A modified technique of the triple pelvic osteotomy: early results

A modification of the triple pelvic osteotomy for children over 8 years and the young adult is described. The results of the first 32 cases are reviewed. These show that the indications for the operation can be widened so that not only primary dysplasias but also subluxated or dislocated hips with secondary dysplasia can be operated on successfully. The operation is done in two stages. At first the patient is lying prone. The osteotomy of the ischial ramus is done dorsally by cutting the connection between the sciatic notch and obturator foramen immediately behind and below the acetabulum. In the second stage, with the patient lying supine, the pubic and the iliac osteotomy are performed rather circular and parallel to the hip joint. These modifications have several advantages: (a) the operator has a direct field of view at all times; (b) the osteotomy is performed close to the acetabulum, thus allowing a great amount of lateral rotation and medial displacement of the acetabulum, thereby providing good coverage of the femoral head by hyaline cartilage; and (c) the ischial ramus and its ligaments to the sacrum are left intact, leading to greater stability of the pelvis and spine.     

Pelviureteral inhibitory reflex and ureteropelvic excitatory reflex: role of the two reflexes in regulation of urine flow from the renal pelvis to the ureter

The mechanism by which the ureteropelvic junction (UPJ) regulates the passage of urine from the renal pelvis to the ureter, and prevents urinary backflow from the the ureter to the renal pelvis, is not completely understood. The current communication studies this mechanism in 18 dogs. With the dogs under anesthesia, nephrostomy was done through which two catheters (one pressure and one balloon-tipped) were introduced into the UPJ and the renal pelvis, respectively. Renal pelvis distension with a balloon filled with 1 ml of saline effected a rise of renal pelvic pressure from a mean basal pressure of 4.8 +/- 1.2 cm H2O to 6.9 +/- 2.3 cm H2O (P < 0.05). The basal UPJ pressure of 12.6 +/- 2.7 cm H2O showed no significant change with 1 ml distention of the renal pelvic balloon (P > 0.05). Renal pelvic distension with 2, 3, and 4 ml caused a significant rise of renal pelvic pressure to 8.4 +/- 2.7 (P < 0.05), 10.6 +/- 2.2 (P < 0.01), and 11.8 +/- 1.9 (P < 0.01) cm H2O, respectively, and a significant drop of UPJ pressure to 4.8 +/- 1.2, 4.7 +/- 1.1, and 4.6 +/- 1.2 cm H2O (P < 0.01), respectively. Ureteric distension with a balloon filled with 0.5 ml of saline significantly raised the ureteric pressure from a mean basal value of 4.3 +/- 1.4 cm H2O to 14.7 +/- 3.3 cm H2O (P < 0.01) and the UPJ pressure to a mean of 20.8 +/- 3.8 (P < 0.05). Ureteric distension with 1 and 1.5 ml of saline led to an elevation of ureteric and UPJ pressure which was not significantly different from that observed with distension with 0.5 ml (P > 0.05). In contrast, the UPJ showed no significant pressure change upon distension of the locally anesthetized renal pelvis or ureter, respectively. Likewise, the locally anesthetized UPJ exhibited no significant pressure response to renal pelvic or ureteric distension. The study demonstrates that urine might have to accumulate in the renal pelvis up to a certain volume and pressure so as to effect UPJ opening, which occurs at its maximum irrespective of the distending volume. UPJ opening upon renal pelvic distension postulates a reflex relationship which we call "pelviureteral inhibitory reflex." This reflex is believed to regulate the passage of urine from the renal pelvis to the ureter. Ureteric distension closes the UPJ; we call this reflex action the "ureteropelvic excitatory reflex" as it seems to prevent reflux of urine through the UPJ and thus protects the kidney. The concept that the UPJ acts as a physiologic sphincter is put forward.     

The value of obturator canal bypass. A review

OBJECTIVE: To review the value of obturator canal bypass with respect to long-term results. DESIGN: Case series and literature review. SETTING: University of Vienna Medical School in Austria. PATIENTS/METHODS: Personal experience with 34 consecutive patients and 125 cases published since 1982 with respect to patient data, patency, and survival are compared and jointly analyzed retrospectively. INTERVENTIONS: Patients received obturator canal bypass for lesions of the pelvic or common femoral vessels precluding orthotopic reconstruction. MAIN OUTCOME MEASURES: The rates of patient survival, limb salvage, and graft patency were analyzed. RESULTS: The postoperative mortality rate in the present series was 14.7%. The limb salvage rate after 5 years was 76.5%. One- and 5-year secondary patency rates were 75.3% and 54.9%, respectively. All grafts in patients without atherosclerosis were patent at a median of 34 months. For 57 cases documented in the literature, 1- and 5-year patency rates were 70.8% and 59.7%, respectively. Combined analysis of 90 obturator canal bypasses revealed rates of 72.7% and 56.9% of patent grafts at 1- and 5-years, respectively. CONCLUSIONS: The use of obturator canal bypass is recommended in deep groin infections and especially in patients with lesions of the pelvic vessels due to other occlusive vascular disease.     

