Campaigns to reduce mental illness stigma in Europe: a scoping review

Background: Evidence has emerged in recent decades about effective and ineffective methods to reduce mental illness related stigma and discrimination. As more European countries start national anti-stigma campaigns, there is potentially more to learn from their experiences, but also a risk that, with such rapid developments, lessons may be missed.

Aim: This scoping review aims to identify and discuss European stigma reduction campaigns conducted to date.

Methods: We searched electronic databases, hand-searched reference lists of identified articles and contacted stigma experts to enquire about ongoing initiatives.

Results: We identified anti-stigma campaigns in 21 European countries and regions. We found considerable variation in their content, delivery formats, duration and target groups.

Conclusions: Although anti-stigma campaigns have been implemented in many European countries, the level of attention paid to sharing lessons learned is variable. It is vital that campaigns are evaluated, to maximise their potential impact both on the target population, and that the findings are disseminated widely to allow international learning.

Viewpoint survey of mental health service users' experiences of discrimination in England 2008-2012

PURPOSE

Research suggests levels of discrimination among mental health service users in England are high, but fell over the course of the first phase of the Time to Change programme to reduce stigma and discrimination (2008-2011). The aim of this study was to determine changes in discrimination levels, both overall and by the area of life in which discrimination is experienced, since Time to Change began and over the first year of its second phase (2011-2012).

METHOD

Separate samples of mental health service users were interviewed annually from 2008 to 2012 using the Discrimination and Stigma Scale. In 2011 and 2012, social capital was also measured using the Resource Generator-UK.

RESULTS

Sample percentages of participants reporting the experience of discrimination in one or more life areas for years 2008-2012 were 91.4, 86.5, 86.2, 87.9 and 91.0 %, respectively. A multivariable logistic regression model was performed to test for significant differences by study year, weighted to match the study population and adjusted for employment status and diagnosis as potential confounding factors. The odds of reporting discrimination in one or more life areas were significantly lower as compared to 2008 for all subsequent years except for 2012 (0.76, 95 % CI 0.49-1.19). However, a weighted multiple regression model provided evidence of decreased mean overall discrimination in 2012 as compared to 2008 (mean decrease -7.57, 95 % CI -11.1 to -4.0, p < 0.001). The weighted mean number of social resources was 13.5 in 2012 as compared to 14.0 in 2011 (mean difference -0.60, 95 % CI -1.25 to 0.06).

CONCLUSIONS

While the overall level of discrimination across the life areas studied has fallen over 2008-2012, there is no evidence that more people using mental health services experience no discrimination. We suggest that the pattern suggesting a recent rise in discrimination following an earlier reduction may be linked to economic austerity. Further, the welfare benefits system has become an increasing source of discriminatory experience.

The hinged back plate mechanism in glassy wax tests of New Zealand male soft scale insects (Hemiptera: Coccoidea: Coccidae)

Male scale insects (Hemiptera: Coccoidea) undergo a metamorphosis of the neometabola type, from scale-like nymph through prepupa and pupa to winged adult. The nymphal instar before prepupa secretes a waxy protective covering that remains in place throughout metamorphosis and these covers are characteristic of each family of scale insects. Most scale insect families (e.g. mealybugs, eriococcids, diaspidids) have rather loosely woven male covers, but male nymphs in the family Coccidae (soft scales) construct more rigid, glassy wax tests, which need a special mechanism for adult emergence. In the New Zealand male soft scales, a suture across the posterior quarter of the test enables the back plate to flex at a pair of hinges, to be raised up off the substrate, and so allow egress. The waxy back plate hinges are secreted by groups of tubular ducts on the abdominal dorsum of 2nd-instar males, during construction of the test. Scanning electron micrographs (SEMs) show the detail and diversity of hinge types. The wax tests of most New Zealand Coccidae, both female and male, are apparently unique in that they are constructed in rows of hexagonal plates, separated by sutures, however in the male test, the sutures are all fused except for the back plate suture. The two species in the endemic New Zealand genus Pounamococcus have male tests more like those of species in the Australian genus Austrolecanium.

Health status of children with moderate to severe cerebral palsy

The aim of the study was to evaluate the health of children with cerebral palsy (CP) using a global assessment of quality of life, condition-specific measures, and assessments of health care use. A multicenter population-based cross-sectional survey of 235 children, aged 2 to 18 years, with moderate to severe impairment, was carried out using Gross Motor Function Classification System (GMFCS) levels III (n = 56), IV (n = 55), and V (n = 122). This study group scored significantly below the mean on the Child Health Questionnaire (CHQ) for Pain, General Health, Physical Functioning, and Impact on Parents. These children used more medications than children without CP from a national sample. Fifty-nine children used feeding tubes. Children in GMFCS level V who used a feeding tube had the lowest estimate of mental age, required the most health care resources, used the most medications, had the most respiratory problems, and had the lowest Global Health scores. Children with the most severe motor disability who have feeding tubes are an especially frail group who require numerous health-related resources and treatments. Also, there is a relationship among measures of health status such as the CHQ, functional abilities, use of resources, and mental age, but each appears to measure different aspects of health and well-being and should be used in combination to reflect children's overall health status.

