Bone structure and volumetric density in young adults born prematurely: a peripheral quantitative computed tomography study

Prematurity is known to be associated with reduced bone mineral density (BMD) in childhood, but whether this condition has long-term detrimental consequences on adult bone structure is not known. In this study, we measured with peripheral quantitative computed tomography (pQCT) the total bone cross-sectional area, cortical area and wall thickness, cortical and trabecular density, and a density-weighed polar section modulus as a bone strength index (BSI) at distal and shaft sites of right radius and tibia in a group of 40 prematurely born, otherwise normally developed and healthy young adults (17 women and 23 men, aged 18 to 27 years) and compared their data to corresponding data obtained from a group of 42 control subjects born term (20 women and 22 men, aged 18 to 28 years). Body height and weight were similar in both groups, but the preterm group had significantly lower BSI values at distal sites of tibia (approximately -16%) and radius (approximately -13%) and at tibial shaft (approximately -11%) as compared to control group. In the weight-bearing tibia, BMC was lower and the lower BSI values were mainly due to smaller total bone cross-sectional area. For unknown reason, this prematurity-associated detrimental effect seemed to concern more men than women. In contrast, prematurity was not associated with volumetric trabecular and cortical densities at any measured bone site while the typical sex differences in bone density were observed. We conclude that prematurity is associated with somewhat smaller cross-sectional bone dimensions in terms of body size in young adulthood. Due to the cross-sectional design, this study could not reveal specific reasons but they may pertain to nutrition during the neonatal period and living habits in general.     

Review Article Reducing the risk of sudden infant death syndrome: A review of the scientific literature

In March 1997 a multidisciplinary forum was convened by the National SIDS Council of Australia to review recent evidence concerning risk factors of sudden infant death syndrome (SIDS) and to revise and refine the current guidelines for reducing the risk of SIDS. The forum provided an assessment of the evidence for recommendations to reduce the risk of SIDS using an evidence-based process. Strong evidence has now accumulated that the intervention campaigns to reduce prone sleeping during infancy have been followed by SIDS rate declines. Recent data indicate that the supine position is not associated with an increase in significant morbidity outcomes and provides greater protection for SIDS than the side position, which may be unstable. Covering of the baby's head by bedding is strongly related to SIDS. The infant's sleeping environment should be carefully set up to ensure that the baby's head, including the face, cannot be obstructed during sleep.
  Parental smoking is strongly associated with SIDS. Structural supportive interventions for parental smoking cessation are required. Bedsharing increases the risk of SIDS amongst smokers and the data are currently not sufficient to provide complete reassurance to nonsmoking parents that bedsharing is safe. Infants should be maintained in a comfortable temperature zone. The evidence for a protective effect of breast-feeding is conflicting, so breast-feeding cannot be promoted strongly as reducing the risk of SIDS. Immunisation has not been associated with SIDS.
  Parents and carers should be aware of the current guidelines. Health professionals should also be aware of the evidence on which the current recommendations are based. Effective health education programmes should lead to a further decline in SIDS mortality in Australia.     

Characteristics of the infant thermal environment in the control population of a case—control study of SIDS

Abstract This report examines the thermal environment during last sleep of a control population to investigate how the thermal environment of the infant's bedroom varies by season, external temperature and by certain maternal and infant characteristics. Two age-matched control infants were chosen for each case, one of which was also matched on birthweight. The home visits were not pre-arranged and were matched on climatic conditions, time of year and time period of day for the index case. The initial response rate for controls ( n = 108) was 86%. Although there was a large amount of variation in the infant thermal environment, thermal insulation correlated with room temperature ( r =−0.44, P = 0.0001) and external temperature ( r =− 0.30, P = 0.002). The thermal environment of the infant, as defined by excess thermal insulation for room temperature, did not vary by indoor or outdoor temperature, but higher average values were observed in teenage mothers (mean difference = 2.7 tog [95% Cl = 0.3, 5.2]), infants who slept in an adult bed (mean difference = 2.6 tog [− 0.1, 5.4]) and infants with an illness (mean difference = 0.8 tog [− 0.3,1.9]). There was a tendency for the thermal environment of infants to be higher and more variable during winter, supporting previous hypotheses that paradoxical overheating may occur in some infants during winter. Further work is required to provide a set of recommendations on the optimal thermal conditions for post-neonatal infants.     

Non-invasive Neuromodulation in Primary Headaches

Purpose of Review

There is growing interest in neuromodulation for primary headache conditions. Invasive modalities such as occipital nerve stimulation, deep brain stimulation and sphenopalatine ganglion stimulation are reserved for the most severe and intractable patients. Non-invasive options such as vagal nerve stimulation (nVNS), supraorbital nerve stimulation (nSONS) and transcranial magnetic nerve stimulation (TMS) have all emerged as potentially useful headache treatments. This review examines the evidence base for non-invasive neuromodulation in trigeminal autonomic cephalalgias and migraine.

