Aesthetic sequelae of septoplasty

BACKGROUND: Low bone mineral content (BMC) has been reported in patients with inflammatory bowel disease. The aim of the present study was to measure BMC in patients with Crohn's disease. METHODS: BMC was monitored for a mean period of 5.5 years in 108 patients. The patients were divided into two groups: group A, patients with the colon preserved; group B, patients with a resected colon. The mean length of the resected small intestine was 90 cm. RESULTS: The BMC of the lumbar spine expressed as Z-score ((actual value-mean)/s) was significantly reduced: mean Z-score for group A, -0.51, P < 0.05; group B, -0.80, P < 0.001. The BMC of the femoral neck was significantly reduced: mean Z-score for group A, -1.24, P < 0.001; group B, -1.23, P < 0.001. A Z-score below -2.0 of spine or femoral neck BMC was found in 10% and 23% of the patients, respectively. The BMC of the femoral neck decreased significantly in both groups during the study period (group A, -2.2%, P < 0.001; group B, -1.21%, P < 0.05). The BMC of the lumbar spine did not change. There was an inverse correlation between the initial Z-score and the rate of change in BMC (P < 0.05). We found no correlation between Z-score or change in BMC and period of prednisolone treatment. Moreover, there was no correlation between the length of the resected small intestine and BMC or annual percentage change in BMC. CONCLUSION: At inclusion the BMC of the spine and femoral neck was low in patients with Crohn's disease. During the study significant bone loss was only demonstrated in the femoral neck. BMC or rate of change in BMC was not related to treatment with steroids or length of the resected small intestine.     

Femoral and spinal bone mineral density in Japanese osteoporotics with hip fracture

In the present study, bone mineral density (BMD) of femoral neck and lumbar spine was compared between 38 Japanese female patients with hip fracture (age 63-89 years, mean +/- SD 76 +/- 7 years) and 162 age-matched female controls (age 62-90 years, mean +/- SD 75 +/- 7 years). BMD was measured in the femoral neck and lumbar spine (L2-4) using dual-photon absorptiometry (Norland model 2600). BMD values of femoral neck as well as lumbar spine were significantly lower in patients with hip fracture than in controls (0.504 +/- 0.097 v 0.597 +/- 0.101, p < 0.01, for femoral neck; 0.661 +/- 0.146 v 0.720 +/- 0.128, p < 0.05, for lumbar spine). Patients with hip fracture and controls were stratified according to their BMD levels at two measuring sites, and the ratio of the number of patients and controls at each BMD level was calculated as an indicator of fracture rate. This ratio showed an exponential increase as the femoral neck BMD declined, but only a gradual increase as the lumbar spine BMD declined. Specificity-sensitivity analysis revealed that BMD values of 0.59 and 0.54 g/cm2 at the femoral neck provided a specificity of 52% and 68% with a sensitivity of 90% and 75%, respectively. These findings suggest that Japanese patients with hip fracture are more osteoporotic than age-matched controls and that the selective measurement of femoral neck would be useful for predicting the risk of hip fracture.     

Peripheral osteopenia in adult patients with insulin-dependent diabetes mellitus

Alterations in bone metabolism in diabetes mellitus is a topic of special interest. Bone blood flow is increased in the distal limb of diabetic patients, which is believed to increase osteoclastic activity. We measure bone mineral density using dual-photon absorptiometry in the distal lower limb, the femoral neck, and the lumbar spine in 41 IDDM patients and in 30 control persons. In the diabetic group there was a 10% reduction of bone mineral density in the femoral neck (p < 0.01) and a 12% reduction in the distal limb (p < 0.001) compared with the control group. No significant difference was found in the lumbar spine (p = 0.22). Our data yield incidence for peripheral osteopenia in IDDM-patients, independent of any systemic bone disease such as osteoporosis. A link between decreased bone mineral density and diabetic neuropathy has been observed for the femoral neck (p < 0.001), but not for the distal limb or axial skeleton. Whether there is a common aetiological link or a casual connection between diabetic neuropathy and bone mineral density has still to be determined.     