Dual X-ray absorptiometry assessment of body composition in children with altered body posture

Many children have contractures and/or deformities that preclude positioning in a fully supine position. The purpose of this study was to evaluate the effects of "poor" positioning on the assessment of body composition with dual X-ray absorptiometry (DXA) in thirty-seven normal child volunteers ages 3-16 yr. Multiple whole-body DXA scans of each child were performed: duplicate scans in the correct fully supine position, two scans while simulating different positions typical of children with contractures, and a scan while positioned in the full lateral position as a "worst-case" scenario. Also evaluated were the precision of duplicate measures in the altered positions, the effect of knee flexion contractures, and the impact of metallic orthopedic fixation devices. Errors in body composition assessment did occur from "poor" positioning. In those positions simulating children with contractures, the mean errors were 4-6% for measures of bone mineral content, 1-3% for lean body mass, and 5-11% for fat mass. Measures in the correct fully supine position and the contracted positions were highly correlated. The errors obtained by altering position were small. If errors of this magnitude are of significance, then corrective equations could be utilized to improve accuracy. Precise and reasonably accurate measures of body composition can be obtained with DXA in children with disabilities and deformities that preclude fully supine positioning.

Bone mineral density 6 years after a hip fracture: a prospective, longitudinal study

The purpose of this prospective study was to extend the results of previous studies to determine if an accelerated rate of loss of bone mineral density (BMD) continues for 6 years after a hip fracture. Eighty-five elderly patients who had sustained a hip fracture had determinations of BMD made at the time of fracture; 55 of these patients were available for reassessment of BMD 1 year later, and 21 were available for reassessment of BMD 6 to 7 years later. The change in BMD from injury to 1 year and from 1 to 6 years was determined and correlated with pre- and postinjury variables, such as ambulatory ability, dietary intake of calcium, serum vitamin D levels, and mental status. There was a marked decrease in BMD in the in the first year after fracture, with the mean change in BMD being -4.3% at the femoral neck and -1.8% at the lumbar spine. Between 1 and 6 years after fracture, however, there was a dramatic increase in the BMD at both the femoral neck and lumbar spine measurement sites. Relative to 1 year after fracture, the mean increases were 7.7% at the femoral neck and 4.5% at the lumbar spine. In many cases, the loss of bone mineral that occurred in the first year after fracture was completely recouped in the subsequent 5 years. Five of the 21 patients (24%) sustained a contralateral hip fracture in the 6 years after the index fracture. Lumbar spine BMD was lower at baseline (p = 0.112), 1 year after fracture (p = 0.007), and 6 years after fracture (p = 0.003) in patients who sustained a second hip fracture than in those who did not. There was a general decrease in the functional activity level of patients in the 6 years after a hip fracture, but there were no statistically significant relationships between changes in BMD and the functional mobility of patients. The mean calcium intake in patients improved remarkably in the 6 years after fracture, but there was no correlation between daily calcium intake and changes in BMD. During the first year after a hip fracture, there is a rapid loss of bone mineral from the lumbar spine and contralateral femoral neck. Between 1 and 6 years after fracture, however, BMD is likely to increase, perhaps to levels greater than those at baseline. Although this investigation is small, the findings of this study point to the importance of further larger studies to further clarify the natural history of BMD after a hip fracture and the potential impact of pharmacological intervention on that natural history.

Bone mineral density and fractures in boys with Duchenne muscular dystrophy

The relationships between bone density, mobility, and fractures were assessed in 41 boys with Duchenne muscular dystrophy. Bone density in the lumbar spine was only slightly decreased while the boys were ambulatory (mean z-score, -0.8), but significantly decreased with loss of ambulation (mean z-score, -1.7). In contrast, bone density in the proximal femur was profoundly diminished even when gait was minimally affected (mean z-score, -1.6), and then progressively decreased to nearly 4 standard deviations below age-matched normals (mean z-score, -3.9). These are consistent with the findings that 18 (44%) of the boys sustained a fracture, 66% of these fractures involved the lower extremities, and there were no spinal compression fractures. Furthermore, four (44%) of nine boys who were walking with aids or support at the time of fracture never resumed walking after the fracture. Osteoporosis is most profound in the lower extremities of boys with Duchenne muscular dystrophy, and begins to develop early while still ambulating. Frequent fractures that may result in loss of ambulation are the clinical consequences.

Bone mineral content and body composition in children and young adults with cystic fibrosis

With dual energy X-ray absorptiometry (DEXA), it is possible to quantitate important aspects of growth in children with cystic fibrosis (CF), supplementing the usual measures of height and weight. Of particular concern during growth is the accumulation of bone mineral, since osteoporosis and fractures are well-recognized problems in end-stage disease. Various measures of growth and body composition were examined in 40 children and young adults (ages 5.7-20.3 years, mean 11.9 years) and compared to age-, gender-, and race-matched normal controls. The mean (+/- SE) weight Z-score of the 40 CF patients was -0.70 +/- 0.11, and the mean height Z-score was -0.66 +/- 0.15. Relative to their matched normal controls, the CF patients had a deficit in total body bone mineral averaging 19.1% +/- 3.0%. The deficits in total body bone mineral correlated with pulmonary and nutritional measures of disease severity. Serum vitamin D levels, calcium intake, age, gender, use of steroids, and CF genotype were not found to be significant factors. In this group of children and young adults with CF, height and weight measures of growth were not dramatically reduced (mean Z-scores = -0.7), yet large deficits in total body bone mineral averaging nearly 20% were identified.