Recent Findings

Although a number of open-label series of non-invasive neuromodulation devices have been published, there is very little controlled evidence for their use in any headache condition. Open-label evidence suggests that nVNS may have a role in the prophylactic treatment of cluster headache and there is limited evidence to suggest it may be useful in the acute treatment of cluster and potentially migraine attacks. There is limited controlled evidence to suggest a role for nSONS in the prophylactic treatment of episodic migraine but there is no evidence to support its use in cluster headache. TMS may be efficacious in the acute treatment of episodic migraine has no controlled evidence to support its use as a preventative in any headache condition.

Summary

Non-invasive neuromodulation techniques are an attractive treatment option with excellent safety profiles but their use is not yet supported by high-quality randomised controlled trials.

     

A matched comparison of revision rates of cemented Oxford Unicompartmental Knee Replacements with Single and Twin Peg femoral components,based on data from the National Joint Registry for England,Wales, Northern Ireland and the Isle of Man

Background and purpose — Registries report high revision rates after unicompartmental knee replacement (UKR) due, in part, to aseptic loosing. In an attempt to improve Oxford UKR femoral component fixation a new design was introduced with a Twin rather than a Single peg. We used the National Joint Registry (NJR) to compare the 5-year outcomes of the Single and Twin Peg cemented Oxford UKRs.Patients and methods — We performed a retrospective observational study using NJR data on propensity score matched Single and Twin Peg UKRs (matched for patient, implant and surgical factors). Data on 2,834 Single Peg and 2,834 Twin Peg were analyzed. Cumulative implant survival was calculated using the Kaplan–Meier method and comparisons between groups performed using Cox regression models.Results — In the matched cohort, the mean follow up for both Single and Twin Peg UKRs was 3.3 (SD 2) and 3.4 years (SD 2) respectively. The 5-year cumulative implant survival rates for Single Peg and Twin Peg were 94.8% (95% CI 93.6–95.8) and 96.2% (CI 95.1–97.1) respectively. Implant revision rates were statistically significantly lower in the Twin Peg (hazard ratio [HR)] = 0.74; p = 0.04). The revision rate for femoral component aseptic loosening decreased significantly (p = 0.03) from 0.4% (n = 11) with the Single Peg to 0.1% (n = 3) with the Twin Peg. The revision rate for pain decreased significantly (p = 0.01) from 0.8% (n = 23) with the Single Peg to 0.3% (n = 9) with the Twin Peg. No other reasons for revision had significant differences in revision rates.Interpretation — The revision rate for the cemented Twin Peg Oxford UKR was 26% less than the Single Peg Oxford UKR. This was mainly because the revision rates for femoral loosening and pain more than halved. This suggests that the Twin Peg component should be used in preference to the Single Peg design.

Unicompartmental knee replacement (UKR) for anteromedial knee arthritis has many advantages over total knee replacement (TKR) (Wilson et al. 2019). However, national registries suggest that UKR revision rates are several times higher than TKR, with aseptic loosening a leading cause (New Zealand Joint Registry 2016, National Joint Registry 2018).The most commonly used UKR is the Phase 3 Oxford UKR. The initial Phase 3 femoral component, like its predecessors, was spherical and cemented. It had a single peg that was thought to be helpful as it allowed the component to seat optimally (Figure 1). However, as 25–50% of aseptic loosening was femoral (Mohammad et al. 2018), it was felt that the introduction of a Twin Peg component that might improve fixation would be advantageous. During surgery a small hole is made in the femur anterior to the main peg hole to stabilize the femoral saw guide. A second peg, which would fit in the small hole, was therefore added, allowing the new component to be used with standard instrumentation. In order to support the peg, the spherical part of the component was extended about 15° further anteriorly. To accommodate this extension more bone is removed anteriorly, which decreases the risk of the bearing impinging This also allows the femoral component to be implanted in increased flexion.Open in a separate windowFigure 1.The Oxford UKR with Single and Twin Peg femoral component.The Twin Peg cemented femoral component was introduced in 2003 but has only been widely used since 2009 (Figure 1) (White et al. 2015). A cementless version of the Twin Peg component was also introduced at a similar time. The Twin Peg cemented component is used with the same cemented tibial component and polyethylene bearing as the Single Peg component. We are not aware of any direct comparative clinical studies of Single Peg and Twin Peg cemented femoral components.The National Joint Registry for England, Wales, Northern Ireland and Isle of Man (NJR) is the largest replacement registry (National Joint Registry 2018). We used NJR data to compare the revision rate and mechanisms of implant failure, in particular femoral component aseptic loosening, following cemented medial Oxford UKRs using Single and Twin Peg femoral components.     