Abnormal myelination in a patient with ring chromosome 18

BACKGROUND: Most adult anatomical texts state that the deep inguinal ring is situated midway between the anterior superior iliac spine and the pubic tubercle. The aim of this study was to determine if this was true in prepubescent children. METHODS: A total of 107 inguinal ligaments and canals were measured during inguinal operations in 80 children (68 boys, age range 1-118 months). RESULTS: The length of the inguinal ligament increased from a median of 4.3 cm (range 3.6-6.8) at less than 1 year of age to 7.5 cm (range 6.7-10.1) at over 4 years of age. The internal ring was situated medial to the midpoint of the inguinal ligament throughout childhood. The ratio of internal ring to public tubercle over inguinal ligament length was 42% (range 27-58) at less than 2 years; and 34% (range 25-46) at over 4 years. The inguinal canal remained short (median 1 cm (range 0.7-1.1) at less than 2 years, and median 1.1 cm (range 0.7-2.3) at over 4 years) suggesting that growth of the inguinal region in this age group occurs outside the canal. CONCLUSIONS: These results have implications for the siting of incisions, and question the necessity of opening the inguinal canal in children.     

Impetigo in French Guyana. A clinical, bacteriological, toxicological and sensitivity to antibiotics study]

Acromegalic patients present an increase of osteoblastic and osteoclastic activity, showing a different effect on the axial and appendicular skeletal structures. At this regard controversial data about bone mineral density (BMD) have been published in literature. In fact an increase of BMD levels in femoral neck and Ward's triangle without any difference in lumbar spine has been described. On the other hand normal BMD levels at forearm and reduced BMD levels at lumbar spine were found. These patients seem to have a reduction of trabecular BMD similar to postmenopausal osteoporotic patients despite normal or slightly elevated cortical BMD. Recently, it has been described that cytokines, in particular tumor necrosis factor-alpha (TNF-alpha) and interleukin-1 (IL-1), are implicated in the pathogenetic mechanism of postmenopausal osteoporosis. Taking into account that growth hormone (GH) can increase TNF-alpha and IL-1 secretion by mononuclear blood cells, the evaluation of possible relationship between the reduced BMD at lumbar spine and circulating cytokines levels was carried out in acromegalic patients. In addition we evaluated the effect of acute octreotide administration on serum TNF-alpha and IL-I concentrations. Eleven patients with active acromegaly and eleven healthy age-, sex-, weight- and heightmatched subjects were enrolled in this study. BMD was significantly reduced at lumbar spine (0.80 +/- 0.29 g/cm2 vs 1.02 +/- 0.11 g/cm2; p < 0.01), but not at femoral neck level or at Ward's triangle level (0.92 + 0.15 g/cm2 vs 0.97 + 0.11 g/cm2, p = NS; and 0.74 +/- 0.16 g/cm2 vs 0.85 +/- 0.1 g/cm2, p = NS) when compared to controls. Baseline serum levels of TNF-alpha and IL-1 were in the normal range both in patients and controls. After acute octreotide administration, no differences in circulating TNF-alpha and IL-1 levels were found. In conclusion, acromegalic patients present a reduced BMD at lumbar spine but not at femoral neck level and Ward's triangle. Circulating cytokines such as TNF-alpha and IL-1 are in the normal range. These data suggest that cytokines are not involved in the pathogenesis of GH-excess induced osteoporosis. The possibility that the GH excess might affect bone turnover inducing an increase of cytokines acting by a paracrine/autocrine mechanism cannot be ruled out.     

Does the vitamin D receptor genotype predict bone mineral loss in haemodialysed patients?

BACKGROUND: It has been suggested that the vitamin D receptor (VDR) gene BsmI-polymorphism is a genetic determinant of bone metabolism. DESIGN: To test this hypothesis, the relationship between VDR genotypes, bone mineral density (baseline and after 18 months) and parameters of calcium metabolism and bone turnover were investigated prospectively in 88 haemodialysed patients not receiving active vitamin D metabolites. METHODS: Whole body, lumbar spine and femoral neck bone mineral density (BMD) were assessed by dual energy X-ray absorptiometry (DEXA). In addition calcium, phosphorus, 25(OH)D3, 1,25(OH)2D3, osteocalcin serum concentrations, alkaline phosphatase activity and intact 1,84 PTH levels were measured. RESULTS: VDR genotype BB, Bb and bb were found in 27, 49 and 24% of patients. Initial BMD (g/cm2) of whole body, lumbar spine and femoral neck did not differ between genotypes (whole body: BB 1.055 +/- 0.120, Bb 1.082 +/- 0.102, bb 1.128 +/- 0.120; lumbar spine: BB 1.075 +/- 0.199, Bb 1.079 +/- 0.185, bb 1.099 +/- 0.170; femoral neck: BB 0.808 +/- 0.160, Bb 0.862 +/- 0.127, bb 0.842 +/- 0.125; mean +/- SD), but the decrease of whole body and femoral neck BMD during 18 months was significantly (P < 0.02) different between the genotype groups (whole body: BB -0.048 +/- 0.028, Bb -0.031 +/- 0.029, bb -0.024 +/- 0.023; femoral neck BB -0.044 +/- 0.069, Bb -0.032 +/- 0.081, bb -0.012 +/- 0.029 g/cm2). CONCLUSION: This preliminary study suggests faster mineral loss in BB genotype of VDR in haemodialysed patients.     