Longitudinal evaluation of bone mineral density in children receiving chemotherapy

PURPOSE

Some children who survive a childhood malignancy have diminished bone mineral density (BMD). The purpose of this study is to assess when, and perhaps why, this problem develops.

PATIENTS AND METHODS

BMD was longitudinally monitored in 37 children for a minimum of 1 year (mean, 23.4 months; range, 12 to 41 months) during and, in some cases, after chemotherapy. Evaluations included serum analyses (vitamin D, calcium, and alkaline phosphatase), assessment of calcium intake, and measures of growth and nutrition (height, weight, and skinfolds).

RESULTS

BMD was already diminished at the start of treatment in some patients; 6 of 13 patients (46%) had a BMD z score in the hip or spine of < -1.0. However, only 1 patient (8%) was < -2.0. Most patients did not have a significant drop in BMD z scores during chemotherapy, but one in four did decrease at least 0.5 standard deviations. Age greater than 10 years, a drop in height z score, and treatment with cranial irradiation correlated with a drop in BMD z scores during treatment. In the year immediately after completion of chemotherapy, no consistent "catch-up" was observed in BMD z scores.

CONCLUSIONS

In some patients, BMD z scores are diminished at the time of diagnosis and a drop may occur during treatment in others. Multiple factors related to the disease process and treatment likely contribute to these observations. Cranial irradiation, perhaps by impacting on growth hormone homeostasis, is one such factor. Fortunately, most survivors of a childhood malignancy will not have large deficits in BMD later in life.

Lateral femoral scan: an alternative method for assessing bone mineral density in children with cerebral palsy

BACKGROUND

Children with cerebral palsy (CP), often nonambulatory and/or on anticonvulsants, are at increased risk for fractures. Bone mineral density (BMD) measured by the conventional techniques of dual-energy X-ray absorptiometry (DXA) often cannot be reliably or easily measured in these patients.

OBJECTIVE

To find an alternative site to whole body, spine and hip that can be conveniently used to measure BMD in CP patients.

MATERIALS AND METHODS

Having observed that CP patients prefer to lie on their sides, we explored measuring BMD at the distal femur in the lateral projection. A total of 92 scans were performed without sedation in 34 children and adolescents with CP, aged 4-19 years. Four femoral shaft subregions were created: two trabecular and two cortical.

RESULTS

The coefficients of variation (CV %) were generally higher for opposite-side comparisons (n = 12 patients) than for same-side comparisons (n = 16 patients). For intra- and interobserver analyses, CV % were higher for cortical regions than for trabecular regions. Overall, the CV % were similar to those for hip and spine.

CONCLUSION

This peripheral site in the femur should be considered as an alternative for patients with CP when whole-body, hip and spine DXA are not practical.

Vitamin D levels in noninstitutionalized children with cerebral palsy

Calcitriol (1,25-dihydroxy vitamin D) is an important hormone in calcium and phosphate metabolism. Levels of calcitriol and its precursor, 25-hydroxy vitamin D (calcidiol), were measured in a heterogeneous group of 125 noninstitutionalized children and adolescents with spastic cerebral palsy. Levels of each were correlated with: (1) clinical factors including mobility, prior fracture, and use of anticonvulsants; (2) nutrition and growth parameters including skinfolds, body mass index, and use of vitamin supplements; and (3) other serum analyses including osteocalcin as a marker of bone formation, calcium, and alkaline phosphatase. Levels of calcidiol and calcitriol did not correlate with any of the various clinical, nutritional, or growth parameters examined. The prevalence of low (< 10 ng/mL) levels of calcidiol was significant (19%), and dependent on the season of the year in which the level was measured. In contrast, less than 2% of the patients were found to have a low (< 20 pg/mL) level of calcitriol and the mean was comparable to normal pediatric subjects. Levels of calcitriol are maintained in noninstitutionalized children with cerebral palsy despite anticonvulsants, poor nutrition, and calcidiol levels that vary greatly with the seasons.

The correlation between dual-energy X-ray absorptiometry measures of bone density in the proximal femur and lumbar spine of children

OBJECTIVE

To assess the correlation between a pediatric patient's proximal femur and lumbar spine bone mineral density (BMD) Z-scores, and the side-to-side difference between proximal femurs.

DESIGN

Three hundred and thirty-nine patients aged 2.2-17.0 years with an assortment of underlying conditions underwent dual-energy X-ray absorptiometry (DXA) measures of BMD in both proximal femurs and the lumbar spine.