Head and neck replacement endoprosthesis for pathologic proximal femoral lesions

Records of 28 patients with pathologic lesions in the proximal femur treated by implantation of a femoral head and neck replacement prosthesis between 1984 and 1995 were reviewed. Mean clinical followup was 47.8 months in the eight living patients and 15.8 months in the 20 patients who had died. The underlying diagnosis was metastatic disease or myeloma in 22 patients. The most frequently occurring indication for implantation of this device was a pathologic fracture in 26 patients (18 displaced, eight impending), followed by resection and reconstruction in two patients. All femoral components were cemented: 23 were bipolar hemiarthroplasties and five were total hip arthroplasties. Implant survivorship was good (93%), with only two prostheses removed during the followup period, both for infection. However, radiographic analysis revealed increasing lucencies with time, particularly in the most proximal zones, resulting in radiographic failure in an additional case. Deep infection occurred in three cases, leading to resection arthroplasty in two patients. Periprosthetic fractures occurred in three cases, but only one occurred intraoperatively. Despite a high complication rate, the good implant survival during the shortened life span of these patients supports the continued use of femoral head and neck replacement prostheses in this population.     

Bone mineral density assessment in children with inflammatory bowel disease

BACKGROUND & AIMS: Children with inflammatory bowel disease (IBD) are at risk for osteoporosis because of undernutrition, delayed puberty, and prolonged corticosteroid use. The aim of this study was to compare bone mineral density (BMD) in children with IBD with that in normal children and to assess the effects of nutritional and hormonal factors and corticosteroid dosages on BMD. METHODS: One hundred sixty-two subjects (99 with IBD and 63 healthy sibling controls) were enrolled. Patients underwent anthropometric assessment, pubertal staging, bone age radiography, and BMD assessment by dual energy x-ray absorptiometry of the lumbar spine, femoral neck, and radius. Laboratory evaluations included serum calcium, phosphate, alkaline phosphatase, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, parathyroid hormone, osteocalcin, urinary N-telopeptides, albumin, insulin-like growth factor I, and testosterone or estradiol. Cumulative corticosteroid doses were calculated. RESULTS: BMD Z scores at the lumbar spine and femoral neck were lower in patients with IBD, and lower in those with Crohn's disease compared with those with ulcerative colitis. Low BMD persisted after correction for bone age in girls with Crohn's disease (lumbar spine, P = 0.004; femoral neck, P = 0.002). Cumulative corticosteroid dose was a significant predictor of reduced BMD. BMD did not correlate with measures of calcium homeostasis, except elevated serum phosphate and urine calcium levels in girls. CONCLUSIONS: Low BMD occurs in children with IBD (more in Crohn's disease than in ulcerative colitis), especially pubertal and postpubertal girls. Cumulative corticosteroid dose is a predictor of low BMD, but other factors in Crohn's disease remain undetermined.     

Dual-energy X-ray absorptiometry in osteonecrosis of the femoral head

Osteonecrosis of the hip classically produces a heterogeneous density in the femoral head, although the bone marrow ischemia extends down to the femoral neck and trochanters. Also, bone insufficiency fractures due to diffuse bone loss have been implicated in the genesis of osteonecrosis. OBJECTIVES: To use dual-energy X-ray absorptiometry to quantify the bone changes produced by osteonecrosis of the hip and to compare bone mineral density values in patients with osteonecrosis of the hip and in controls. METHODS: Bone mineral density was measured at the femoral neck (total femoral neck, Ward's triangle, and trochanter), femoral head and lumbar spine using dual-energy X-ray absorptiometry (DPX, L Lunar) in 22 patients with osteonecrosis of the hip and in 22 age- and sex-matched controls. RESULTS: In the patients with osteonecrosis, bone mineral density on the affected side was higher than on the opposite side at the femoral head (+18%), femoral neck (+7%), and Ward's triangle (+6%) and lower at the trochanter (-4%). These differences were most marked at the more advanced end of the osteonecrosis spectrum. As compared to age-specific normative values, the osteonecrosis patients had moderately decreased bone mineral density values at the lumbar spine (-0.53 +/- 1.1 SD or -6 +/- 1.5%) and at the femoral neck on the normal side (-0.9 +/- 1.4 SD or 12 +/- 1.8%). As compared to the controls, bone mineral density was significantly decreased at Ward's triangle (-25%; P: 0.04) and nonsignificantly decreased at the lumbar spine (-4.7%; P: 0.15) and at the femoral neck (-15%; P: 0.09).     

