Evaluation of ability of biochemical markers of bone turnover to predict a response to increased doses of HRT

Antiresorptive therapy is usually given in a fixed dose, and we hypothesized that some patients receiving standard doses of hormone replacement therapy (HRT) might benefit from a higher dose, particularly if their bone turnover decreases after increasing the dose of HRT. Eighty-eight women who had been receiving standard-dose (0.625 mg/day) conjugated equine estrogens (CEE) for at least one year were randomized to take either standard-dose (0.625 mg/day, n = 36) or high-dose (1.25 mg/day, n = 52) therapy. Subjects with a uterus were allowed to take either 10 mg of medroxyprogesterone cyclically or 5 mg daily, according to personal preference. Bone Mineral Density (BMD) and biochemical markers of bone turnover were followed for 2 years. Mean bone turnover decreased significantly (-4.1% to -19.1%) after 6 months of high-dose CEE. Decreases in serum BSAP (bone-specific alkaline phosphatase) and serum or urine NTX ( N-terminal telopeptide crosslink of type I collagen) on high-dose therapy were not predictive of an improvement in BMD, but a decrease in serum CrossLaps did predict an improvement in BMD. Mean change in BMD in subjects with a significant decrease in serum CrossLaps at the anteroposterior spine was 3.1% +/- 3.9% versus 1.2% +/- 2.9% for subjects with no significant change in CrossLaps, P < 0.02. There was, however, a wide range of changes in BMD in patients with or without a significant change in CTX on high-dose HRT, making it impossible to predict an improvement in BMD based on an individual's changes in turnover. Measuring of bone density and bone turnover with better precision might be more successful in guiding individual dosing of antiresorptive therapy.

A.T.L.S. on the ski slopes--a steamboat experience

The Steamboat Mountain Ski Patrol incorporates local emergency physicians and a visiting trauma surgeon as a second-tier response to life-threatening mountain events. The case of a 48-year-old man surviving a potentially lethal postinjury tension pneumothorax and a review of the 1989-1990 major trauma experience on this ski mountain underscores the value of this concept.

Pseudoexfoliative fibrillopathy in the conjunctiva. A relation to elastic fibers and elastosis

Pseudoexfoliative (PSX) material in the conjunctiva was found to have a close association with elements of the elastic system in 13 eyes of patients with PSX disease studied ultrastructurally. Pseudoexfoliation aggregates were rare within vascular walls but frequent in proximity to the plasmalemma of stromal fibroblasts. No amyloid was found. A striking feature was the association of PSX fibers with the elastosis seen in many of the specimens. Typical PSX fibers were present in clumps of oxytalan and around small elastic fibers. In five cases with more advanced elastosis, the aggregates of PSX fibers were larger and their usual loose fibrogranular matrix was extensively replaced by a dense elastotic one. Morphology of PSX here varied from typical to thicker, fragmented, and sometimes nondiagnostic fibers. This intermingling of PSX and elastotic materials suggested that PSX fibrillopathy is itself a type of elastosis, possibly resulting from abnormal aggregation of components related to elastic microfibrils.

Bile duct dyskinesia. Clinical and manometric study

Unexplained right upper quadrant symptoms have often been attributed to bile duct dyskinesia. In this study we evaluated the pressure profile of the sphincter of Oddi in 10 patients with recurrent episodes of right upper quadrant pain, intermittent mild transaminasemia, and a normal pancreatobiliary tract. Nine healthy volunteers served as control. A triple-lumen catheter with an external diameter of 1.7 mm and recording sites at 2-mm intervals was introduced into the papilla through the endoscope. Ductal pressure, basal sphincter of Oddi pressure, and the amplitude and propagation direction of the phasic contractions of the sphincter were determined in patients and subjects. All measurements were performed relative to duodenal pressure, which was taken as zero. There was no significant difference between patients and subjects in the amplitude and frequency of phasic contractions of sphincter of Oddi. In contrast, the patients demonstrated a higher sphincter of Oddi pressure (p less than 0.005) and increased proportion of retrograde propagation direction of phasic contractions (p less than 0.01). It is concluded that a subpopulation of patients with unexplained abdominal pain demonstrated abnormal pressure profile of the sphincter of Oddi.

The portable Doppler: practical applications in EMS care

The practical application of a new, commercially available, portable Doppler ultrasound device to the operation of a busy city-county emergency department and ambulance service was investigated. An initial evaluation using healthy volunteers confirmed accuracy and reproducibility of the Doppler blood pressure readings comparable to that of auscultatory and palpatory measurement. In selected patients, the Doppler readings correlated well with readings from patients who had intra-arterial lines. When used in several low flow states, such as testing adequacy of cardiopulmonary resuscitation (CPR) and verification of electromechanical dissociation, the Doppler aided the clinical evaluation and treatment in many cases where traditional methods were useless. The Doppler was also helpful in the evaluation of local arterial injury but this unit was not found sensitive enough for venous disease. Finally, the Doppler enhanced the obtaining of vital signs in the noisy environment of our ambulances.