RESULTS

Z-scores in the proximal femur and lumbar spine correlated highly (r = 0.73, P = 0.0001), but for individual patients the difference was often significant, and increased as BMD deviated further from normal. For patients with proximal femur Z-scores of 1 to -1 the mean difference between proximal femur and lumbar spine Z-scores was 0.5; with proximal femur Z-scores of less than -3 the mean difference was increased to 1.7. In conditions which symmetrically involve the lower extremities, the right and left proximal femur Z-scores differed on average by only 0.2.

CONCLUSION

BMD measurements for pediatric patients are most easily interpreted by clinicians if converted to Z-scores, yet these are usually available only for the lumbar spine. Age-normalized BMD assessment at more than one site is necessary to provide a more reliable, complete assessment of bone mineral status in pediatric patients.

Accelerated bone mineral loss following a hip fracture: a prospective longitudinal study

The purpose of this prospective study was to monitor the bone mineral density (BMD) of the lumbar spine and contralateral femoral neck in the first year following an osteoporosis-related fracture of the hip. Eighty-three elderly patients (mean age 77 years) who had sustained a hip fracture had determinations of BMD made at the time of fracture; 49 of these patients were available for reassessment of BMD 1 year later. The change in BMD was correlated with pre- and postinjury variables, such as ambulatory ability, dietary intake of calcium, serum vitamin D levels, mental status, and routine serologies. The mean decrease in BMD in the year following fracture was 5.4% from the contralateral femoral neck and 2.4% from the lumbar spine. Calcium intake correlated with the loss of BMD from the femoral neck (p = 0.015), but not the lumbar spine. Patients with daily calcium intakes of less than 500 mg/day had a more than 10% decrease in femoral neck BMD in the year following their hip fracture. Serum 1,25-dihydroxy vitamin D level correlated with loss of MBD from the lumbar spine (p = 0.001), but not from the femoral neck. There was no correlation between the loss of bone mineral from either measurement site and age, sex, level of ambulation, or mental status. The loss of BMD from the femoral neck in the year following a hip fracture is more than five times that reported in the nonfractured population. This accelerated rate of loss can have drastic consequences in an elderly population already exhibiting osteopenia and propensity to fall. Investigation of pharmacologic or other interventions in the first critical year following a hip fracture may potentially blunt this accelerated rate of bone loss and lessen the risk of subsequent fractures.

Calcium intake in children with positive IgG RAST to cow's milk

OBJECTIVE

This study was made to: (i) identify the prevalence of low calcium intakes in a paediatric population with loosely defined 'milk allergy'; and (ii) assess long-term (mean 21 months later) changes in calcium intake following a single nutrition counselling session with those patients initially found to have a low intake.

METHODOLOGY

Calcium intake was assessed in a cross-sectional study of 58 patients ages 5-16 years (mean 9.9 years) with IgG radioallergosorbent test (RAST) class II or higher for cow's milk protein. Those 31 patients found to have a low calcium intake were prospectively re-evaluated 12-30 months later following a single nutrition counselling session.

RESULTS

Calcium intake was < recommended dietary allowance (RDA) for 31 of 58 (53%) patients. The patient's perception of their intake was unreliable; 44% of those who rated their calcium intake fair or good did not meet their RDA. Taking a calcium supplement did not ensure adequate intake; 21% of those taking supplements still did not meet their RDA. Milk intake predicted calcium intake; 8% of those who did not drink milk vs 68% of those who did drink at least some milk met their RDA without supplementation. The 31 patients with low intakes received counselling and were re-evaluated at an average follow-up of nearly 2 years. Calcium intake was increased a mean of 360 mg/day and use of supplements increased from 10 to 52% of the group. Despite these positive changes, 48% still did not meet their RDA.

CONCLUSION

Limited milk intake is likely to be associated with suboptimal calcium intake. Efforts should be made to educate the family about the importance of calcium and its non-dairy sources. With many families repeated discussions of this issue may be necessary to influence calcium intake.

Bone density and other possible predictors of fracture risk in children and adolescents with spastic quadriplegia

Forty-three patients with spastic quadriplegia (mean age 7.9 years, range 3.3 to 17.2 years) underwent bone mineral density (BMD) measurement of the lumbar spine and were evaluated between 2.6 and 5.5 years (mean 3.8) later to determine whether this measurement had predicted risk of fracture over the subsequent period of observation. Other potential risk factors that were evaluated include body weight z score, serum vitamin D levels, previous fracture, and hip spica casting. The baseline measurements showed that BMD falls further below normal with increasing age and was more than one standard deviation below age-matched normal mean in 38 of the 43 patients. Fracture rate did not differ between those with low and those with very low spinal BMD. Similarly, serum vitamin D levels and body weight z scores were not predictive of fracture. However, fracture rate was over fourfold greater following spica casting and more than threefold greater following an initial fracture. Fracture rates in the study group were similar to those reported for age- and sex-matched normal children, though generally the location of the fractures and mechanisms of injury differed.

