Decreased fracture incidence after 1 year of pamidronate treatment in children with spastic quadriplegic cerebral palsy

Aim The aim of this study was to assess the rate of fracture before and after a 1‐year course of intravenous pamidronate in children with spastic quadriplegic cerebral palsy (CP) who had previously experienced fractures. Method Twenty‐five children (nine males, 16 females) with quadriplegic CP in Gross Motor Function Classification System (GMFCS) level IV or V who were treated with intravenous pamidronate for approximately 1 year were identified. All participants had previously experienced at least one non‐traumatic fracture. Each received 15 doses of pamidronate over a mean of 13.6 months. Post‐treatment observation ranged from 1 to 10 years 6 months (mean 4y 1mo). The fracture rate before and after commencement of treatment was calculated using the person‐years method. Results The participants had experienced a total of 86 fractures before treatment began, occurring over 280.6 person‐years, giving a fracture rate of 30.6% per year. During the post‐treatment observation period, totalling 107.5 person‐years, 8 of the 25 children experienced a total of 14 fractures. This fracture rate of 13.0% per year is a statistically significant decrease (p=0.02). Interpretation Pamidronate treatment lowered the rate of fracture, and a 1‐year course appears to provide a protective effect after treatment ends. For the majority of participants, this effect lasted 4 years or longer. However, a subset of children suffered a fracture soon after the drug was discontinued. In these children, a longer course of treatment appears to have been necessary.     

Lower extremity bone mineral density in children with congenital spinal dysfunction

Aim  To assess lower extremity bone mineral density (BMD) of children with congenital spinal dysfunction and examine factors that may influence BMD in this population. Method  Forty‐four children (25 females, 19 males) aged 6 to 18 years (mean 11y 11mo, SD 3y 6mo) with congenital spinal dysfunction (35 with myelomeningocele, seven with lipomas, one with sacral agenesis, one with caudal regression) were enrolled in the study. A health survey including ambulatory status, history of bladder augmentation, and history of fracture was administered. Each participant had a physical examination including Tanner stage and neurological level. Dual‐energy X‐ray absorptiometry scans of the lateral distal femur (LDF) and, when possible, lumbar spine were obtained. We reported LDF BMD results as z‐scores for three regions of interest (metaphyseal, metadiaphyseal, and diaphyseal). Univariable and multivariable analyses examined relationships between LDF BMD and the other variables. Results  BMD was significantly related to ambulatory status (14 non‐ambulatory, 15 partly ambulatory, 15 fully ambulatory) and neurological level (13 with low‐level lesions, 15 medium‐level, 16 high‐level) in the univariable analysis (p<0.01 for both in all three regions). Neither history of fracture, nor Tanner stage, nor history of bladder augmentation showed a significant relationship to BMD. The significance of ambulatory status and neurological level in the univariable analysis failed to persist in the multivariable analysis of this study with a small sample size. Interpretation  The LDF measurement proved to be a viable technique for assessing BMD in children with congenital spinal dysfunction. LDF BMD was sensitive to differences in three categories of ambulation. The overall influence of neurological level was not deemed as important as ambulation.     

A CONTROLLED TRIAL OF CONTINUOUS LUMBAR TRACTION IN THE TREATMENT OF BACK PAIN AND SCIATICA

A controlled trial of continuous lumbar traction in the treatmentof back pain and sciatica showed similar improvements in boththe treated group (weighted traction) and the control group(simulated traction). The findings of this study question thejustification of admitting patients with back pain into hospitalsfor purposes of traction alone. KEY WORDS: Back pain, Treatment     

Degos disease: a new simulator of non-accidental injury

Recent high-profile cases have made paediatricians very aware of the serious implications of either missing or wrongly diagnosing non-accidental injury. Subdural fluid collections in non-mobile infants usually represent haemorrhage caused by non-accidental injury. We report a 6-month-old male who presented to the Accident and Emergency Department of Birmingham Heartlands Hospital with bilateral subdural fluid collections and skin ulcers resembling cigarette burns. Non-accidental injury was considered to be the most likely diagnosis. However, while under observation in hospital, the child's neurological condition deteriorated with progressive cerebral infarctions, and serial photographs of the skin lesions showed failure to heal. The revised diagnosis, confirmed histologically, was Degos disease, an extremely rare and often fatal occlusive vasculopathy. The child was treated palliatively and died 8 weeks after presentation. This report informs doctors of a new simulator of non-accidental injury to be considered in infants with otherwise unexplained subdural fluid collections.     