Revision of the nomenclature for the Bacillus thuringiensis pesticidal crystal proteins

The aim of this prospective study was to evaluate the bone mineral density (BMD) at lumbar spine and femoral neck levels and biochemical parameters of bone turnover in 20 consecutive hyperprolactinemic males before and after an 18-month treatment with different dopamine agonists. Six patients received bromocriptine at a dose of 2.5-10 mg/day; 7 patients received quinagolide at a dose of 0.075-0.3 mg/day; 7 patients received cabergoline at a dose of 0.5-1.5 mg/week. BMD, serum PRL, testosterone, dihydrotestosterone, and osteocalcin (OC), and urinary cross-linked N-telopeptides of type I collagen (Ntx) levels were measured before and every 6 months during treatment. At study entry, BMD values were lower in patients than controls at both lumbar spine (0.82 +/- 0.03 vs. 1.18 +/- 0.01 g/cm2; P < 0.001) and femoral neck (0.85 +/- 0.02 vs. 0.92 +/- 0.02 g/cm2; P < 0.05) levels. Osteopenia or osteoporosis was diagnosed in 16 patients at the lumbar spine and in 6 of them at the femoral neck level. A significant inverse correlation was found between lumbar spine and femoral neck BMD values and both PRL levels and disease duration (P < 0.01). In the 20 patients, serum OC levels were significantly lower (2.1 +/- 0.1 vs. 9.3 +/- 2.4 microg/L; P < 0.01), whereas Ntx levels were significantly higher (157.8 +/- 1.1 vs. 96.4 +/- 7.4 nmol bone collagen equivalent/mmol creatinine; P < 0.001) than control values. A significant inverse correlation was found between serum PRL and OC (P < 0.01), but not Ntx, levels. After 18 months of treatment, serum PRL levels were suppressed, and gonadal function was restored in all 20 patients, as shown by the normalization of serum T (from 2.2 +/- 0.2 to 5.0 +/- 0.2 microg/L) and dihydrotestosterone (0.3 +/- 0.02 vs. 0.5 +/- 0.01 nmol/L) levels, without any significant difference among groups. A progressive significant increase in serum OC levels together with a significant decrease in Ntx levels were observed after 6, 12, and 18 months of treatment in the 3 groups of patients. A slight, although significant, increase in BMD values was recorded in all patients after 18 months of bromocriptine, quinagolide, and cabergoline treatment, serum OC levels were normalized after treatment, whereas neither urinary Ntx levels nor BMD values were normalized by 18 months of treatment with dopaminergic agents. In conclusion, treatment with bromocriptine, quinagolide, and cabergoline for 18 months, although successfull in suppressing serum PRL levels and restoring gonadal function, was unable to restore lumbar spine and femoral neck BMD and normalize Ntx levels. However, BMD was slightly increased during treatment, suggesting that additional bone loss was prevented after treatment of hyperprolactinemia.     

An assessment of the anatomical relationship between the pelvic plexus and the rectal wall to determine the indications for its preservation in surgery for rectal cancer

Preservation of the pelvic plexus in surgery for rectal cancer could shorten the distance between the cancer and the lateral resection margin, whereby the curability of the operation may be reduced. To clarify the indications for preserving the pelvic plexus in such surgery, the relationship of the pelvic plexus to the rectum and rectal cancer was investigated anatomically in 12 autopsied specimens and 12 surgical specimens. The rectum and anus were dissected with all the pelvic organs from autopsied cadavers and transverse sections were prepared at 10-mm intervals after fixation. The location of the pelvic plexus was then measured on the tissue preparations, and compared to that of surgical specimens from rectal cancers with concurrent resection of the pelvic plexus. The pelvic plexus was located from 3.3 +/- 1.2 cm above to 2.3 +/- 1.9 cm below the peritoneal reflection in the autopsied specimens. The average distances between the muscularis propria and the pelvic plexus in the autopsied specimens and surgical specimens were 8.3 +/- 3.5 mm and 14.7 +/- 4.5 mm, respectively, showing a significant difference (P < 0.05). Pelvic plexuses were located about 10 mm from the outer margin of rectal muscularis propria. These findings indicate that concurrent resection of the pelvic plexus may be required to secure sufficient surgical clearance in pT3 rectal cancers, especially those invading deeply beyond the muscularis propria (a2).     