Vitamin D levels in children with cystic fibrosis

Serum levels of the important hormone 1,25-dihydroxyvitamin D (1,25-diOHD, calcitriol) have not been extensively evaluated in patients with cystic fibrosis (CF) during the critical period of skeletal growth and development. This study was a cross-sectional, observational assessment of 25-hydroxyvitamin D (25-OHD, calcidiol) and 1,25-diOHD levels in 54 patients with CF. The patients' ages ranged from 4.9 years to 19.5 years (mean, 11.0 years). Levels were correlated with pulmonary function tests, chest x-ray scores, height and weight Z scores, skinfold percentiles, CF genotype, serum chemistries, and use of a vitamin supplement. Levels were compared with those in more than 160 other pediatric patients living in the same region, and all assays were done in the same laboratory. Despite low-normal levels of the 25-OHD precursor, there was a high prevalence of low (18%) and marginal (18%) levels of 1,25-diOHD. None of the various parameters examined correlated with either 25-OHD or 1,25-diOHD levels. The cause, clinical significance, and treatment of low levels of this important hormone in children with CF warrant further study.

Bone density in survivors of childhood malignancies

PURPOSE

The purpose of this study was to assess bone mineralization in survivors of childhood malignancies.

PATIENTS AND METHODS

Bone mineral density (BMD) of the lumbar spine was measured in 60 patients aged 5.5-20.1 years (mean, 12.4 years) who had no known disease 1.0-14.5 years (mean, 4.3 years) after completing treatment for a malignancy. The age-normalized BMD findings (Z scores) were correlated with multiple variables, including measures of growth and nutrition, type of malignancy, and various treatments, including use of steroids, methotrexate, or cranial irradiation.

RESULTS

BMD was normal in most patients with a mean Z score of -0.28 + 0.14 (+/- SE). Only 8% of the patients were more than 2 SDs below age-matched normal BMD. Weight Z score was the major determinant of BMD Z score. Calcium intake and height Z score were also important variables.

CONCLUSIONS

Most survivors of childhood malignancies will not be left with a clinically significant deficit in BMD. Risk factors for diminished BMD include low-weight and low-height Z scores and low calcium intake. Therapeutic interventions are available to address these risk factors in those patients with significantly diminished BMD.

Bone mineralization in the affected extremities of children with spastic hemiplegia

To assess the impact of neurologic involvement on bone mineralization, dual-energy X-ray absorptiometry was used to quantitate bone mineral content (BMC), bone mineral density (BMD), fat and lean muscle mass in the limbs of 19 children with spastic hemiplegic cerebral palsy. The BMC in the affected limb was on average 26.5% lower (upper limbs) and 15.6% lower (lower limbs) than in the corresponding uninvolved limb. Lean muscle mass was reduced by 15% and BMD by 6% in the involved limbs and did not differ significantly between upper and lower limbs. The fat content of involved and uninvolved limbs did not differ. Children with poor hand function had greater reductions in BMC (39.3%), BMD (11.3%) and lean muscle mass (22.5%) than did children with better hand function. Thus, bone size and density decrease with increasing neurologic involvement, and weight bearing may slightly lessen the effect.

Isokinetic strength following knee arthroscopy

This study objectively evaluates recovery of quadriceps and hamstring strength following knee arthroscopy in a group of 43 patients given rehabilitation instructions, but limited supervised rehabilitation. Although the patients did not complain of weakness or functional limitation, isokinetic testing 1, 3, and 8 weeks following surgery revealed persistent weakness in many patients. Incomplete recovery was most apparent when patients were categorized by the degree to which they had recovered normal strength. Results expressed as a mean for the entire group indicated reasonably good recovery and obscured the significant weakness persisting in some patients. Knee extension strength tested at 60 degrees/sec had returned to normal 8 weeks after arthroscopy in only 32% of the subjects. Hamstring strength recovery was better, with 71% having normal strength. Patients may not recognize or report muscular weakness following arthroscopy, yet following 8 weeks of self-supervised rehabilitation many will have objective evidence of persistent weakness. In asymptomatic patients the clinical significance of this weakness is unknown.

Bone density in children and adolescents with cystic fibrosis

OBJECTIVE

To assess bone mineralization in children and adolescents with cystic fibrosis.

DESIGN

A cross-sectional, observational study of bone mineral density (BMD) in the lumbar vertebrae and the proximal femur of 62 patients aged 4.9 to 17.8 years (mean, 10.7 years). The age-normalized BMD findings (z scores) were correlated with multiple variables, including measures of pulmonary disease, nutritional status and growth, genotype, calcium intake, and serum 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D levels.

RESULTS

The mean BMD z score was -1.03 +/- 0.14 (+/- SE) in the lumbar vertebrae and -0.71 +/- 0.17 in the proximal femur. The BMD in this age range declined relative to normal values at a rapid rate of roughly 1 SD every 6 to 8 years. The BMD z scores correlated well with multiple measures of disease severity, particularly weight and forced expiratory volume in 1 second.

CONCLUSIONS

Significant osteoporosis in adults with CF results at least in part from a failure to accumulate bone mineral at a normal rate during skeletal growth and development. The cause of this is likely multifactorial. With increasing longevity, the skeletal consequences of CF become an important consideration.

