Bone and hormones. Effects of growth hormone on bone tissue in adults

GROWTH HORMONE INSUFFICIENCY: Bone mass is reduced and bone remodeling diminished in case of growth hormone insufficiency. ACROMEGALY: In acromegaly, cortical bone mass increases due to excessive growth hormone. The effect on trabecular bone is less well established. ON THE CELLULAR LEVEL: Growth hormone stimulates the bone formation action of osteoblasts and their synthesis of insulin-like growth factor I. EFFECTS OF TREATMENT: Contradictory results have been obtained in adults treated with growth hormone for insufficiency. Generally, markers of bone remodeling are increased, but the effect on bone density is less clear. Long-term studies are needed. EFFICACY OF GROWTH HORMONE TREATMENT ON OSTEOPOROSIS: Growth hormone has been found to have an effect. Several randomized trials have demonstrated moderate increases in bone density.     

Bone and hormones. Estrogens and antiestrogens: action on osteoporosis

ESTROGEN INSUFFICIENCY: Estrogens play a cardinal role in bone tissue in women. Estrogen insufficiency leads to accelerated bone loss within 5 to 8 years after menopause. HORMONE SUBSTITUTION THERAPY: Substitution therapy prevents postmenopausic bone loss (lumbar vertebrae, hip, radius) and reduces the risk of osteoporotic fracture. Cohort studies have demonstrated that women given hormone substitution therapy for at least 7 years have a significantly higher bone density than untreated women. Although still controversial, it would appear that the risk of breast cancer increases with prolonged use of hormone substitution therapy. SERM: Observations in patients given tamoxifen, an antiestrogen used in the treatment of breast cancer, have led to the concept of selective estrogen receptor modulators (SERM), a new class of compounds with estrogen agonistic or antagonistic activity, depending on the tissue. Among these molecules, raloxifen has reached advanced clinical testing phases. Phase III trials have demonstrated that raloxifen can prevent bone loss and reduce the risk of vertebral fractures while reducing total cholesterol and LDL-cholesterol in menopaused women without stimulating the endometrium. SERMs are a promising alternative to hormone substitution therapy for the treatment of menopaused women.     

Diagnostik des benignen Prostatasyndroms

The diagnostic work-up of lower urinary tract symptoms (LUTS) in the German guidelines consists of obligatory and optional diagnostic parameters. Recommendations for assessing LUTS include patient history, symptom questionnaires (IPSS international prostate symptoms score), physical examination, urine analysis, prostate-specific antigen, uroflowmetry, ultrasound examination of the urinary bladder, including postvoid residual urine and ultrasound examination of the upper urinary tract. Optional tests are voiding diary, pressure-flow studies, ultrasound measurement of detrusor wall thickness, urethrocystography and urethrocystoscopy. Ultrasound measurement of detrusor wall thickness in particular has a 95 % positive predictive value in diagnosing bladder outlet obstruction. With all diagnostic parameters it is possible to treat LUTS in a risk-adapted manner.     

Tissue Engineering der Harnröhre und des Harnleiters

Congenital or acquired disorders of the urethra or ureter often require adequate tissue transfer for reconstruction. A variety of biomaterials have proved to be useful in the reconstruction of the urethra or ureter in animal models and meanwhile even clinically. Innovative tissues such as acellular matrices can be placed in the host and function as a scaffold to allow the natural process of tissue regeneration. Biodegradable scaffolds can also be used as cell transplantation vehicles for the reconstruction of urethral or ureteral tissue. One of the limitations of cell-based tissue engineering techniques however is the difficulty of growing genitourinary-associated cells in large quantities in primary cultures. It can be speculated that stem cell research might help to overcome this specific problem in the future.     

Hüftarthroskopische Therapie bei veralteten extrakapsul?ren traumatischen Hüftluxationen bei Kindern

We report about the first hip arthroscopies of extracapsular neglected hip dislocations with concomitant injuries in two children (2 and 4 years old). The major problem of traumatic hip dislocation is avascular necrosis. Further problems are possible concomitant injuries. It is important not to cause further damage by therapeutic procedures. In a 4-year-old child the hip could be reduced under visualization and in a 2-year-old child with epiphyseal fracture the extent of the operation could be reduced. In both children large avulsion injuries of the ligamentum capitis femoris could be resected via hip arthroscopy. Hip arthroscopy can reduce surgical morbidity considerably and can possibly contribute to prevention of the feared avascular necrosis of the femoral head.     

Rückfu?valgus

The clinical finding of flatfoot is characterized by a flattening of the medial longitudinal arch and valgus deformity of the hindfoot. The differential diagnosis of flatfoot is the physiological, flexible, contracted flatfoot, which occurs as a congenital or acquired deformity. Congenital flatfoot deformity requires early intensive therapy, while a flexible flatfoot in children has a good prognosis and conservative treatment usually leads to a stable and sufficient load-bearing foot. Severe flatfoot in children can be corrected successfully by simple, minimally invasive procedures. In adults with symptomatic flatfoot, which usually occurs due to an insufficiency of the tendon of the tibialis posterior, conservative therapy with insoles, shoe modifications and physiotherapeutic measures can lead to significant improvement, otherwise surgical correction is recommended. Early, stage-appropriate therapy helps to prevent an impending decompensation of the hindfoot.     