Effects of growth hormone (GH) replacement on bone metabolism and mineral density in adult onset of GH deficiency: results of a double-blind placebo-controlled study with open follow-up

It is known that GH stimulates bone turnover and that GH-deficient adults have a lower bone mass than healthy controls. In order to evaluate the influences of GH replacement therapy on markers of bone turnover and on bone mineral density (BMD) in patients with adult onset GH deficiency, a double-blind placebo-controlled study of treatment with recombinant human GH (rhGH; mean dose 2.4 IU daily) in 20 patients for 6 months and an extended open study of 6 to 12 months were conducted. Eighteen patients, fourteen men and four women, with a mean age of 44 years with adult onset GH deficiency were evaluated in the study. Compared with placebo, after 6 months serum calcium (2.39 +/- 0.02 vs 2.32 +/- 0.02 mmol/l, P = 0.037) and phosphate (0.97 +/- 0.06 vs 0.75 +/- 0.05 mmol/l, P = 0.011) increased and the index of phosphate excretion (0.03 +/- 0.03 vs 0.19 +/- 0.02, P < 0.001) decreased significantly, and there was a significant increase in the markers of bone formation (osteocalcin, 64.8 +/- 11.8 vs 17.4 +/- 1.8 ng/ml, P < 0.001; procollagen type I carboxyterminal propeptide (PICP), 195.3 +/- 26.4 vs 124.0 +/- 15.5 ng/ml, P = 0.026) as well as those of bone resorption (type I collagen carboxyterminal telopeptide (ICTP), 8.9 +/- 1.2 vs 3.3 +/- 0.5 ng/ml, P < 0.001; urinary hydroxyproline, 0.035 +/- 0.006 vs 0.018 +/- 0.002 mg/100 ml glomerular filtration rate, P = 0.009). BMD did not change during this period of time. IGF-I was significantly higher in treated patients (306 +/- 45.3 vs 88.7 +/- 22.5 ng/ml, P < 0.001). An analysis of the data compiled from 18 patients treated with rhGH for 12 months revealed similar significant increases in serum calcium and phosphate, and the markers of bone turnover (osteocalcin, PICP, ICTP, urinary hydroxyproline). Dual energy x-ray absorptiometry (DXA)-measured BMD in the lumbar spine (1.194 +/- 0.058 vs 1.133 +/- 0.046 g/cm2, P = 0.015), femoral neck (1.009 +/- 0.051 vs 0.936 +/- 0.034 g/cm2, P = 0.004), Ward's triangle (0.881 +/- 0.055 vs 0.816 +/- 0.04 g/cm2, P = 0.019) and the trochanteric region (0.869 +/- 0.046 vs 0.801 +/- 0.033 g/cm2, P = 0.005) increased significantly linearly (compared with the individual baseline values). At 12 months, BMD in patients with low bone mass (T-score < -1.0 S.D.) increased more than in those with normal bone mass (lumbar spine 11.5 vs 2.1%, P = 0.030, and femoral neck 9.7 vs 4.2%, P = 0.055). IGF-I increased significantly in all treated patients. In conclusion, treatment of GH-deficient adults with rhGH increases bone turnover for at least 12 months. BMD in the lumbar spine and the proximal femur increases continuously in this time (open study) and the benefit is greater in patients with low bone mass. Therefore, GH-deficient patients exhibiting osteopenia or osteoporosis should be considered candidates for GH supplementation. However, long-term studies are needed to establish that the positive effects on BMD are persistent and are associated with a reduction in fracture risk.     

Disease and nonbattle injury among United States soldiers deployed in Bosnia-Herzegovina during 1997: summary primary care statistics for Operation Joint Guard

Lesions of the acetabular labrum should be treated by correcting the causes. In a steep acetabulum where the femoral head brings the acetabular labrum under tension and traction, the acetabulum should be rotated by triple pelvic osteotomy to slightly over-corrected acetabular measurements. Severely diminished acetabular and femoral anteversion can also lead to tears and impingement of the labrum. Then rotation of the femoral neck and/or rotations of the acetabulum by triple osteotomy to 15-20 degrees of anteversion are indicated. Our triple osteotomy technique differs from that of others mainly in the ischial osteotomy. It is performed from the posterior approach between the sciatic notch next to the ischial spine and the obturator foramen and is directed 20-30 degrees anteriorly from the frontal (coronal) plane. The osteotomies therefore are placed close enough to the acetabulum to allow free rotation, but they do not interfere with the circulation of the acetabulum, and the ligaments between the sacrum and ischium are left in normal tension. Our normal values of the acetabular position were tested by correlating the measurements with the absence of pain. The optimum is reached with a CE angle and a VCA angle of 30-35 degrees, an angle of the weight-bearing zone of +5 to -5 degrees and a migration index of 10-15%. Overcorrections again caused pain and should be avoided. Diminished anteversion of femur and acetabulum towards 0 degree also caused pain and should be corrected by triple and femoral osteotomy to 15-20 degrees of anteversion. In earlier follow-ups of 216 hips 5-10 years postoperatively, 82.3% of the joints showed no change in the degree of osteoarthrosis. Survival rate curves regarding the absence of pain demonstrated that pain was experienced again when joints were corrected insufficiently or overcorrected, while in good corrections the joints were free of pain in about 75%.     