Neuropsychological and psychiatric differences between Alzheimer's disease and Parkinson's disease with dementia

OBJECTIVE: To examine neuropsychological and neuropsychiatric differences between patients with probable Alzheimer's disease and patients with Parkinson's disease and dementia. METHODS: Thirty three patients with probable Alzheimer's disease and 33 patients with Parkinson's disease and dementia were matched for age, sex, and mini mental state examination scores and given a battery of neuropsychological and neuropsychiatric tests. RESULTS: Patients with Parkinson's disease with dementia had a significantly higher prevalence of major depression than patients with Alzheimer's disease; patients with Alzheimer's disease showed more severe anosognosia and disinhibition than patients with Parkinson's disease. Whereas no significant between group differences were found on tests of memory and language, demented patients with Parkinson's disease had a significantly greater impairment on a test of visual reasoning than patients with Alzheimer's disease. CONCLUSION: There were significant psychiatric differences between patients with Alzheimer's disease and demented patients with Parkinson's disease, but neuropsychological differences were restricted to a single cognitive domain.     

Longitudinal bone mineral density changes in early rheumatoid arthritis

A prospective longitudinal study of patients with early RA was performed to examine the influence of disease duration, disease activity and physical activity on bone loss. Sixty-seven patients with non-steroid treated RA of less than 5 yr duration, including 16 patients with disease duration less than 6 months, had BMD measurements of the femoral neck and the lumbar spine over a 12-month period using dual energy X-ray absorptiometry. The BMD changes were compared with values from 72 control patients and were also correlated with serial measurements of disease activity (measured by the Stoke Index) and disability [measured by the Health Assessment Questionnaire (HAQ) score], at 3-monthly intervals over the 12-month period. No significant differences in BMD changes were found between RA patients and controls overall. Patients with disease duration of less than 6 months had significantly greater loss of BMD at the femoral neck (-3.9%, S.E.M. 1.5) than the remainder of the cohort (-0.2%, S.E.M. 0.7) (P = 0.02) and controls (-0.8%, S.E.M. 0.6). Lumbar spine BMD changes correlated with the initial Stoke Index (Rs-0.373, P = 0.01) but not mean Stoke Indices. There was no correlation of BMD changes with age or HAQ scores. These findings suggest that significant bone loss occurs within the first few months of disease in patients with RA.     

An algorithm for the management of femoral neck fractures

The choice of total hip arthroplasty should probably be reserved for those rare patients with preexisting osteoarthritis of the hip in the setting of a subcapital hip fracture. Additionally, relative indications for total hip arthroplasty may include the presence of contralateral hip disease; the presence of metabolic bone disease, which may controvert internal fixation or reasonable results with endoprosthetic replacement; and those patients with high activity expectations or life expectancy greater than 5 years. Given the diminished performance of hemiarthroplasty with time and activity, it may be argued that the most cost effective solution to the subcapital hip fracture in the majority of patients may be the reduction and internal fixation pathway, with elective conversion, when necessary, of the approximately 25% of patients who suffer avascular necrosis to total hip arthroplasty. It appears that hemiarthroplasty is best suited for the elderly household ambulator, whereas total hip arthroplasty is the better alternative either as the elective solution to failed internal fixation of femoral neck fractures or in the occasional community ambulator with high activity expectations and irreducible femoral neck fractures. Younger patients, and those with minimally displaced fractures, should be treated with internal fixation in an attempt to preserve the natural hip joint.     

