Femoroacetabular impingement: an overlooked cause of hip pain

Femoroacetabular impingement is a cause of hip pain arising from abnormal contact between the proximal femur and the acetabulum during terminal hip motion. This is caused by a structural abnormality at the femoral head/neck junction or the acetabulum. The problem usually presents in young adults and can often go undiagnosed for years. Failure to identify and properly restore the biomechanics has been hypothesized to lead to the early onset of hip osteoarthritis; thus, early recognition is important. In this case study, we report on a 31-yr-old patient with many years of bilateral hip pain who underwent successful treatment of bilateral femoroacetabular impingement.     

The effect of simulated solar UV irradiation on tretinoin in tretinoin gel microsphere 0.1% and tretinoin gel 0.025%

Topical tretinoin is highly effective and widely used in the treatment of acne vulgaris. Tretinoin gel microsphere 0.1% (TGM)--alone or in combination with erythromycin-benzoyl peroxide (EBP) or clindamycin-benzoyl peroxide (CBP) topical gels-and tretinoin gel 0.025% (TG)--alone or, combined with EBP-were exposed to simulated solar UV irradiation to determine the degree of tretinoin photodegradation/isomerization. The investigation revealed that 94% and 84% of the initial tretinoin in the TGM formulation remained stable after 2 and 6 hours, respectively, of simulated solar UV irradiation. When combined with EBP topical gel, 89% and 81% of the initial tretinoin remained stable after 2 and 6 hours, respectively, of exposure to simulated solar UV irradiation; 86% and 80% of the tretinoin remained stable after 2 and 6 hours, respectively, when combined with CBP topical gel. In contrast, only 19% and 10% of the tretinoin remained unchanged after 2 and 6 hours, respectively, of simulated solar UV irradiation of TG. Combined with the EBP topical gel, undegraded tretinoin quantities were further reduced to 7% and 0% at 2 and 6 hours, respectively, with TG. These data suggest that the TGM formulation offers marked protection against tretinoin photodegradation compared with TG, even in the presence of a topical gel containing a potent antibiotic or a strong oxidizing agent. Although simulated solar UV irradiation is not entirely reflective of actual conditions, the results appear to be substantial.     

Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report

OBJECTIVE: This report describes the participants and compares the acute and longer-term treatment outcomes associated with each of four successive steps in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial. METHOD: A broadly representative adult outpatient sample with nonpsychotic major depressive disorder received one (N=3,671) to four (N=123) successive acute treatment steps. Those not achieving remission with or unable to tolerate a treatment step were encouraged to move to the next step. Those with an acceptable benefit, preferably symptom remission, from any particular step could enter a 12-month naturalistic follow-up phase. A score of or=11 (HRSD(17)>or=14) defined relapse. RESULTS: The QIDS-SR(16) remission rates were 36.8%, 30.6%, 13.7%, and 13.0% for the first, second, third, and fourth acute treatment steps, respectively. The overall cumulative remission rate was 67%. Overall, those who required more treatment steps had higher relapse rates during the naturalistic follow-up phase. In addition, lower relapse rates were found among participants who were in remission at follow-up entry than for those who were not after the first three treatment steps. CONCLUSIONS: When more treatment steps are required, lower acute remission rates (especially in the third and fourth treatment steps) and higher relapse rates during the follow-up phase are to be expected. Studies to identify the best multistep treatment sequences for individual patients and the development of more broadly effective treatments are needed.     

Cohort differences in the progression of developmental pathways: evidence for period effects on secular trends of violence in males

BACKGROUND: Rates of violence in the USA have fluctuated widely over the past few decades. Theorists have examined period and cohort effects, but there appear to be no studies examining these effects on progression in developmental pathways towards violence. OBJECTIVE: To assess whether differences in progression among individuals in the Pittsburgh Youth Study are consistent with period or cohort effects. DESIGN: Multivariate logistic regression was conducted to examine differences between cohorts in the odds of progressing through the developmental pathway towards violence. Adjusted and unadjusted odds ratios (ORs) and corresponding 95% CI are reported. SETTING: Pittsburgh Pennsylvania, from 1987 to 2000. SUBJECTS: Two cohorts of male adolescents from the Pittsburgh Youth Study. The youngest cohort (n = 503) was followed from median ages 7 to 20, and the oldest cohort (n = 506) was followed up from median ages 13 to 25. MAIN OUTCOME MEASURE: The odds of progression along a developmental pathway towards violence. RESULTS: There was no statistically significant difference between the cohorts in progression from minor aggression to physical fighting (OR = 1.13, 95% CI 0.77 to 1.65). However, after adjustment for major risk factors, the oldest cohort was significantly more likely to progress from physical fighting to violence (OR = 2.34, 95% CI 1.39 to 3.92). CONCLUSIONS: These results provide initial evidence that cohort effects, which would be present early in development, do not contribute significantly to later differences in reported violence and raises the possibility of whether period effects can explain these differences.     

The incidence and management of priapism in Western Australia: a 16 year audit

The objective of the study was to conduct a retrospective audit of patients who presented with priapism in Western Australia during the years 1985-2000. We searched the records of the teaching hospitals in metropolitan Perth and those of the Keogh Institute for Medical Research for the diagnostic code for priapism. A total of 82 episodes of priapism in 63 patients occurred over this 16 year period. In all, 62 episodes occurred after intracavernosal injections (ICI) and 20 were due to other causes. Treatment of priapism included simple aspiration of blood, intracavernosal injection of alpha-adrenergic agents and surgical shunt procedures. Priapism occurring outside the setting of ICI was more likely to require surgery; seven of 20 episodes. After ICI therapy, eight of 62 episodes required shunts. The use of prostaglandin E1 as the drug of choice in ICI therapy in 1989 led to a fall in the incidence of ICI-induced priapism. Priapism is a major side effect of ICI therapy and an uncommon, although important, side effect of other conditions. The incidence of priapism has fallen with the introduction of prostaglandin E1 monotherapy as the favoured drug for ICI therapy of erectile failure.     