Bone-mineral density in children and adolescents who have spastic cerebral palsy

Bone-mineral density was studied in a heterogeneous group of 139 children (mean age, nine years; range, three to fifteen years) who had spastic cerebral palsy. The evaluation included serum analyses and a nutritional assessment based on a dietary history and anthropometric measurements. The bone-mineral density of the proximal parts of the femora and the lumbar spine was measured with dual-energy x-ray absorptiometry and was normalized for age against a series of ninety-five normal children and adolescents who served as controls. Bone-mineral density varied greatly but averaged nearly one standard deviation below the age-matched normal means for both the proximal parts of the femora (-0.92 standard deviation) and the lumbar spine (-0.80 standard deviation). Ambulatory status was the factor that best correlated with bone-mineral density. Nutritional status, assessed on the basis of caloric intake, skinfolds, and body-mass index, was the second most significant variable. The pattern of involvement, durations of immobilization in a cast, and a calcium intake of less than 500 milligrams per day were additional factors of less significance. The age when the child first walked, previous fractures, use of anticonvulsants, and serum vitamin-D levels did not correlate with bone-mineral density after adjustment for covariance with the ambulatory status and the nutritional status. Serum levels of calcium, phosphate, alkaline phosphatase, and osteocalcin were not reliable indicators of low bone-mineral density.

Small bowel herniation after laparoscopically assisted vaginal hysterectomy

Laparoscopically assisted vaginal hysterectomies have been done with increasing frequency in the United States. To date, minimal complications have been noted with this procedure. The authors review a series of 90 individuals and note a three percent small bowel obstruction rate. This complication is more common in this group of patients than in patients having a standard abdominal hysterectomy. Since this operation has been commonly performed, it is often possible to convert an abdominal hysterectomy to a vaginal approach, this increase in complications is exceedingly high. The authors recommend closure of lateral abdominal wall port sites under direct laparoscopic visualization to prevent this serious complication.

Metastatic breast carcinoma to the os calcis presenting as heel pain

A 47-year-old woman who had been treated for breast carcinoma 11 years previously developed significant heel pain of unclear etiology, which ultimately proved to be metastatic adenocarcinoma. A low index of suspicion and falsely negative plain radiographs contributed to a delay in diagnosis. No other osseous metastases besides those to the foot were identifiable at the time of diagnosis. Breast carcinoma is one of the most common malignancies and frequently metastasizes to bone. Despite this, metastases to the hands or feet (acrometastases) have been identified in only a few cases. It is likely that acrometastases are more common than reported but unrecognized.

Correlates of bone mineral density in elderly patients with hip fractures

Ninety-seven elderly patients with acute fractures of the proximal femur sustained as a result of minimal trauma were studied with regard to variables that may potentially influence the incidence or outcome of fractures of the proximal femur. The mean bone mineral density (BMD) measured at the femoral neck was approximately 2 SDs below age- and sex-adjusted normals. There was a preferential loss of bone mineral from the femoral neck in younger patients with hip fractures (Z score -3.10 +/- 0.23) (mean +/- SEM) compared with the lumbar spine (Z score -1.71 +/- 0.41). Mean daily calcium intake was well below the recommended levels and calcium intake < 400 mg/day was associated with lower lumbar spine BMD Z scores (p = 0.01). Ambulatory ability was unassociated with BMD Z scores. The results of this study suggest that the femoral neck is a site of preferential bone loss in younger postmenopausal patients, and screening of patients at risk of hip fracture should measure BMD at this site. Calcium supplementation may play a role in decreasing the incidence of hip fractures.

Bone mineralization in children and adolescents with a milk allergy

To evaluate the correlation between dietary calcium intake and mineralization of the immature skeleton 55 children and adolescents aged 5-14 years (mean, 9.5 years) with a positive radioallergosorbent test (RAST) for serum antibodies to cow's milk protein were evaluated. Bone mineral density (BMD) in the lumbar spine and proximal femurs were measured by dual energy X-ray absorptiometry. BMD at each site for each subject was converted to an age-adjusted Z score based on our own series of 95 normal pediatric controls. Calcium intake was determined using a detailed food frequency questionnaire administered by a nutritionist during a 30-40-min interview. Dietary adjustments to the condition varied and resulted in a wide range of calcium intakes. Calcium supplements were taken by 22% of the subjects and were included in the determination of daily calcium intake. The group of 55 subjects was divided into quartiles based on calcium intake (mean +/- S.E mg calcium/day): Group 1, 409 +/- 21, Group 2, 663 +/- 16, Group 3, 950 +/- 32, Group 4, 1437 +/- 124. Bone density Z scores in the proximal femur serially increased across the calcium intake groups (mean +/- S.E.): Group 1, -0.16 +/- 0.31; Group 2, 0.05 +/- 0.33; Group 3, 0.44 +/- 0.24; Group 4, 0.79 +/- 0.41 (P = 0.03). A similar pattern was found with lumbar spine BMD Z scores: Group 1, -0.16 +/- 0.27; Group 2, 0.10 +/- 0.21; Group 3, 0.18 +/- 0.20; Group 4, 0.30 +/- 0.25 (P = 0.05). These data add further to the evidence that dietary calcium intake is important for optimal mineralization of the growing skeleton.