Performance of the preliminary definition of improvement in juvenile idiopathic arthritis patients treated with methotrexate: experience from Bangladesh

Objective: To evaluate the performance of Preliminary Definition of Improvement (PDI) in juvenile idiopathic arthritis (JIA) patients treated with methotrexate (MTX). Methods: This was a prospective observational study done in the paediatric department of Bangabandhu Sheikh Mujib Medical University (BSMMU) during April 2005–August 2006. All the patients fulfilling the International League of Associations for Rheumatology classification criteria had the American College of Rheumatology core set of variables assessed at baseline and follow‐up at the 4th, 12th and 24th week of treatment. Variables in the core set are: (1) physician's global assessment of disease activity; (2) parents’ or patients’ global assessment of disease activity; (3) functional ability; (4) number of joints with active arthritis; (5) number of joints with limited range of motion; and (6) erythrocyte sedimentation rate. Patients were classified as improved or not improved according to PDI. The following definition of improvement was selected: 30% improvement from baseline in three of any six variables in the core set with no more than one of the remaining variables worsening by > 30%. Results: A total of 40 children with JIA, completed 6 months treatment. At the end of 6 months, most of the patients (92.5%) had been declared as improved according to PDI. Among the core set variables, active arthritis, physicians’ and patients’ global assessment of disease activity, detected the highest percentage of patients improved (92.5%) and functional assessment detected the lowest (37%). Conclusion: The PDI identified that a maximum number of JIA patients treated with MTX had improved.     

Preliminary report of a randomized,double-blind placebo-controlled trial of a Chinese herbal medicine preparation CH-100 in the treatment of chronic hepatitis C

The treatment of chronic hepatitis C is relatively unsatisfactory and many patients have turned to unproven alternative medicines to modify the course of their illness. We report a study of a Chinese herbal medicine preparation CH-100 in the management of chronic hepatitis C. Patients with documented chronic hepatitis C were randomly allocated to receive active herbal or placebo tablets (five tablets thrice daily). Patients were followed monthly and evaluated by a Western and a traditional Chinese medical practitioner. Therapy was monitored by measurement of liver function tests, creatinine and full blood count on a monthly basis. Twenty patients in each group were well matched for age, sex, duration of illness, previous interferon therapy and alcohol intake. Active Chinese herbal medication was associated with a signi?cant reduction in alanine aminotransferase (ALT) levels over the 6 month study period (P<0.03). No patient cleared the virus but four normalized their ALT on treatment. Appropriately prescribed Chinese herbal medicine may have a role in the management of chronic hepatitis C and further controlled studies are indicated.     

Molecular structures of CPF-dipeptides,inhibitors for the binding of CD4 with gp120

The dipeptides N-carbomethoxycarbonyl-phenylalanyl-benzyl esters (CPFs) play a significant role in the prevention of HIV-I virus infection by interacting with the glycoprotein gp120, one of the envelope proteins of the HIV-1 virus. Of the four possible isomers of CPF. (L-pro-L-phe), (L-pro-D-phe), (D-pro-L-phe) and (D-pro-D-phe). herein denoted LL etc., the crystal structures of LL, stereoisomeric LD and the racemic mixture of LD DL have been determined. All three peptides crystallize in the orthorhombic system and they all have similar cell dimensions: (i) LL. P2₁2₁2₁, (a= 13.699(2), b= 25.893(5), c= 6.155(1) Å, Z = 4, D_eale= 1.333 g cm-3, R= 0.070 for 1247 observed reflections: (ii) LD. P2₁2₁2₁, a = 11.663(2), b= 26.557(2), c = 7.281(1) A. Z = 4. D_eale= 1.290 g cm^?3R= 0.054 for 1918 observed reflections; (iii) LD/DL, Pbc2₁, a= 11.953(2), b = 24.208(8), c= 7.782(2) A, Z = 4, D_eale= 1.292 g cm^?3, R= 0.080 for 894 observed reflections. Both the enantiomeric LD and the LD in racemic LD DL have a similar conformation, an extended peptide chain with φ₁= - 76, -73; ψ₁= 160, 158°.φ₂= 123, 131° and Ψ₂= - 172, -167°, while peptide LL adopts a bent conformation at the Phe residue. φ₁= -69°. Ψ₁= 158°,Ψ₂=- 60° and Ψ₂=?34°. Despite their conformational differences. all three dipeptides pack very similarly in the crystal. The molecules associate by a single intermolecular N-H…O hydrogen bond to form a column along the short crystallographic c-axis. In each structure, the column is made tip of a hydrophilic core with hydrophobic groups, primarily phenyl rings, projecting outward.     

Social marketing: a critical appraisal

This article provides a critical analysis of the growing useof social marketing in the field of health promotion. In responseto a recent article by A. Hastings and G. Haywood (Health PromotionInternational, 6, 135–134), three questions are askedabout each of the proposed tenets of social marketing: are theseideas new? are they more effective than current health promotionpractices? and do they raise any particular ethical concerns?On each of these counts, the analysis suggests that the purportedbenefits of social marketing might not be as great as proponentsclaim. There are also some problematic unintended consequencesthat arise from the use of social marketing methods. The narrowfocus on individual behavior change and the potentially manipulativetechniques for inducing behavior change are of particular concern.The paper concludes with a call for further discussion aboutthe limits and potential iatrogenic side-effects of using socialmarketing strategies for health promotion.