Pelvic stress injuries: the relationship between osteitis pubis (symphysis pubis stress injury) and sacroiliac abnormalities in athletes

OBJECTIVE: To demonstrate with radiographic imaging the association between pubic stress injury and sacroiliac abnormalities in athletes. DESIGN AND PATIENTS: Eleven athletes (9 men and 2 women), comprising seven male long-distance runners, one male soccer player, one male and two female basketball players, were imaged with plain films for complaints of pubic symphysis pain, sciatica, groin pain, or a combination of these complaints. In addition to the plain films, four patients were imaged with CT, two patients had MR imaging, and a bone scan was performed in three patients. Anteroposterior plain films of the pelvis of 20 patients without back pain or pubic pain were evaluated for comparison as a control group (ages 18-72 years, average 49 years; 11 women and 9 men). RESULTS: All athletes showed plain film evidence of either sclerosis, erosions or offset at the pubic symphysis. Four had avulsion of cortical bone at the site of insertion of the gracilis tendon. Four patients demonstrated sacroiliac joint abnormalities on plain films consisting of sclerosis, erosions and osteophytes, and in one of these athletes, bilateral sacroiliac changes are present. Two patients with normal sacroiliac joints on plain films had a bone scan showing increased radionuclide uptake bilaterally at the sacroiliac joints. One patient with both plain film and CT evidence of sacroiliac abnormalities had an MR examination showing abnormal signal at both sacroiliac joints and at the pubic symphysis. A sacral stress fracture was found on CT in one patient with complaints of sciatica. In the control group, six patients, all over the age of 55 years, had mild sclerosis of the symphysis, but no plain film evidence of sacroiliac abnormalities. CONCLUSION: We have found a group of athletes in whom stress injuries to the pubic symphysis are associated with changes in the sacroiliac joint as demonstrated by degenerative changes or in the sacrum as manifested as a sacral stress fracture. These findings are probably due to abnormal stresses across the pelvic ring structure that lead to a second abnormality in the pelvic ring. The abnormality in the sacrum is not always well seen with conventional imaging. Recognition of the association of stress injury of the symphysis with back pain is important in that it can help avoid inappropriate studies and diagnostic confusion.     

Bone density, bone turnover, and hormone levels in men over age 75

BACKGROUND: Osteoporosis is a substantial problem in older men, with 25% of all hip fractures occurring in men. The mechanisms of bone loss in older men are unknown, but elevated parathyroid hormone (PTH) and diminished testosterone (T) levels are postulated as contributing factors. METHODS: We measured bone mineral density (BMD), sex hormones, bone turnover markers, and calcium regulating hormones in a group of community-living men over the age of 75. RESULTS: Thirty-five men (mean age 79; range 75-88 years) without disease or medication known to affect bone metabolism participated in the study. Whole body BMD was 1.21+/-.15 g/cm2; lumbar spine BMD (L1-L4) was 1.10+/-.15 g/cm2; femoral neck BMD was .77+/-.14 g/cm2; and trochanteric region was .71+/-.13 g/cm2. The femoral neck and trochanteric region values were more than 1 SD below the mean for adult men (age 25-33 years) in 28/35 and 15/35 men, respectively. Deoxypyridinoline levels were above the normal range for premenopausal women in 23% of the men; N-telopeptide and C-telopeptide demonstrated a wide scatter, but the values remained in the normal range. T levels were found to be below normal range for adult men in 12 of 32 (38%) subjects and the PTH levels above the normal range in 8 of 35 (23%) subjects. Bone resorption markers correlated inversely with BMD of the whole body, femur, and spine (r=-.22 to -.48). There was an inverse correlation between total T and spine BMD which became insignificant after correcting for body mass index (BMI). In addition, there was no correlation between free or bioavailable testosterone and BMD. 1,25-(OH)2D levels correlated inversely with BMD at the femur and whole body, but no association was found with PTH or 25 OH-D. CONCLUSIONS: Men over 75 years of age had a wide range of BMD but frequently had low values at femoral sites. T levels were below the normal range in 38% of men, and PTH levels were elevated in 23% of men. There was an inverse correlation between total T and spine BMD which may have been dependent on the common effect of BMI. Bone mineral density was inversely related to markers of bone resorption.     

Bone disease in children and adolescents undergoing successful renal transplantation

Little is known about the extent and severity of bone disease in children undergoing successful renal transplantation. To address this issue, 47 patients with stable renal function 3.2 +/- 1.7 years after transplantation (Tx) underwent iliac crest bone biopsy. The mean age of patients was 12 +/- 2.0 years; 36 had received cadaveric renal grafts, whereas 11 had undergone living-related Tx. Immunosuppressive drugs included cyclosporine 0.17 +/- 0.4 mg/kg/day, prednisone 7.5 +/- 2.1 mg/kg/day, and either azathioprine 1.6 +/- 0.9 mg/kg/day or mycophenolate mofetil 30 +/- 3 mg/kg/day. In addition to quantitative bone histomorphometry, the bone mineral content (BMC) of the lumbar spine was measured by dual energy X-ray absorptiometry (DXA) in 24/47 patients. Thirty-one transplant recipients had normal bone formation (N-Bfr), 11 had mild hyperparathyroidism (HPT) and 5 had adynamic skeletal lesions (AD). The interval since Tx, duration of dialysis before Tx and cumulative prednisone dose did not differ among groups. Trabecular bone area was highest in subjects with HPT. Unexpectedly, eroded bone perimeter exceeded normal reference values both in patients with AD and in those with N-Bfr; the osteoid area and osteoid perimeter were also elevated in these two groups. Hyperparathyroidism improved or resolved after Tx in all 14 subjects with this skeletal lesion prior to Tx, but one patient developed AD after Tx. Bone histology did not change after Tx in those with N-Bfr during regular dialysis, but bone formation increased after Tx in two of three patients with AD during regular dialysis. Z-scores for height in pre-pubertal patients after Tx were below age-appropriate values in each histologic subgroup, but values did not differ among groups. Z-scores for bone mineral content at the lumbar spine were also less than age-predicted values, -0.67 +/- 1.2. After adjusting for the degree of growth retardation, height-adjusted z-scores for lumbar spine BMC after Tx were above normal in all three histologic groups (0.68 +/- 1.0). The results suggest that reductions in bone mass and post-transplant osteoporosis are not prominent findings in pediatric renal transplant recipients when the influence of growth retardation on bone mass measurements by DXA is carefully considered.     

