A multifaceted intervention to improve treatment of osteoporosis in postmenopausal women with wrist fractures: a cluster randomized trial

In a cluster randomized trial, we evaluated the effect of a multifaceted intervention (directed at both patient and primary care physician) on the rates of testing and treatment of osteoporosis in postmenopausal women within six months of their wrist fracture. Compared to usual care, women in the intervention practices were three times more likely to receive bone mineral density testing and prescribed osteoporosis treatments.

INTRODUCTION

Postmenopausal women with wrist fractures are at increased risk of future fragility fractures, yet they frequently do not receive evaluation and treatment for osteoporosis. We set out to evaluate a multifaceted intervention designed to improve management of osteoporosis in older women with recent wrist fractures.

METHODS

Cluster randomized trial of 270 women cared for in 119 primary care practices. We recruited postmenopausal women with an acute wrist fracture from the emergency departments of hospitals in southeastern Ontario, Canada. Family practices were randomly assigned to either the intervention or usual care. The intervention consisted of a mailed reminder with a summary of treatment guidelines and letter sent to the primary care physician, in addition to an educational package and letter to the women. The primary outcome was the proportion of women prescribed osteoporosis therapy within 6 months of their fracture.

RESULTS

The mean age of women was 69(10.9) years. The intervention increased the proportion of women started on osteoporosis medications (28% vs. 10%) of controls, adjusted OR 3.45, 95% CI, 1.58-7.56, p = 0.002) and the proportion who had a bone mineral density (BMD) test (53.3% vs. 26%) of controls, OR 3.38, 95% CI, 1.83-6.26, p < 0.001). In addition to the intervention, having a female physician was a predictor of increased testing and treatment rates.

CONCLUSION

A multifaceted intervention significantly improved rates of osteoporosis treatment and BMD testing in postmenopausal women with wrist fractures.

Magnetic resonance imaging for in vivo assessment of three-dimensional patellar tracking

We have developed a non-invasive measurement technique which can ultimately be used to quantify three-dimensional patellar kinematics of human subjects for a range of static positions of loaded flexion and assessed its accuracy. Knee models obtained by segmenting and reconstructing one high-resolution scan of the knee were registered to bone outlines obtained by segmenting fast, low-resolution scans of the knee in static loaded flexion. We compared patellar tracking measurements made using the new method to measurements made using Roentgen stereophotogrammetric analysis in three cadaver knee specimens loaded through a range of flexion in a test rig. The error in patellar spin and tilt measurements was less than 1.02 degrees and the error in lateral patellar shift was 0.88 mm. Sagittal plane scans provided more accurate final measurements of patellar spin and tilt, whereas axial plane scans provided more accurate measurements of lateral translation and patellar flexion. Halving the number of slices did not increase measurement error significantly, which suggests that scan times can be reduced without reducing accuracy significantly. The method is particularly useful for multiple measurements on the same subject because the high-resolution bone-models need only be created once; thus, the potential variability in coordinate axes assignment and model segmentation during subsequent measurements is removed.

Underestimation of meningococci in tonsillar tissue by nasopharyngeal swabbing

The relation between carriage of Neisseria meningitidis and progression to invasive disease is not fully understood. We assessed the rate of N. meningitidis carriage by conventional swabbing and immunohistochemistry in patients undergoing tonsillectomy. Swabbing detected only a quarter of carriers, and bacteria were identified beneath the mucosal surface in tonsillar tissue by immunochemical testing. Our results indicate that N. meningitidis is more widespread in the population than previously thought, and have broad implications for disease prevention and cure.

A surgical planning and guidance system for high tibial osteotomy

OBJECTIVE

To develop a three-dimensional pre-surgical planner and an intraoperative guidance system for high tibial osteotomy. The parameters that describe the placement and orientation of the osteotomy resection planes were to be transmitted to an accompanying guidance system that allowed the surgeon to reproducibly perform the planned procedure.

MATERIALS AND METHODS

The planning system and guidance system were coded using OpenGL on UNIX workstations. In vitro tests were performed to compare the reproducibility of the computer-enhanced technique to that of the traditional technique, and an in vivo pilot study was initiated.

