Evaluation of Bone Mineral Status in Adolescent Idiopathic Scoliosis

Background

Several reports have suggested low bone mineral density (BMD) in patients with adolescent idiopathic scoliosis (AIS). We determined bone mineral status in patients with AIS to evaluate the effect of brace treatment on BMD.

Methods

BMD was measured in 46 patients (mean age, 17.8 ± 4.9 years) with AIS (17 with brace and 29 without brace) by dual-energy X-ray absorptiometry scan and compared the results to an age-matched (mean age, 16.6 ± 3.9 years) control group (n = 54).

Results

The AIS group had significantly lower bone mass at the lumbar spine (Z-score, -1.500 vs. -0.832) and hip (Z-score, -1.221 vs. -0.754) except at the femoral neck. No difference in BMD was found between patients with AIS who used a brace and those who did not.

Conclusions

The results confirmed that BMD was low in AIS patients and it was not affected by brace treatment.     

Young woman with hypophosphatasia: A case report

Hypophosphatasia is a rare inherited disease defined by teeth and bone mineralization impairment leading to depletion of tissue non‐specific alkaline phosphatase. We define a young woman diagnosed with hypophosphatasia (after several times alkaline phosphatase levels were low) was discovered following femoral fracture. A 30‐year‐old woman who presented for a history of early permanent teeth loss during the last 5 years and HPP‐like symptoms in family history and bone radiograph verified bowing, deficient mineralization, and symmetrical subtrochanteric stress fractures of femurs was referred to our clinic for further management. Blood test findings defined raised phosphorus levels on two occasions at 6.2 and 5.7 mg/dl and insufficient 25‐hydroxy vitamin D level. HPP early diagnosis and adequate treatment, depending on the clinical symptoms along with laboratory tests, could be effective in decreasing the suffering of the disease and side effects.     

Characterization of donor dendritic cells and enhancement of dendritic cell efflux with CC-chemokine ligand 21: a novel strategy to prolong islet allograft survival

Dendritic cells (DCs) are the most potent antigen-presenting cells, yet little data are available on the differential characteristics of donor and recipient DCs (dDCs and rDCs, respectively) during the process of islet allograft rejection. DTR-GFP-DC mice provide a novel tool to monitor DC trafficking and characteristics during allograft rejection. We show rapid migration of dDCs to recipient lymphoid tissues as early as 3 h post-islet allotransplantation. Compared with rDCs, dDCs express different patterns of chemokine receptors, display differential proliferative capacity, and exhibit a higher level of maturity; these findings could be attributed to the effects of injury that dDCs undergo during islet cell preparation and engraftment. Intriguingly, we detected dDCs in the spleen of recipients long after rejection of islet allografts. Given that dDCs express high levels of CCR7, islets were cultured before transplant with the ligand for CCR7 (CCL21). This novel method, which enabled us to enhance the efflux of dDCs from islet preparations, resulted in a prolongation of islet allograft survival in immunocompetent recipients. This study introduces dDCs and rDCs as two distinct types of DCs and provides novel data with clinical implications to use chemokine-based DC-depleting strategies to prolong islet allograft survival.     

A multidisciplinary audit of clinical coding accuracy in otolaryngology: financial,managerial and clinical governance considerations under payment‐by‐results