Evaluation of low density spine software for the assessment of bone mineral density in children

Pediatric dual-energy X-ray absorptiometry spine scans often cannot be analyzed with standard software due to a failure to identify the bone edges of low density vertebrae. Low density spine (LDS) software improves bone detection compared with standard software. The objective of this study was to compare bone mineral density (BMD) measurements obtained with the standard and LDS software in 27 healthy nonobese, 32 obese, and 41 chronically ill children, ages 2-18 years. Lumbar spine (L1-L4) BMD, measured by standard analysis, ranged from 0.531-1.244 gm/cm2. Reanalysis with the LDS software resulted in a systematic increase (mean +/- SD) in estimated bone area of 17.0+/-5.0%, an increase in bone mineral content of 6.1+/-6.3%, and a mean decrease in BMD of 8.7+/-1.7% (all p < 0.001). This resulted in a mean decrease in BMD Z score of 0.7+/-0.2. Linear regression models, predicting standard BMD from LDS BMD, were fit for the three subject groups (R2 = 0.993-0.995). Small differences in slopes were detected across groups (p = 0.07); LDS BMD predicted higher standard BMD in obese subjects. In conclusion, LDS analysis resulted in a clinically significant decrease in measured BMD. The association between analysis methods was exceptionally high (R2 > 0.99), indicating that LDS BMD accurately predicts standard BMD. Although LDS BMD in obese subjects predicts higher standard BMD results than in nonobese subjects, the small difference is of questionable clinical significance. LDS software is a useful tool for the assessment of BMD in children.     

Health care coverage and access for children in an urban state: the New York perspective

To clarify the role of the intestine, kidney, and bone in maintaining calcium homeostasis during pregnancy and lactation and after the resumption of menses, a longitudinal comparison was undertaken of 14 well-nourished women consuming approximately 1200 mg Ca/d. Measurements were made before conception (prepregnancy), once during each trimester of pregnancy (T1, T2, and T3), early in lactation at 2 mo postpartum (EL), and 5 mo after resumption of menses. Intestinal calcium absorption was determined from the enrichment of the first 24-h urine sample collected after administration of stable calcium isotopes. Bone mineral of the total body and lumbar spine was measured by dual-energy X-ray absorptiometry and quantitative computerized tomography, respectively. Twenty-four-hour urine and fasting serum samples were analyzed for calcium, calcitropic hormones, and biochemical markers of bone turnover. Despite an increase in calcium intake during pregnancy, true percentage absorption of calcium increased from 32.9+/-9.1% at prepregnancy to 49.9+/-10.2% at T2 and 53.8+/-11.3% at T3 (P < 0.001). Urinary calcium increased from 4.32+/-2.20 mmol/d at prepregnancy to 6.21+/-3.72 mmol/d at T3 (P < 0.001), but only minor changes in maternal bone mineral were detected. At EL, dietary calcium and calcium absorption were not significantly different from that at prepregnancy, but urinary calcium decreased to 1.87+/-1.22 mmol/d (P < 0.001) and trabecular bone mineral density of the spine decreased to 147.7+/-21.2 mg/cm3 from 162.9+/-25.0 mg/cm3 at prepregnancy (P < 0.001). Calcium absorption postmenses increased nonsignificantly to 36.0+/-8.1% whereas urinary calcium decreased to 2.72+/-1.52 mmol/d (P < 0.001). We concluded that fetal calcium demand was met by increased maternal intestinal absorption; early breast-milk calcium was provided by maternal renal calcium conservation and loss of spinal trabecular bone, a loss that was recovered postmenses.     