RESULTS

In vitro, the computer-enhanced technique produced a significant reduction, by one half, in both the maximum error of correction and the standard deviation of the correction error. Preliminary in vivo results on six patients suggest that similar error diminution will occur during regular clinical application of the technique.

CONCLUSIONS

Both studies showed that the computer system is simple to use. The work suggests that three-dimensional planning and performance of high tibial osteotomy is essential for accurate correction of the alignment of the lower limb.

Comparison of chromosome 1 aneusomy detected by interphase cytogenetics and DNA ploidy in carcinoma of the breast

Aneuploidy is an important prognostic factor in many cancers. Chromosome 1 abnormalities are present in most breast carcinomas. These may be part of a non-specific increase in DNA (aneuploid status) or represent a restricted chromosomal abnormality. In 16 breast carcinomas we compared chromosome 1 aneusomy with ploidy status. Patients were selected from a mammographically screened population and interphase tumour nuclei were studied by in situ hybridization using a chromosome 1 pericentromeric probe. Ploidy status was assessed by image cytometry on disaggregated cells from paraffin blocks. Of eight cases showing chromosome 1 aneusomy, six (75%) were aneuploid and two diploid. Six (75%) of the eight eusomic cases were aneuploid. This study demonstrates that chromosome 1 aneusomy does not always reflect a gross aneuploid status but, in some tumours, is part of a more restricted chromosomal abnormality. Interphase cytogenetics, possibly using a small panel of pericentromeric probes, may be more sensitive than DNA cytometry for detecting abnormal nuclear DNA content.

Patterns of knee arthrosis and patellar subluxation

This study was based on the unexpected observation of lateral patellofemoral subluxation in the varus osteoarthritic knee. Standardized radiographs of 109 knees (65 patients with osteoarthritis) were selected randomly from the authors' database and retrospectively reviewed. Hip-knee-ankle alignment data were correlated with patellofemoral subluxation and tilt, as well as with radiographic patellofemoral grades for arthrosis. The amount and site of patellofemoral arthrosis were correlated with patellar position and limb alignment. Patellae that were located centrally in the trochlear groove had the lowest radiographic score for arthrosis. Subluxation of the patella, either medially or laterally, was correlated with increased radiographic scores. Limb alignment was not correlated with the radiographic score. A significant percentage of varus knees (28%) had unexpected lateral subluxation of the patella. This observation has not been reported previously. It may have an impact on surgical decision-making for total knee arthroplasty and osteotomy.

Phase behavior and arrangement of molecular species in mixtures of a mixed chain and a symmetric phosphatidylethanolamine in the gel and fluid phases

1-Octadecanoyl, 2-decanoylphosphatidylethanolamine (C(18:0)C(10:0)PE) has been reported to exhibit mixed interdigitated gel-phase packing of the phospholipid acyl chains (Mason, J.T. and Stephenson, F.A. (1990) Biochemistry 29, 590-598). In contrast, ditetradecanoylphosphatidylethanolamine (C(14:0)C(14:0)PE) packs without significant interdigitation of the phospholipid acyl chains across the bilayer center. In this report, the gel-fluid transition temperatures of C(18:0)C(10:0)PE and C(14:0)C(14:0)PE in multilamellar dispersions were determined by fluorescence anisotropy of cis-parinaric acid and trans-parinaric acid with a descending temperature scan rate of 0.67 degrees C/min. The transition mid-points detected for C(18:0)C(10:0)PE with cis-parinaric acid were 19 degrees C in water, 18 degrees C at pH 8.1, and 14 degrees C at pH 10. The phase diagram for C(14:0)C(14:0)PE and C(18:0)C(10:0)PE at pH 10 suggests complete mixing in the fluid phase and considerable immiscibility in the gel phase. Cross-linking of equimolar mixtures of C(14:0)C(14:0)PE and C(18:0)C(10:0)PE with dimethylsuberimidate at pH 10 revealed a random arrangement of the two species in the fluid phase, confirming the notion that C(18:0)C(10:0)PE and C(14:0)C(14:0)PE are miscible in the fluid phase, as determined from the phase diagram. In contrast, cross-linking of the equimolar mixture of C(18:0)C(10:0)PE and C(14:0)C(14:0)PE in the gel phase at 0 degrees C revealed a non-random arrangement, demonstrating and confirming immiscibility in the gel phase.