Disseminated nocardiosis in a child with acute lymphoblastic leukemia]

Nocardiosis is a rare infectious disease in children. We report here a disseminated nocardiosis in a child with acute lymphoblastic leukemia. The patient presented prolonged febrile neutropenia and nodular pneumopathy. Based on the amplification of a 16S rDNA, a PCR assay detected Nocardia sp. in the patient's bronchoalveolar lavage (BAL) fluid. Culture of BAL samples yielded Nocardia nova colonies after 2 weeks of incubation. Hepatic, splenic, renal and cerebral localisations were detected on extension checkup. trimethoprime-sulfamethoxazole and amikacine were started given the results of PCR assay, with a good response. Improvement of the patient's general condition led to complete chemotherapy under ciprofloxacine and ceftriaxone treatment, without nocardiosis reactivation. Nocardiosis is a rare complication in children with acute lymphoblastic leukemia. trimethoprime-sulfamethoxazole prophylaxis is widely used to prevent Pneumocystis jiroveci infection in children with haematologic malignancies. As Nocardia species are usually sensible, trimethoprime-sulfamethoxazole could play a role in Nocardia prophylaxis in such population. In our patient, compliance with trimethoprime-sulfamethoxazole had been low. Nocardia species are relatively fastidious growth bacteria and are difficult to isolate with classical bacteriological techniques. Molecular methods are now available, with a good sensitivity and fast results allowing to start an appropriate antibiotherapy before culture results, as early treatment is a major prognosis factor in nocardiosis. Nocardia infection should be suspected in case of nodular pneumopathy in immunocompromised children. An extension checkup should be performed to detect secondary localisations.     

Arterial elasticity identified by pulse wave analysis and its relation to endothelial function in patients with coronary artery disease

Patients with coronary artery disease (CAD) have impaired endothelial function. Arterial elasticity is modulated by endothelial function. The association between arterial elasticity and endothelial function has not been reported in patients with CAD. The present study was designed to investigate whether endothelial dysfunction contributes to impaired arterial elasticity. Thirty patients with CAD and 30 control subjects were recruited. Large and small artery elasticity indices were non-invasively assessed using pulse wave analysis. Brachial artery endothelium-dependent and -independent function were assessed by vascular response to flow-mediated vasodilation (FMD) and sublingual nitroglyceride (NTG), respectively. C1 large artery elasticity index was not different in the CAD group compared with the control group. However, C2 small artery elasticity index was significantly reduced in the CAD group compared with the control group. Flow-mediated vasodilation (FMD) was also impaired in the CAD group compared with the control group. Flow-mediated vasodilation (FMD) in the brachial artery correlated with C2 small arterial elasticity index. But NTG-mediated brachial artery vasodilation was similar between the two groups. The present findings suggest that the patients with CAD have reduced C2 small arterial elasticity index and impaired FMD. Endothelial dysfunction is involved in diminished arterial elasticity, suggesting that C2 small arterial elasticity index is a novel surrogate measure for the clinical evaluation of endothelial function.     

Feed us nutrition: final year medical students' perceptions of nutrition medical education

Background: Nutrition is recognised as an integral aspect of Australian medical education. Since medical students will learn more of a subject they consider important, there is a need for their perceptions of nutrition to be investigated. Aims: To identify final year medical students' perceptions about nutrition and its inclusion in their medical course, and to compare priority nutrition topics identified with those previously identified by Faculty and General Practitioners (GPs) who teach in the undergraduate curriculum. Methods: A cross-sectional survey of all final year medical students attending the University of Newcastle was conducted, using a distributed questionnaire, comprising three sections: demographics, perceptions about nutrition and its inclusion in the medical course, and a listing of 38 major nutrition topics. Main outcome measures were: interest in nutrition, and whether it should be included in the undergraduate medical curriculum; rated importance of listed nutrition topics; comparison between students and Faculty and GPs. Frequency distributions and Chi square analyses were used to compare group responses. Results: Seventy-one per cent of the students were interested in nutrition and 94% believed it should be included in the medical curriculum. More than 60% of the students nominated 21 of the 38 topics essential or important. Thirteen of these topics were also highly rated by Faculty and GPs, although Faculty and GPs rated more topics as essential or important. Conclusions: Newcastle medical students are interested in nutrition and believe it should be included in their medical curriculum. This may be due to their clinical exposure and the educational milieu of the University of Newcastle Medical School. Exposure to nutrition in their undergraduate education appears to be an important determinant for priority designated nutrition topics.     

The paroxysmal hemicrania-tic syndrome

Two cases of paroxysmal hemicrania (PH) associated with trigeminal neuralgia are reviewed. The paroxysmal hemicrania component in one patient was episodic, while it was chronic in the other. Each headache type responded completely to separate treatment, highlighting the importance of recognizing this association. We review the six other cases of chronic paroxysmal hemicrania-tic (CPH-tic) reported, and suggest that the term paroxysmal hemicrania-tic syndrome (PH-tic) be used to describe this association.