Outcome in elderly injured patients: injury severity versus host factors

To evaluate the differences between the outcome of elderly patients with severe injuries and that of their contemporaries with a less severe injury, we reviewed 42 severely injured elderly patients and compared them with 76 patients with a femoral neck fracture. We analysed the influence of injury severity and host factors (age, sex and pre-injury medical status) on outcome. The in-hospital mortality rate was 31 per cent in the severely injured patients and 3 per cent in those with a femoral neck fracture. Home was the main discharge destination in the severely injured elderly (34 per cent) and a nursing home in patients with a femoral neck fracture (65 per cent). Functional outcome 1 year after injury was better in the severely injured elderly group. Long-term survival was mainly determined by host factors and not by injury severity. Physicians and policy makers should be careful in predicting the outcome of elderly injured patients merely on the basis of injury severity, because host factors are of greater importance.     

Eight-year outcome associated with clinical options in the management of femoral neck fractures

This study involved a review of the medical records of 367 patients treated surgically after femoral neck fracture. Linkage of these records with claims files from the Health Care Financing Administration allowed as many as 8 years of followup to analyze the rates of hospital readmission rates for revision, other postoperative complications and mortality. The results revealed: (1) a significantly higher revision rate was associated with internal fixation for the treatment of displaced femoral neck fractures in patients older than 80 years of age; no differences in revision rates were seen between internal fixation or hemiarthroplasty for the treatment of nondisplaced femoral neck fractures in this patient age group; (2) no differences in revision rates were found between internal fixation or hemiarthroplasty for the treatment of displaced femoral neck fractures in patients between the ages of 65 to 80 years; (3) a significantly higher mortality rate was associated with internal fixation than hemiarthroplasty for patients who were between the ages of 65 and 80 years; and (4) no differences in medical or surgical complications, revision rates, or other outcomes were found between unipolar and bipolar prostheses, or between anterior and posterior surgical approaches for hemiarthroplasty in patients who were age 65 years or older.     

Femoral neck fracture in the elderly--differential procedure

Recent investigations and new devices allow specific regimens in the management of dislocated femoral neck fractures. Very old, immobile patients with a bad prognosis should be treated with a femoral head prosthesis. Patients with either arthritis, osteopenia, dysplasia or rheumatoid arthritis should receive a total hip prosthesis. The remaining population (age > 65 years) with dislocated femoral neck fractures and intact acetabulum should be managed with a bipolar hemialloarthroplasty. The protrusion rate is not significant.     

Twenty-four-hour blood pressure profile and blood pressure responses to head-up tilt tests in Parkinson's disease and multiple system atrophy

OBJECTIVE: To investigate the 24 h blood pressure profile in patients with Parkinson's disease with intact autonomic function or with autonomic failure and patients with multiple system atrophy (MSA), and to assess whether these patients exhibit posture-related variations in blood pressure. PATIENTS AND METHODS: We studied 24 patients with Parkinson's disease (11 with autonomic failure) and 13 patients with MSA (all with autonomic failure). Autonomic failure was determined by autonomic tests. An oscillometric recorder was used for ambulatory blood pressure monitoring. Tilt-table tests were performed with a head-up tilt position of 60 degrees. RESULTS: An alteration in the normal 24 h blood pressure profile was observed in 82% of Parkinson's disease patients with autonomic failure and in 85% of those with multiple system atrophy, but not in the patients with intact autonomic function. Head-up tilt tests revealed a significantly higher supine blood pressure in Parkinson's disease patients with autonomic failure and in those with MSA than in Parkinson's disease patients with intact autonomic function. Tilting resulted in a marked fall in blood pressure in patients with MSA; in Parkinson's disease patients with autonomic failure, the fall was comparatively slighter. CONCLUSIONS: We conclude that autonomic failure contributes to the alterations in the day-night blood pressure profile that may possibly be ascribed to postural dysregulation of blood pressure. We hypothesize that nocturnal hypertension is a risk factor in the development of additional cerebrovascular disease in patients with Parkinson's disease or MSA who are affected by autonomic failure.     