Kyphosis and fractures in children and young adults with cystic fibrosis

The purpose of this study was to examine children and adolescents with cystic fibrosis for an increased frequency of fracture and excessive thoracic kyphosis, which may result from inadequate skeletal mineralization. In a survey of 143 patients (ages 4.7 to 21.9 years; mean, 11.3 years), the fracture rate for male patients from birth to 5 years of age was higher than for female patients and both rates were comparable with those for normal children. In contrast, female patients 6 to 16 years of age with cystic fibrosis had a higher-than-normal fracture rate and a higher rate than their male counterparts. Review of the chest radiographs showed that thoracic kyphosis correlated with age and with disease severity as judged by Brasfield scoring. In the > 15-year-old age group, kyphosis exceeding 40 degrees, the upper limit of normal, was found in 77% of the female patients and 36% of the male patients. The cause of these findings is uncertain and perhaps multifactorial, but osteopenia is likely a contributing factor. As the life expectancy of patients with cystic fibrosis continues to increase, the skeletal consequences, particularly in female patients, may become increasingly significant.

Etiology of late-onset tibia vara: is varus alignment a prerequisite?

One widely held theory on the pathogenesis of adolescent late-onset tibia vara is that obesity coupled with mild preexisting varus alignment produces forces sufficient to retard growth in the medial portion of the proximal tibial physis and initiates the development of the condition. Two cases are presented in which neutral mechanical alignment was clearly documented in an extremity that subsequently developed adolescent late-onset tibia vara within 19 months. We conclude that in at least some cases, preexisting varus alignment is not a prerequisite for the development of adolescent late-onset tibia vara.

Knee flexor-extensor strength in children

Isokinetic measurements of knee flexion extension in children and adolescents are a useful means of quantifying strength. In the routine clinical situation with a unilateral problem, evaluation of the affected extremity is usually based on comparisons with the unaffected side. To interpret these results, there must be an appreciation for normal side-to-side differences. Twenty-one normal, healthy children (ages 6-16 years) were evaluated using a Cybex II isokinetic dynamometer at 90 and 240 degrees/sec. In children who were able to generate peak torque values greater than 50 ft-lbs, the side-to-side differences in peak torque averaged 11 +/- 12% (mean +/- SD). A similar amount of variability has been reported with adults. For children with whom peak torque values were less than 50 ft-lbs, the side-to-side differences were much greater (mean = 22 +/- 19%). The stronger leg was equally likely to be on the nondominant side as the dominant side. Side-to-side variability was slightly decreased if the mean of several repetitions was used for comparisons rather than comparing just the single highest peak torque values.

Magnetic resonance evaluation of "metaphyseal" changes in Legg-Calvé-Perthes disease

Twenty involved hips in 16 patients with Legg-Calvé-Perthes disease (LCP) were studied with both plain radiographs and magnetic resonance imaging (MRI) scans to better evaluate the existence of "metaphyseal" changes. Thirty-four sets of radiographs and MRI scans were reviewed in a blinded fashion and compared for the presence and location of these changes. Of 23 hips with plain radiographic metaphyseal changes, 11 showed no such changes on MRI scans (48%). Twelve hips did show MRI changes located in the anterior metaphysis. One hip studied three times had a discrete cystic change located in the central metaphysis. Of 11 hips with no plain radiographic changes in the metaphysis, five showed metaphyseal changes on MRI. Metaphyseal changes in LCP remain poorly understood. Even with use of MRI, fine distinction between physis and metaphysis still proved difficult. It appears that most metaphyseal changes are physeal and epiphyseal irregularities. A few hips have truly metaphyseal lesions. The significance of these "cysts" is unclear.

An evaluation of pre- and postoperative nonsteroidal antiinflammatory drugs in patients undergoing knee arthroscopy. A prospective, randomized, double-blinded study

The potential benefits of a nonsteroidal antiinflammatory drug to 67 patients undergoing knee arthroscopy were evaluated in a prospective, randomized, placebo-controlled, double-blinded study. Group A received the drug (diclofenac, 75 mg twice daily) for 3 to 5 days before and for 7 days after surgery. Group B received a placebo preoperatively and the drug postoperatively. Group C received a placebo at both times. Codeine was available postoperatively for all patients if needed. Outcomes reported by the subjects included pain, crutch use, and return to activities. Outcomes assessed by physicians included knee effusion, range of motion, and gait. Knee flexion and extension strengths were measured isokinetically pre- and postoperatively. Pain scores on the 1st postoperative day were higher in Group C than in Group A. Pain scores at all other time points were not significantly different in the three treatment groups. Groups A and B required less codeine during the first 72 hours after surgery than Group C (mean, 2.9 +/- 1.0 versus 6.8 +/- 1.0 pills). Recovery of function, recovery of strength, and physical examination parameters were not significantly different in the three treatment groups. Diclofenac was an effective analgesic in the immediate postoperative period. Recovery from arthroscopy, however, was not enhanced by taking the drug.

