histopathology.     

Coronary and left ventricular pacing as standby in invasive cardiology.

Coronary pacing using as unipolar negative electrode a guidewire placed in a coronary branch was tested in 349 sites of 300 consecutive patients undergoing coronary angioplasty. It was possible for 339 sites (97%). The threshold currents ranged from 1 to 15 (mean +/- standard deviation 3.4 +/- 2.4) mA. Side effects were seen in 13 patients (4%): 6 (2%) had transient coronary spasm, 4 (1%) had diaphragmatic stimulation, and 3 (1%) had stinging pain at the skin electrode. Of the 10 cases with pacing failure, left ventricular pacing was successfully tested in 5 by introducing the coronary wire or another wire into the left ventricle. It yielded a threshold of 2-8 (3.2 +/- 2.7) mA. Therapeutic pacing for significant bradycardia was required in 7 patients (2%). It was successful in all. Coronary or left ventricular pacing appears to be a simple and reliable temporary measure. When there is no wire in the coronary artery or for diagnostic catheterization, left ventricular pacing can be done using the same setup and any type of guidewire.     

Association of extent and infection of pancreatic necrosis with organ failure and death in acute necrotizing pancreatitis.

BACKGROUND & AIMS: Organ failure is the usual cause of death in acute necrotizing pancreatitis. Our objective was to study whether the extent and infection of pancreatic necrosis correlate with organ failure and mortality. METHODS: All consecutive patients with acute pancreatitis were prospectively studied. They underwent a detailed clinical and investigative evaluation. Pancreatic necrosis, diagnosed on a computed tomography scan, was graded as <30%, 30%-50%, and >50% necrosis and characterized as either sterile or infected. Logistic regression analysis was done to find out the association of the extent and infection of pancreatic necrosis with organ failure and mortality. RESULTS: Of 276 patients (mean age, 41.25 years; 172 men), 104 had pancreatic necrosis: 30 had <30% necrosis, 37 had 30%-50% necrosis, and 37 had >50% necrosis; 74 had sterile necrosis, and 30 had infected necrosis. Of them, 37 (35%) patients developed organ failure. Two significant factors were associated with the development of organ failure, the extent of necrosis (<30% necrosis vs 30%-50% necrosis: P = .03; odds ratio [OR], 5.82; 95% confidence interval [CI], 1.15-29.45; <30% necrosis vs >50% necrosis: P = .0004; OR, 18.86; 95% CI, 3.75-94.92) and infected pancreatic necrosis (P = .02; OR, 3.29; 95% CI, 1.17-9.24). The overall mortality was 22%. Infected pancreatic necrosis (P = .006; OR, 4.99; 95% CI, 1.56-16.02) and Acute Physiology, Age, and Chronic Healthy Evaluation II score (P = .004; OR, 1.28; 95% CI, 1.08-1.52) were 2 independent predictors of mortality. CONCLUSIONS: Extent of necrosis and infected pancreatic necrosis were associated with the development of organ failure in patients with acute necrotizing pancreatitis. Infected pancreatic necrosis was the most significant predictor of mortality.     

Molecular basis of a progressive juvenile-onset hereditary cataract

In a recent paper, patients with a progressive juvenile-onset hereditary cataract have been reported to have a point mutation in the human gammaD crystallin gene (Stephan, D. A., Gillanders, E., Vanderveen, D., Freas-Lutz, D., Wistow, G., Baxevanis, A. D., Robbins, C. M., VanAuken, A., Quesenberry, M. I., Bailey-Wilson, J., et al. (1999) Proc. Natl. Acad. Sci. USA 96, 1008-1012). This mutation results in the substitution of Arg-14 in the native protein by a Cys residue. It is not understood how this mutation leads to cataract. We have expressed recombinant wild-type human gammaD crystallin (HGD) and its Arg-14 to Cys mutant (R14C) in Escherichia coli and show that R14C forms disulfide-linked oligomers, which markedly raise the phase separation temperature of the protein solution. Eventually, R14C precipitates. In contrast, HGD slowly forms only disulfide-linked dimers and no oligomers. These data strongly suggest that the observed cataract is triggered by the thiol-mediated aggregation of R14C. The aggregation profiles of HGD and R14C are consistent with our homology modeling studies that reveal that R14C contains two exposed cysteine residues, whereas HGD has only one. Our CD, fluorescence, and differential scanning calorimetric studies show that HGD and R14C have nearly identical secondary and tertiary structures and stabilities. Thus, contrary to current views, unfolding or destabilization of the protein is not necessary for cataractogenesis.     

Anti-tuberculosis treatment in private pharmacies, Kathmandu Valley, Nepal.

SETTING: Urban municipality of 150000 citizens in Kathmandu Valley, Nepal. OBJECTIVE: To determine 1) the perceptions among private pharmacists of characteristics of tuberculosis (TB) patients visiting private pharmacies in the area, 2) the sales of different anti-tuberculosis drugs, and 3) the interaction between private health providers and pharmacists. DESIGN: Between January and April 1998, semi-structured interviews were conducted with 98% (49/50) of the private drug-retailers in the area. RESULTS: Thirty-two (65%) pharmacies had sold anti-TB drugs during the last month. Forty-three (88%) said that most TB patients were of low socio-economic status and rarely bought drugs for more than a week at a time. Only eight (16%) reported that TB patients usually returned to buy the full course of drugs. Seventy-two per cent of total spending on anti-tuberculosis drugs was for different kinds of combinations of drugs. Nine per cent was spent on plain rifampicin, believed to be sold only to tuberculosis/leprosy patients. During the previous month, 5/13 (38%) of pharmacies with no doctors attached had sold anti-tuberculosis drugs compared with 27/38 (71%) of pharmacies with doctors attached to them (P < 0.05). CONCLUSION: The private sector offers an available and acceptable but non-affordable service for many TB patients. A substantial amount of anti-TB drugs are being sold in the private pharmacies. There is therefore a potential role for pharmacists to play in collaborative efforts between the private and public sector in TB control activities.