Anterior knee pain after intramedullary nailing of a tibial shaft fracture: an ultrasound study of the patellar tendons of 36 patients

OBJECTIVES: Chronic anterior knee pain is a common complication following intramedullary nailing of a tibial shaft fracture. The etiology of pain is often not known. This study sonographically examined the patellar tendons of patients with a nailed tibial shaft fracture. DESIGN: Prospective study. SETTING: University hospital. PATIENTS: Fifty consecutive patients with a nailed tibial shaft fracture were initially included in the study. Thirty-six of them could be measured at an average of 2.5 +/- 0.5 years after nail insertion (1.0 +/- 0.3 years after nail extraction). INTERVENTION: Reamed intramedullary nailing with 2 interlocking bolts at both ends of the nail (Grosse-Kempf-nail, Howmedica). MAIN OUTCOME MEASUREMENTS: The ultrasound investigation of the patellar tendons of the 36 patients. RESULTS: Twelve (33%) patients were painless and 24 (67%) patients had anterior knee pain at follow-up. With the reference to the mean difference in the thickness of the distal part of the patellar tendon in the operated limb versus nonoperated limb, the result was 1.4 +/- 1.1 mm in the chronic pain group and 2.6 +/- 2.5 mm in the painless group (P = 0.135, [95% confidence interval for the group difference = -0.4-2.8]). The corresponding values for the proximal part of the patellar tendon was 1.4 +/- 1.3 mm in the chronic pain group and 2.3 +/- 2.3 mm in the painless group (P = 0.251, [95% confidence interval for the group difference = -0.7-2.4]). There were no statistically significantly differences between study groups in the blood circulation of the patellar tendon or at the entry point, calcification of the patellar tendon, granulation tissue at the entry point, or occurrence of low echo areas in the patellar tendon. CONCLUSION: After intramedullary nailing of a tibial shaft fracture, patients with or without anterior knee pain show similar changes in the ultrasound investigation of their patellar tendons. Based on those findings, it does not appear to make any difference as to the approach used (paratendinous or transtendinous) for intramedullary nailing of the tibia.     

Fixation of syndesmotic ruptures in 38 patients with a malleolar fracture: a randomized study comparing a metallic and a bioabsorbable screw

OBJECTIVES: To compare the performance of a metallic and a biodegradable screw in the fixation of tibia-fibula syndesmotic ruptures. DESIGN: A randomized, prospective, and blinded study. SETTING: Central hospital, Department of Surgery. PATIENTS: Forty consecutive patients with a clinically verified syndesmotic rupture in association with a malleolar fracture, of whom 38 completed the study. INTERVENTION: After syndesmosis rupture was diagnosed, implant selection was performed intraoperatively by a strict randomization with sealed envelopes. Eighteen patients were treated with a metallic screw, and 20 with a bioabsorbable polylevolactic acid screw. The metallic screws were removed in a second operation at 8 weeks postoperatively. All patients had a treatment-blinded clinical and radiographic control after a mean follow-up of 35 (range 17-51) months. MAIN OUTCOME MEASURES: Return to previous physical activity level, evaluation of ankle stability, range of motion, circumference of the ankle, and a radiographic evaluation of both ankles including a measure of the talocrural, medial joint, and syndesmotic space widths. RESULTS: More patients with a polylevolactic acid screw returned to their previous activity level, and there was less swelling in the ankles of these patients, but joint motion was similar between the groups. The mean values of syndesmotic and medial joint spaces were significantly higher in the radiographs of the operated ankles when compared to the uninjured ankle, but there was not a correlation to the type of screw used. CONCLUSIONS: Polylevolactic acid screws worked as well, or slightly better than, metallic ones in syndesmosis fixation in patients with an ankle fracture.     