Developmental subtypes of juvenile bipolar disorder

The incidence of hip fractures has increased over the past decades, and for patients with hip fractures, medical and social conditions have deteriorated during the same time. In this study the results of orthopaedic rehabilitation of patients with Parkinson's disease and a hip fracture are compared with those in all other hip fracture patients. A total of 74 patients with Parkinson's disease and hip fracture were compared with 1,361 patients without the disease. Prior to fracture, patients with Parkinson's disease were less likely to be living an independent life in their own homes. Postoperatively women with Parkinson's disease were hospitalized for a significantly longer period. Postoperative rehabilitation was significantly slower and less successful than among patients without the disease. Patients with Parkinson's disease comprise a subgroup of hip fracture patients who need more rehabilitation resources than can easily be provided at an ordinary orthopaedic ward. A team-work between an orthopaedic surgeon, a neurologist and a rehabilitation unit seems to be mandatory in order to achieve shorter hospitalization and earlier return to the pre-fracture environment.     

Recognition by familiarity is preserved in Parkinson's without dementia and Lewy-Body disease.

Objective: The retrieval deficit hypothesis states that the lack of deficit in recognition often observed in patients with Parkinson's disease is because of the low retrieval requirements of the task, given that these patients have retrieval and not encoding deficits. To test this hypothesis we investigated recognition memory by familiarity in Parkinson's patients and in patients with Lewy Bodies disease and Parkinson with dementia. Method: We analyzed to what extent the experimental groups were able to recognize by familiarity in a typical yes/no recognition memory task. The experimental groups were patients with early nondemented Parkinson's disease, advanced nondemented Parkinson's disease, demented Parkinson's patients, and patients with dementia with Lewy Bodies. We compared their performance with a group of young and another group of old healthy participants. The estimation of familiarity was made by analyzing recognition of word targets and distractors consisting of combinations of different letters in comparison with a condition in which targets and distractors were composed of similar letters, even though subjects were unaware of the independent variable. Results: The results indicate that familiarity was used at the same level by controls, patients with early Parkinson's disease and patients with dementia with Lewy Bodies. Although late Parkinson patients also used familiarity, its effect was only marginally significant. Patients with Parkinson's disease and dementia were not capable of using familiarity in recognition memory. Conclusions: Our results support the retrieval deficit hypothesis as Parkinson's patients without dementia show no deficit in a situation in which the retrieval requirements are minimal. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predicting the mechanical outcome of femoral neck fractures fixed with cancellous screws: an in vivo study

OBJECTIVE: The goal of this project was to determine, by using a retrospective cohort analysis, the relative importance of fracture geometry, bone density, and quality of fracture reduction in predicting redisplacement of femoral neck fractures fixed with multiple cancellous screws in a patient population. DESIGN: A retrospective analysis of quantitative geometric and bone density data from forty-seven patients with femoral neck fractures fixed with cancellous screws was performed. SETTING: Radiographs retrieved after analysis of a statewide hospital database were digitized and analyzed quantitatively. INTERVENTION: Quantitative data from radiographs included estimates of femoral neck bone density, fracture surface orientation and location, degree of comminution, prefixation displacement, initial reduction position of the fractured component, and final displacement of the fracture after fixation. MAIN OUTCOME MEASUREMENTS: Angular rotation and inferior displacement of the fracture component after fixation. RESULTS: Femoral neck bone density can be correlated to femoral cortical thickness and can be used as a measure of bone density from plain x-rays. Significant relative risk of redisplacement of a femoral neck fracture is correlated with initial inferior offset of the fracture component and varus angulation. Relative risks of other variables, including valgus reduction, Garden Stage 3 and 4 position of the femoral head, low bone density, presence of inferior comminution, a more vertical fracture surface angle, and fracture position, were not significant. CONCLUSIONS: When compared with other geometric and mechanical variables, nonanatomic reduction of a femoral neck fracture, with either inferior offset or varus angulation, is the strongest predictor of postfixation redisplacement of the fracture.     