Schwann cell changes induced as early as one week after galactose intoxication

In the past, several techniques have been developed to study and analyse the 3D characteristics of the human spine: multi-view radiographic or biplanar 3D reconstructions, CT-scan 3D reconstructions and geometric models. Extensive evaluations of three of these techniques that are routinely used at Sainte-Justine Hospital (Montréal, Canada) are presented. The accuracy of these methods is assessed by comparing them with precise measurements made with a coordinate measuring machine on 17 thoracic and lumbar vertebrae (T1-L5) extracted from a normal cadaveric spine specimen. Multi-view radiographic 3D reconstructions are evaluated for different combinations of X-ray views: lateral (LAT), postero-anterior with normal incidence (PA0 degree) and postero-anterior with 20 degrees angled down incidence (PA20 degrees). The following accuracies are found for these reconstructions obtained from different radiographic setups: 2.1 +/- 1.5 mm for the combination with PA0 degree-LAT views, and 5.6 +/- 4.5 mm for the PA0 degree-PA20 degrees stereopair. Higher errors are found in the postero-anterior direction, especially for the PA0 degree-PA20 degrees view combination. Pedicles are found to be the most precise landmarks. Accuracy for CT-scan 3D reconstructions is about 1.1 +/- 0.8 mm. As for a geometric model built using a multiview radiographic reconstruction based on six landmarks per vertebra, accuracies of about 2.6 +/- 2.4 mm for landmarks and 2.3 +/- 2.0 mm for morphometric parameters are found. The geometric model and 3D reconstruction techniques give accurate information, at low X-ray dose. The accuracy assessment of the techniques used to study the 3D characteristics of the human spine is important, because it allows better and more efficient quantitative evaluations of spinal dysfunctions and their treatments, as well as biomechanical modeling of the spine.     

Persistence of mammary artery branches and blood supply to the left anterior descending artery

BACKGROUND: Partial harvesting of the left internal mammary artery (LIMA) is a widespread technique used during minimally invasive coronary operations performed through a left anterior small thoracotomy. The influence of persisting LIMA branches was investigated to evaluate their effect on the blood flow of the left anterior descending artery. METHODS: Thirty patients, 15 with totally (group A) and 15 with partially (group B) harvested LIMAs, were evaluated. All the patients underwent postoperative angiography, during which a flow map of the LIMA was performed. The average peak velocity and the diastolic-to-systolic peak velocity ratio were recorded. The LIMA graft flow pattern was recorded in the proximal and distal thirds of the artery. Intramammary adenosine (12 to 14 microg) was injected and the average peak velocities before and after injection were calculated. RESULTS: The average peak velocity was similar in both groups in the proximal and distal thirds of the LIMA (25 +/- 7 and 26 +/- 5 cm/sec, respectively, in group A versus 27 +/- 5 and 25 +/- 5 cm/sec, respectively in group B; p = NS). The diastolic-to-systolic peak velocity ratio was similar proximally (0.78 +/- 0.3 in group A versus 0.69 +/- 0.3 cm/s in group B; p = NS), but not distally (1.72 +/- 0.1 in group A versus 0.97 +/- 0.3 in group B; p < 0.0005). The LIMA graft flow reserve was similar both proximally and distally (2.6 +/- 0.6 and 2.5 +/- 0.3 cm/s, respectively, in group A versus 2.6 +/- 0.5 and 2.6 +/- 0.3 cm/s, respectively, in group B; p = NS). CONCLUSIONS: The persistence of LIMA branches does not influence the blood flow of the left anterior descending artery after acute adenosine-induced myocardial hyperemia. If a left anterior small thoracotomy is used in left anterior descending artery direct revascularization, complete LIMA harvesting is not mandatory and depends on the personal preference of the surgeon.     

Bone disease in patients with primary sclerosing cholangitis: prevalence, severity and prediction of progression

BACKGROUND/AIMS: Osteopenia is a common complication in some chronic cholestatic liver diseases. Our aims were to determine the prevalence and severity of bone disease in patients with primary sclerosing cholangitis; and identify risk factors to predict the presence and progression of osteopenia. METHODS: Eighty-one patients involved in a randomized trial of ursodeoxycholic acid were analyzed. Bone mineral density of the lumbar spine was determined at entry and at annual intervals. RESULTS: Bone mineral density of the lumber spine in primary sclerosing cholangitis patients was significantly lower than expected when compared to normal values adjusted for age, sex and ethnic group at entry (p<0.005), and after 1 year (p<0.05), 2 years (p<0.05), 4 years (p<0.005) and 5 years of follow-up (p<0.005). Seven patients (8.6%) had bone mineral density of the lumber spine below the fracture threshold at entry. These patients were significantly older, had a longer duration of inflammatory bowel disease and more advanced primary sclerosing cholangitis. The rate of bone loss in primary sclerosing cholangitis patients and expected in normal controls was 0.01+/-0.02 g x cm(-2) x year(-1) and 0.003+/-0.003 g x cm(-2) x year(-1), respectively (p = NS), and was similar in patients receiving placebo and ursodeoxycholic acid. Age was the only variable inversely related with baseline bone mineral density of the lumber spine (p<0.0001). None of the variables predicted progression of the bone disease. CONCLUSIONS: Severe osteoporosis occurs in few patients with primary sclerosing cholangitis, but it should be suspected in patients with longer duration of inflammatory bowel disease and more advanced liver disease. Its presence, severity and progression cannot be accurately evaluated by routine clinical, biochemical, or histological variables. Ursodeoxycholic acid does not affect the rate of bone loss in primary sclerosing cholangitis.     