Ungeplante Zweiteingriffe nach Frakturen des oberen Sprunggelenks

The purpose of the present study was to analyze the risk factors associated with unexpected second procedures and strategies of revision surgery. Within a 5 year period 647 patients with closed ankle fractures AO type 44 were identified of which 77 (11.9%) needed revision surgery. Complications were addressed to 4 main groups: deep infections (IG) were seen in 29 patients (4.5%), problems with primary wound closure (WG) in 22 patients (3.4%), insufficient reduction (KG) in 22 patients (3.4%) and other causes (RG) included 4 patients (0.6%). Significant predictive factors for soft tissue complications were higher age, comorbidities with peripheral arteriosclerosis, high American Society of Anesthesiologists (ASA) score and diabetes mellitus. AO 44 type B2 and B3 fractures were often associated with soft tissue problems. The more complex fracture types AO 44 C1-C3 and A2-A3 were significantly associated with problems of insufficient congruency post-surgery. The distribution of the mean revision rate was significantly different (p<0.01) for all groups: IG 4.59, WG 3.5, KG 1.55, RG 1.25. In summary, we strongly recommend immediate reduction of displaced fractures and to consider a more detailed fracture classification. To reduce the amount of unexpected ankle procedures individual risk factors should be weighed against the advantages of optimal open reduction and internal fixation.     

Temperaturerh?hung unter Oxybutynin bei Patienten mit Spina bifida

Paraplegic spina bifida patients often suffer from disturbed sweat secretion in the paretic regions. A diminished sweat production of caudal parts of the body is compensated by an increased secretion of sweat in parts cranial to the lesion to maintain temperature homoeostais. If the sweat secretion is blocked by anticholinergic effects of urotherapeutic drugs (for instance oxybutynin) hyperthermia can result as a side effect as these casuistic examples show.An 8-year-old girl with a lumbar meningomyelocele and a neurogenic bladder reported a dry skin and hyperthermia up to 38,5°C during oral therapy with oxybutynin (0.4 mg per kg body weight) during hot summer days. Similar symptoms were shown by a 7-year-old male patient with a sacral meningomyelocele and neurogenic bladder on oral therapy of 0.35 mg oxybutynin per kg body weight. A 4-year-old female patient with lumbar spina bifida and neurogenic bladder reacted to intravesical administration of 0.4 and 0.3 mg per kg body weight during early summertime with hyperthermia up to 38°C. In this case the medication had been started in wintertime and was primarily well tolerated.Hyperthermia under treatment with anticholinergic drugs has mainly been published for geriatric patients with sometimes fatal outcome. In the pediatric literature there is only one warning regarding the use of oxybutynin in children with spina bifida living in high temperature regions. It is remarkable that hyperthermia can also happen after intravesical administration of oxybutynin in usual dosage.     

Zur Bedeutung der MRT-Diagnose „bone bruise“ bei kindlichen Wirbelsäulenverletzungen

ZusammenfassungHintergrund Die MRT stellt ein sensitives, nicht strahlenbelastendes bildgebendes Verfahren dar und bietet sich daher für die Diagnostik kindlicher Wirbelsäulenverletzungen an. Als ein indirektes Verletzungszeichen lässt sich hierbei u. U. ein sog. bone bruise nachweisen, ohne dass weitere Verletzungen sichtbar werden. Ziel der vorliegenden Arbeit war es, die klinische Bedeutung dieser Diagnose bei kindlichen Wirbelsäulenverletzungen zu untersuchen.Patienten und Methoden Zwischen 1998 und 2003 wurden in unserer Klinik insgesamt 66 Kinder mit Wirbelsäulenverletzungen konservativ behandelt. 34 dieser Kinder erhielten während der Primärdiagnostik eine MRT. Im Rahmen einer retrospektiven Studie wurden 20 Kinder, bei welchen die Diagnose einer Wirbelkörperverletzung vorwiegend durch den Nachweis eines bone bruise im initialen MRT geführt worden war, sowohl klinisch als auch mittels MRT nachuntersucht.Ergebnisse Alle 20 Kinder gaben bei der Nachuntersuchung subjektiv weitgehende Beschwerdefreiheit an. Bei der objektiven Untersuchung fanden sich keine klinischen Auffälligkeiten. Bei keinem der Kinder war im Rahmen der Nachuntersuchung MR-tomographisch eine Persistenz des bone bruise feststellbar. Eine sekundäre Sinterung der betroffenen Wirbelkörper war in keinem Fall aufgetreten.Schlussfolgerung Kindliche Wirbelsäulenverletzungen, die mit einem mittels MRT nachgewiesenen bone bruise ohne weitere bildmorphologische knöcherne oder diskoligamentäre Läsionen einhergehen, sind in der Regel als prognostisch günstig einzustufen. Bei entsprechender Therapie, die in einer kurzfristigen, schmerzadaptierten Bettruhe und einer anschließenden frühfunktionellen Behandlung besteht, wurden bei unseren Patienten keine sekundären Sinterungen beobachtet.* Beide Autoren haben gleichen Anteil an dieser Arbeit und teilen sich die Erstautorenschaft.     

Pathophysiologie von Drang-, Belastungs- und Mischinkontinenz

According to the new ICS classification, urinary incontinence is subdivided by symptomatic, clinical, and urodynamic criteria. Understanding the pathophysiological interactions is important to find the correct diagnosis. Disturbances in bladder storage include urge incontinence due to neurogenic or non-neurogenic (idiopathic) detrusor hyperactivity as well as stress urinary incontinence caused by an insufficient urethral closure mechanism due to reduced pressure transmission (active-passive), hypotonic urethra, hyporeactivity of sphincter musculature, or involuntary relaxation of the urethra. Stress and urge incontinence can occur in combination and then be defined as mixed incontinence.