Postprandial hypotension and orthostatic blood pressure responses in elderly Parkinson's disease patients

OBJECTIVE: To investigate the change in systolic blood pressure (SBP) induced by meals and to compare their impact on the orthostatic SBP response in elderly Parkinson's disease with that in control patients. DESIGN: Ten elderly patients suffering from Parkinson's disease were compared with 10 age-matched elderly control patients. METHODS: The postprandial SBP change was measured by means of ambulatory blood pressure monitoring with the patient in the supine position. Orthostatic SBP responses were measured the next day by means of active standing and passive head-up tilting tests performed before and after the patients had their lunch. RESULTS: In Parkinson's disease patients, a postprandial SBP drop of 27 mmHg in the supine position was found compared with a drop of 8 mmHg in controls. In Parkinson's disease patients, that drop was moderately correlated to the orthostatic SBP responses and significantly correlated to the preprandial supine baseline SBP level. The orthostatic fall in SBP was greater with passive than with active standing and with both it was greater in Parkinson's disease patients than in the control subjects. The fall in orthostatic blood pressure was reduced by a previous meal. In contrast, there was no difference in orthostatic heart rate responses between the patients and the controls. CONCLUSIONS: Parkinson's disease patients demonstrated a significant postprandial drop in SBP and a tendency towards orthostatic hypotension, which was not worsened by the meal, probably owing to a stronger sympathetic activation. Postprandial supine SBP change and orthostatic SBP responses were only moderately associated in Parkinson's disease patients. In addition to autonomic dysfunction, an increased baseline SBP level might contribute to both phenomena.     

Factors influencing the results in the treatment of patients with femoral neck fractures (author's transl)

The results of 213 consecutive operatively treated patients with fractures of the femoral neck were evaluated. Especially the effects of improved operative technique, careful pre- and postoperative care and intensified rehabilitation were observed. The series consisted of 151 women and 62 men, 111 femoral neck fractures and 102 trochanteric fractures. Nailing was performed on 54 femoral neck fracture patients and endoprothesis operation on 57 patients. No statistically significant differences were proved when the two consecutive two years series were compared with one another concerning the nailing results and the frequence of thrombosis and infection. However, by means of early weight-bearing and improved pre- and postoperative care the 6 months mortality decreased statistically significantly (chi2 = 6.58, p less than 0.05).     

Prevalence of reduced bone mineral density in systemic lupus erythematosus and the role of steroids

OBJECTIVE: To determine the prevalence of reduced bone mineral density (BMD) in a large female cohort of systemic lupus erythematosus (SLE) and to determine the role of steroids and disease related variables. METHODS: All females with SLE managed by rheumatologists affiliated with a single center were invited to undergo BMD measurement of the lumbar spine and left femoral neck by dual energy X-ray absorptiometry (DEXA), standardized examination, and medical record review. RESULTS: Ninety-seven females with a mean (SD) age of 44.2 (14.9) years were studied. Low bone mass [defined as BMD > 1 standard deviation (SD) below young adult mean] was present in 44.3 and 42.1% at the lumbar spine and femoral neck, respectively. Osteoporosis (defined as BMD > 2.5 SD below young adult mean) was present in 13.4 and 6.3% at the lumbar spine and femoral neck, respectively. Steroid usage showed a strong inverse relationship with BMD in the lumbar spine, but a less strong relationship in the femoral neck. CONCLUSION: The findings of high prevalence of reduced BMD and association with steroid therapy have important implications for the routine management of SLE.     

Learning and forgetting processes in Parkinson's disease: a model-based approach to disentangling storage, retention and retrieval contributions

Learning and forgetting a prose passage was studied in 20 patients with Parkinson's disease and in 20 normal control subjects by means of stochastic models, with the aim of identifying the learning and retaining abilities that are affected by Parkinson's disease. Results suggested that Parkinson's disease patients are impaired in developing automatic processing both during learning and retaining, while functions that require active attention are spared. The automatic/intentional dissociation, which is the hallmark of motor disturbance in Parkinson's disease, extends to memory abilities, and, on the grounds of neuroanatomical, neurochemical and neurophysiological correlates, suggests that the memory deficit in Parkinson's disease may be contingent on a dysfunction of the medial prefrontal-cingulate cortex.