Effects of heat and moisture exchangers on minute ventilation, ventilatory drive, and work of breathing during pressure-support ventilation in acute respiratory failure

OBJECTIVES: To evaluate the effect of two commonly used heat and moisture exchangers on respiratory function and gas exchange in patients with acute respiratory failure during pressure-support ventilation. DESIGN: Prospective, randomized trial. SETTING: Intensive care unit of a university hospital. PATIENTS: Fourteen patients with moderate acute respiratory failure, receiving pressure-support ventilation. INTERVENTIONS: Patients were assigned randomly to two treatment groups, in which two different heat and moisture exchangers were used: Hygroster (DAR S.p.A., Mirandola, Italy) with higher deadspace and lower resistance (group 1, n = 7), and Hygrobac-S (DAR S.p.A.) with lower deadspace and higher resistance (group 2, n = 7). Patients were assessed at three pressure-support levels: a) baseline (10.3 +/- 2.4 cm H2O for group 1, 9.3 +/- 1.3 cm H2O for group 2); b) 5 cm H2O above baseline; and c) 5 cm H2O below baseline. Measurements obtained with the heat and moisture exchangers were compared with those values obtained using the standard heated hot water humidifier. MEASUREMENTS AND MAIN RESULTS: At baseline pressure-support ventilation, the insertion of both heat and moisture exchangers induced in all patients a significant increase in the following parameters: minute ventilation (12.4 +/- 3.2 to 15.0 +/- 2.6 L/min for group 1, and 11.8 +/- 3.6 to 14.2 +/- 3.5 L/min for group 2); static intrinsic positive end-expiratory pressure (2.9 +/- 2.0 to 5.1 +/- 3.2 cm H2O for group 1, and 2.9 +/- 1.7 to 5.5 +/- 3.0 cm H2O for group 2); ventilatory drive, expressed as P41 (2.7 +/- 2.0 to 5.2 +/- 4.0 cm H2O for group 1, and 3.3 +/- 2.0 to 5.3 +/- 3.0 cm H2O for group 2); and work of breathing, expressed as either power (8.8 +/- 9.4 to 14.5 +/- 10.3 joule/ min for group 1, and 10.5 +/- 7.4 to 16.6 +/- 11.0 joule/min for group 2) or work per liter of ventilation (0.6 +/- 0.6 to 1.0 +/- 0.7 joule/L for group 1, and 0.8 +/- 0.4 to 1.1 +/- 0.5 joule/L. for group 2). These increases also occurred when pressure-support ventilation was both above and below the baseline level, although at high pressure support the increase in work of breathing with heat and moisture exchangers was less evident. Gas exchange was unaffected by heat and moisture exchangers, as minute ventilation increased to compensate for the higher deadspace produced in the circuit by the insertion of heat and moisture exchangers. CONCLUSIONS: The tested heat and moisture exchangers should be used carefully in patients with acute respiratory failure during pressure-support ventilation, since these devices substantially increase minute ventilation, ventilatory drive, and work of breathing. However, an increase in pressure-support ventilation (5 to 10 cm H2O) may compensate for the increased work of breathing.     

Possibility of postnatal left ventricular growth in selected infants with non-apex-forming left ventricles

To evaluate postnatal left ventricular growth potential, we reviewed the echocardiograms of seven infants with left ventricles that did not form an apex. Prostaglandins were used to maintain patency of the ductus arteriosus in six infants. Associated abnormalities included aortic stenosis in five, coarctation in three, and left atrial isomerism in one. Initial echocardiographic measurements (7 +/- 9 days) were compared with measurements at 1 month (36 +/- 9 days). Weight (3.0 +/- 0.1 vs 3.0 +/- 0.5 kg) and body surface area (BSA) (0.2 +/- 0.01 vs 0.2 +/- 0.01 m2) did not change. Comparing initial measurements with measurements at 1 month, there were significant increases (p < 0.05) in aortic annulus diameter (4.5 +/- 0.5 vs 5.6 +/- 0.7 mm), aortic root diameter indexed to BSA (2.9 +/- 0.5 vs 3.7 +/- 0.7 cm/m2), ratio of the long axis of the left ventricle to the long axis of the heart (0.74 +/- 0.1 vs 0.86 +/- 0.1), left ventricular end-diastolic volume indexed to BSA (10 +/- 2 vs 24 +/- 9 ml/m2), left ventricular mass indexed to BSA (27 +/- 13 vs 47 +/- 28 gm/m2), mitral valve area indexed to BSA (2.3 +/- 0.5 vs 3.2 +/- 0.7 cm2/m2), left ventricular area (2.1 +/- 0.5 vs 3.6 +/- 1.1 cm2), and Rhodes score (-2.7 +/- 0.5 vs -1.1 +/- 0.9). Tricuspid valve area indexed to BSA (5.8 +/- 1.5 vs 6.1 +/- 1.1 cm2/m2) and long axis of the heart indexed to BSA (13.0 +/- 2.8 vs 13.6 +/- 2.9 cm/m2) did not change. The increase in measurements appeared adequate for biventricular physiology in five infants (four are alive [3.9 +/- 2.6 years] and one died after not being able to wean from the ventilator). These data suggest that a non-apex-forming left ventricle may have postnatal growth potential.