Impairment of lung function in asbestos-exposed workers in relation to high-resolution computed tomography

OBJECTIVES: The aim of the study was to determine the causes of impairment of ventilatory function and diffusing capacity in smoking asbestos-exposed workers (N=590) showing radiological pleural thickenings or pulmonary fibrosis. METHODS: High-resolution computed tomography (HRCT) and spirometry were performed, and diffusing capacity was measured. The workers were divided into five groups based on the HRCT scoring: pleural disease (N=190), pulmonary fibrosis (N=68), emphysema (N=148), combined fibrosis and emphysema (N=74), and marked adhesions (N=110). The graded lung function impairment was compared between the groups. RESULTS: Moderate impairment of forced expiratory volume in 1 second [odds ratio (OR) 2.72, 95% confidence interval (95% CI) 1.31-5.57] and forced vital capacity (OR 2.81, 95% CI 1.05-6.89) was associated with the persons with combined fibrosis and emphysema. Marked impairment of diffusing capacity was associated with the combined fibrosis and emphysema (OR 4.94, 95% CI 2.48-9.77) but not with pleural disease (OR 0.21, 95% CI 0.09-0.45) or pulmonary fibrosis (OR 0.36, 95% CI 0.08-1.05). For the persons with combined fibrosis and emphysema, the mean fibrosis score did not differ between normal, slightly reduced, or markedly reduced diffusing capacity, but the emphysema score was significantly higher for the patients with marked impairment than for those with normal diffusing capacity (P < 0.01). CONCLUSIONS: Different profiles of asbestos- and smoking-induced pulmonary or pleural disease were found. The results indicate that the most important factor determining the degree of functional impairment in smoking asbestos-exposed workers is the presence of pulmonary emphysema.     

Ultrasound assessment of endothelial function in children

Although the clinical complications of atherosclerosis arise from developed lesions in old age, the atherosclerotic disease is a lifelong process with roots in childhood. Endothelial dysfunction is currently considered an early stage in the pathogenesis of atherosclerosis, which precedes the formation of structural atherosclerotic changes. Improvements in noninvasive imaging modalities, mainly in ultrasound imaging, have made it possible to assess the endothelial health of asymptomatic children with or without cardiovascular risk factors. By using noninvasive ultrasound for endothelial function, important insights have been gained into the early stages of atherosclerosis and the effects of cardiovascular risk factors on vasculature in childhood. The ultrasound test of endothelial function is affordable, available, and safe and may be considered a potent aid in clinical risk stratification of children at high risk for subsequent clinical atherosclerosis in adulthood. At present, this methodology serves only research purposes, as many issues including reproducibility and normal values for healthy children need to be solved before clinical use can be considered. In adults, however, recent studies have shown that attenuated endothelial function predicts the occurrence of future cardiovascular events.     

Sodium transport in airway epithelium correlates with lung compliance in healthy newborn infants

To study the relation between sodium transport in airway epithelium and postnatal pulmonary adaptation, we measured nasal potential difference at 1 to 4 hours and lung compliance at 21 to 48 hours after birth in 20 healthy infants. Sodium transport correlated with lung compliance ( r 2 = 0.40, P < .003). Airway sodium transport plays a role in postnatal pulmonary adaptation.     

Carotid plaque mast cells associate with atherogenic serum lipids, high grade carotid stenosis and symptomatic carotid artery disease. Results from the helsinki carotid endarterectomy study

OBJECTIVE: Increased numbers of mast cells (MCs) are present in ruptured coronary plaques, suggesting to play a role in acute coronary syndromes. We evaluated the distribution densities of MCs, macrophages and T cells in carotid plaques and correlated these findings to stroke risk factors as well as history of stroke or TIA. METHODS AND RESULTS: Seventy-eight carotid samples from 75 patients (16 plaques from asymptomatic patients and 62 from patients with recent ischemic symptoms) undergoing carotid endarterectomy with an internal carotid stenosis >70% that were immunostained and quantified for MCs, macrophages and T cells. The MC distribution density showed positive correlation with the degree of carotid stenosis (p = 0.012), serum levels of total cholesterol (p = 0.021), LDL cholesterol (p = 0.013) and triglycerides (p = 0.005), and an inverse correlation with serum HDL cholesterol levels (p = 0.001). The average MC density (p = 0.023), but not the macrophage (p = 0.58) or T cell (p = 0.74) density, was higher in the symptomatic than in the asymptomatic patients. In a comparison of plaques ipsilateral and contralateral to the thromboembolic event, the densities of the three types of inflammatory cells were similar. CONCLUSIONS: Increased MC distribution density is associated with an atherogenic serum lipid profile, high-grade carotid artery stenosis and symptomatic carotid artery disease. These findings suggest a potential involvement of MCs in the pathophysiology of carotid artery stenosis.     