Objectives: To audit the accuracy of otolaryngology clinical coding and identify ways of improving it. Design: Prospective multidisciplinary audit, using the ‘national standard clinical coding audit’ methodology supplemented by ‘double‐reading and arbitration’. Settings: Teaching‐hospital otolaryngology and clinical coding departments. Participants: Otolaryngology inpatient and day‐surgery cases. Main outcome measures: Concordance between initial coding performed by a coder (first cycle) and final coding by a clinician‐coder multidisciplinary team (MDT; second cycle) for primary and secondary diagnoses and procedures, and Health Resource Groupings (HRG) assignment. Results: 1250 randomly‐selected cases were studied. Coding errors occurred in 24.1% of cases (301/1250). The clinician‐coder MDT reassigned 48 primary diagnoses and 186 primary procedures and identified a further 209 initially‐missed secondary diagnoses and procedures. In 203 cases, patient’s initial HRG changed. Incorrect coding caused an average revenue loss of £174.⁹⁰ per patient (14.7%) of which 60% of the total income variance was due to miscoding of a eight highly‐complex head and neck cancer cases. The ‘HRG drift’ created the appearance of disproportionate resource utilisation when treating ‘simple’ cases. At our institution the total cost of maintaining a clinician‐coder MDT was 4.8 times lower than the income regained through the double‐reading process. Conclusions: This large audit of otolaryngology practice identifies a large degree of error in coding on discharge. This leads to significant loss of departmental revenue, and given that the same data is used for benchmarking and for making decisions about resource allocation, it distorts the picture of clinical practice. These can be rectified through implementing a cost‐effective clinician‐coder double‐reading multidisciplinary team as part of a data‐assurance clinical governance framework which we recommend should be established in hospitals.     

Validation of the Clinical COPD Questionnaire as a psychophysical outcome measure in adult laryngotracheal stenosis

Objectives: To validate the Clinical Chronic Obstructive Pulmonary Disease Questionnaire (CCQ), a patient‐administered instrument developed for bronchopulmonary disease as a disease‐specific psychophysical outcome measure for adult laryngotracheal stenosis. Design: Prospective observational study. Settings: Tertiary/National referral airway reconstruction centre. Participants: Thirty‐three tracheostomy‐free patients undergoing endoscopic laryngotracheoplasty. Main outcome measures: CCQ and the Medical Research Council (MRC) Dyspnoea scale, a previously validated but more limited scale, were administered to patients 2 weeks before surgery, preoperatively, and 2 weeks after endoscopic laryngotracheoplasty. Pulmonary function was assessed preoperatively. Internal consistency was assessed with Cronbach α statistics and test–retest reliability was determined using intraclass correlation. Correlations between CCQ and MRC scale, and pulmonary function were used to assess convergent and divergent validity respectively. Instrument responsiveness was assessed by correlating total and domain‐specific CCQ scores with anatomical disease severity and post‐treatment effect size. Results: There were 12 males and 21 females. Mean age was 44 ± 15 years. Cronbach α coefficient and intraclass correlation coefficient were 0.88 and 0.95 respectively. Total and domain‐specific CCQ scores significantly correlated with the MRC scores (P < 0.001) and significant correlations between CCQ and peak expiratory flow rate and FEV₁ were identified (P < 0.03). There were statistically significant changes in total and domain‐specific CCQ scores when different stenosis severities were compared. Clinical COPD Questionnaire scores also changed significantly and congruently following surgery (P < 0.05 in both cases). Discussion: Clinical COPD Questionnaire is a valid and sensitive instrument for assessing symptom severity and levels of function and well‐being in adult patients with laryngotracheal stenosis and can be used as a patient‐centred disease‐specific outcome measure for this condition.     

Neuropsychological and quantitative oculometric study of a case of sporadic Creutzfeldt-Jakob disease at predementia stage

A quantitative assessment of eye movements and a detailed neuropsychological profile were conducted at predementia stage in a patient who later had histological confirmation of sporadic Creutzfeldt-Jakob disease (CJD). The patient was a middle aged man who presented with abnormal eye movements and poor balance. Neuropsychological deficits suggested orbito-mesial dysfunction, resembling progressive supranuclear palsy. Oculometry showed accurate but dramatically slowed saccades, with normal pursuit movements. Neuropsychology and quantitative oculometry may be of value in the differential diagnosis and earlier detection of dementia-akinetic-rigid syndromes; in particular, because of the highly stereotyped nature of saccades, routine quantitative oculometry can reveal significant impairment at a very early stage in some cases and could thus facilitate earlier diagnosis.