Attitudes of adult 46, XY intersex persons to clinical management policies

PURPOSE: We surveyed a clinic sample of adult 46,XY intersex patients regarding attitudes to clinical management policies. MATERIALS AND METHODS: All adult former patients of 1 pediatric endocrine clinic in the eastern United States whose addresses could be obtained and who consented to participation were surveyed by a comprehensive written followup questionnaire. Three questions on attitudes concerning the desirability of a third gender category and the age at which genital surgery should be done were presented in the context of ratings of satisfaction with gender, genital status and sexual functioning. RESULTS: A total of 72 English speaking patients with 46,XY, including 32 men and 40 women 18 to 60 years old, completed the questionnaire. The majority of respondents stated that they were mainly satisfied with being the assigned gender, did not have a time in life when they felt unsure about gender, did not agree to a third gender policy, did not think that the genitals looked unusual (although the majority of men rated their penis as too small), were somewhat or mainly satisfied with sexual functioning, did not agree that corrective genital surgery should be postponed to adulthood and stated that their genital surgeries should have been performed before adulthood, although there were some significant and important differences among subgroups. CONCLUSIONS: The majority of adult patients with intersexuality appeared to be satisfied with gender and genital status, and did not support major changes in the prevailing policy. However, a significant minority was dissatisfied and endorsed policy changes.     

Mild hypothermia improves survival after prolonged, traumatic hemorrhagic shock in pigs

INTRODUCTION: Clinical studies have demonstrated improved survival after cardiac arrest with induction of mild hypothermia (34 degrees C). Infusion of ice-cold saline seems beneficial. The American Heart Association recommends therapeutic hypothermia for comatose survivors of cardiac arrest. For hemorrhagic shock (HS), laboratory studies suggest that mild hypothermia prolongs the golden hour for resuscitation. Yet, the effects of hypothermia during HS are unclear since retrospective clinical studies suggest that hypothermia is associated with increased mortality. Using a clinically relevant, large animal model with trauma and intensive care, we tested the hypothesis that mild hypothermia, induced with intravenous cold saline (ice cold or room temperature) and surface cooling, would improve survival after HS in pigs. METHODS: Pigs were prepared under isoflurane anesthesia. After laparotomy, venous blood (75 mL/kg) was continuously withdrawn over 3 hours (no systemic heparin). At HS 35 minutes, the spleen was transected. At HS 40 minutes, pigs were divided into three groups (n = 8, each): 1) Normothermia (Norm)(38 degrees C), induced with warmed saline; 2) Mild hypothermia (34 degrees C) induced with i.v. infusion of 2 degrees C saline (Hypo-Ice) and surface cooling; and 3) Mild hypothermia (34 degrees C), induced with room temperature (24 degrees C) i.v. saline (Hypo-Rm) and surface cooling. Fluids were given when mean arterial pressure (MAP) was <30 mmHg. At HS 3 hours, shed blood was returned and splenectomy was performed. Intensive care was continued to 24 hours. RESULTS: At 24 hours, there were two survivors in the Norm group, four in the Hypo-Ice group and seven in the Hypo-Rm group (p < 0.05 versus the Norm group, Log Rank). Time required to achieve 34 degrees C was 17 +/- 9 minutes in the Hypo-Ice group and 15 +/- 4 minutes in the Hypo-Rm group (NS). Compared with the Hypo-Rm group, the Hypo-Ice group required less saline during early HS (321 +/- 122 versus 571 +/- 184 mL, p < 0.05). The Hypo-Ice group also had higher lactate levels than the Hypo-Rm group (p < 0.05). Hypothermia did not cause any increase in bleeding compared with normothermia. CONCLUSION: Mild hypothermia during HS, induced by infusion of room temperature saline and surface cooling, improves survival in a clinically relevant model of HS and trauma. However, the use of iced saline in this model had detrimental effects and did not cool the animal more quickly than room temperature fluids. These findings suggest that optimal methods for induction of hypothermia need to be addressed for each potential indication, e.g. cardiac arrest versus HS.     

Gender differences in bipolar disorder: retrospective data from the first 500 STEP-BD participants

OBJECTIVE: To examine gender differences in a large sample of patients with bipolar illness. METHODS: Exploratory analysis of baseline data from the first 500 patients in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), a multi-center NIMH project. Participants are allowed to have medical and psychiatric comorbidities, and to enter in any mood state, thus making the population more generalizable than many research cohorts. Diagnoses and history were assessed using structured clinical instruments administered by certified investigators. Given the exploratory nature of these analyses, there is no correction of for multiple comparisons. However, we emphasize findings that are statistically significant at the more stringent p < 0.01 level. RESULTS: Compared with men, women had higher rates of BPII (15.3% M versus 29.0% F, p < 0.01), comorbid thyroid disease (5.7% M versus 26.9% F, p < 0.01), bulimia (1.5% M versus 11.6% F, p < .0.01) and post-traumatic stress disorder (10.6% M versus 20.9% F, p < 0.01). Women and men had equal rates of history of lifetime rapid cycling and depressive episodes. Men were more likely to have a history of legal problems (36% M versus 17.5% F, p < 0.01). CONCLUSIONS: Potentially important gender differences in certain illness characteristics were found in our study; however, in contrast to other reports, we did not find higher rates of lifetime depressive episodes or rapid cycling in women. Although our study is limited by its retrospective study design, its results are strengthened by our large sample size and use of structured interviews.