A rare truncating mutation in ADH1C (G78Stop) shows significant association with Parkinson disease in a large international sample

BACKGROUND: Alcohol dehydrogenases (ADHs) may be involved in the pathogenesis of neurodegenerative disorders because of their multiple roles in detoxification pathways and retinoic acid synthesis. In a previous study, significant association of an ADH class IV allele with Parkinson disease (PD) was found in a Swedish sample. PATIENTS: The previously associated single-nucleotide polymorphism plus 12 further polymorphisms in the ADH cluster on human chromosome 4q23 were screened for association in an extension of the original sample that now included 123 Swedish PD patients and 127 geographically matched control subjects. A rare nonsense single-nucleotide polymorphism in ADH1C (G78stop, rs283413) was identified in 3 of these patients but in no controls. To obtain sufficient power to detect a possible association of this rare variant with disease, we screened a large international sample of 1076 PD patients of European ancestry and 940 matched controls. RESULTS: The previously identified association with an ADH class IV allele remained significant (P<.02) in the extended Swedish study. Furthermore, in the international collaboration, the G78stop mutation in ADH1C was found in 22 (2.0%) of the PD patients but only in 6 controls (0.6%). This association was statistically significant (chi(2)(1) = 7.5; 2-sided P = .007; odds ratio, 3.25 [95% confidence interval, 1.31-8.05]). In addition, the G78stop mutation was identified in 4 (10.0%) of 40 Caucasian index cases with PD with mainly hereditary forms of the disorder. CONCLUSION: Findings presented herein provide further evidence for mutations in genes encoding ADHs as genetic risk factors for PD.     

Growth, energy intake, and meal pattern in five-year-old children considered as poor eaters

OBJECTIVE: To investigate whether 5-year-old children considered poor eaters differ from their peers regarding growth, intake of energy and nutrients, or meal pattern.Study design Parental evaluations of children's (n=494) eating at age 5 years were collected using questionnaires, and energy and nutrient intakes and meal pattern of the children were assessed using 4-day food records. Weight and height were measured at birth and at ages 7 and 13 months, and 2, 3, 4, and 5 years. Of the children 30.2% (149) were poor eaters according to the parents. The rest of the sample (n=345) formed the comparison group. RESULTS: Poor eaters were on average lighter and shorter at birth (P=.026 and P=.020, respectively), and at age 5 years (P<.001 for both weight and height) than the comparison children. At age 5 years the poor eaters on average received less of their daily total energy from warm meals (P=.044) and more from snacks (P=.013) than the comparison group, but the mean daily weight-adjusted intake of energy showed no difference between the groups (P=.153). CONCLUSIONS: There appears not to be reason for serious concern about growth and diet of preschool-aged children considered as poor eaters by parents.     

The hygiene hypothesis of atopic disease--an extended version

The hygiene hypothesis of atopic disease suggests that environmental changes in the industrialized world have lead to reduced microbial contact at an early age and thus resulted in the growing epidemic of atopic eczema, allergic rhinoconjunctivitis, and asthma. The epidemiological findings have been combined with the Th1/Th2 paradigm of immune responsiveness to provide a coherent theory. Recent advances in epidemiology and immunology demonstrate, however, that the hygiene hypothesis may need to be extended in three respects. First, the importance of infections in causing immune deviance may be outweighed by other sources of microbial stimulation, perhaps most importantly by the indigenous intestinal microbiota. Second, immunomodulatory and suppressive immune responses complement the Th1/Th2 paradigm. Third, in addition to protection against atopy, protection against infectious, inflammatory, and autoimmune diseases may also depend upon healthy host-microbe interactions implicated in the hygiene hypothesis.     

Human leukocyte antigens B8-DRB1*03 in pediatric patients with nephropathia epidemica caused by Puumala hantavirus

In adults, HLA haplotype B8-DRB1*03 is clearly associated with a severe clinical course of nephropathia epidemica caused by Puumala hantavirus. We investigated whether the same applies in pediatric patients. This HLA haplotype was found in 20 of 39 (51%) of the patients, a significantly higher figure than in the Finnish population (19%). There were, however, no significant differences in the clinical picture between patients with and without HLA B8-DRB1*03.