Prevalence of late-onset tibia vara

We wished to determine the prevalence of late-onset tibia vara in an at-risk population. From a group of 1,117 boys aged 13-19 years, we selected all those who weighed at least 210 pounds. The 140 boys (80 black, 60 white) who met this inclusion criterion were examined for varus alignment. Radiographs of the seven boys who screened positive showed that two boys had late-onset tibia vara. Both boys were black and weighed > 280 pounds. The prevalence of late-onset tibia vara in this obese adolescent black male population was 2.5% (two of 80 boys). Recently, the number of reported cases of late-onset tibia vara has increased dramatically probably owing to an increase in the prevalence of morbid obesity.

Tibia vara: a complication of adolescent obesity

Tibia vara is characterized by inhibited growth of the medial portion of the proximal tibial growth plate, leading to progressive bowleg deformity. Twenty-nine adolescent patients with this condition were reviewed: all were black, 27 (93%) were male, and 19 (66%) had only one side affected. Progressive deformity rather than knee discomfort was the most common presenting complaint. The deformity reportedly developed rapidly during the adolescent growth spurt. The body weights of these patients exceeded the 95th percentile for age and gender by an average of 43 kg. The absence of significant symptoms and a body habitus that obscured the deformity often resulted in delayed diagnosis. Physicians involved in the care of obese black male adolescents should carefully examine them for tibia vara, which has a reported prevalence of 2% to 3% in this population. Treatment options are severely restricted if the condition is not diagnosed early.

Meniscectomy in children and adolescents. A long-term follow-up study

Thirty-nine patients treated with total meniscectomy younger than 16 years of age were studied. The average follow-up period was 21 years; 71% of the patients reported pain; 68%, stiffness; 54%, swelling; and 41%, giving way. Approximately half the patients described progression of symptoms, but only 27% were asymptomatic. Only 10% noted limitations at work, but 62% had limitations in sports. Twelve percent have had further knee surgery. Forty-nine percent received unsatisfactory subjective/functional ratings. On physical examination, 25% of patients had range of motion loss of greater than 5 degrees, 22% had thigh atrophy of greater than 1 cm, and 20% developed substantial instability. Overall, 27% received unsatisfactory objective ratings. Ninety percent of patients had abnormal roentgenograms. Changes occurred predominantly in the meniscectomized compartment. Forty-four percent of patients had unsatisfactory roentgenographic ratings. Overall ratings indicated that 63% of patients' results rated unsatisfactory. More unsatisfactory results occurred in patients with a follow-up period of longer than 26 years, in those with substantial instability, and in males. Few differences existed between medial and lateral meniscectomies or with increasing durations of symptoms preoperatively.

Adolescent tibia vara: alternatives for operative treatment

We reviewed the cases of fifteen obese patients (twenty-one extremities) who had had adolescent tibia vara and had been followed for at least two years. Of the nine patients (eleven extremities) who had been initially managed with lateral tibial hemiepiphyseodesis, eight (ten extremities) were skeletally mature at the time of the review (mean duration of follow-up, five years). The mechanical alignment was judged to be excellent in three of these ten extremities, fair in three, and poor in four. Excellent mechanical alignment was defined as a value within the reported normal range of 5 degrees of varus to 2 degrees of valgus. A poor result was defined as alignment that was more than 5 degrees outside the normal range. After secondary operative procedures, three of the extremities for which the result had been poor and one for which it had been fair had excellent alignment. Five of the nine patients had bilateral involvement. Two of them were managed with bilateral tibial hemiepiphyseodesis; two, with contralateral proximal tibial osteotomy; and one had a mild deformity on the contralateral side that was not treated. Six extremities in six patients (two of whom had a contralateral hemiepiphyseodesis) were managed primarily with proximal tibial osteotomy and were evaluated an average of seven years postoperatively. Two additional patients were managed with proximal tibial osteotomy because of residual varus deformity after the hemiepiphyseodesis.(ABSTRACT TRUNCATED AT 250 WORDS)

Residual bone-mineral density and muscle strength after fractures of the tibia or femur in children

This study compared the bone-mineral density in the proximal part of the femur and the flexion and extension strength of the knee in the fractured and the non-fractured limbs after an uncomplicated fracture of the tibia or femur in children. Thirty-eight children, whose ages ranged from two to fifteen years at the time of the injury, were evaluated at an average of 2.3 years after the injury. The mean difference in bone-mineral density between the fractured and non-fractured limbs was 3.3 per cent (p = 0.004). There was no significant difference between the bone-mineral density of the limbs that had been immobilized for less than four weeks and that of the contralateral, non-fractured limbs. However, the mean difference between the bone-mineral density of the limbs that had been immobilized for more than eight weeks and that of the contralateral limbs was 4.3 per cent (p = 0.006). There was little or no relationship between the time since the injury and the difference in bone-mineral density between the two limbs of the patient at the intervals of follow-up that were studied. No residual weakness in flexion and extension of the knee was detected, and no relationship was established between the limb-to-limb differences in strength and the limb-to-limb differences in bone-mineral density. The residual bone-mineral deficit was found to be minimum after an uncomplicated fracture. This difference, while statistically significant, is unlikely to be clinically important in the long term. However, the fact that there was a deficit raises a potential concern for children who have more severe or repeated injuries.

Assessment of bone mineral content in children

Quantitative digital radiography (QDR) is a new technique for measuring bone mineral content that offers improved precision, shorter study times, and less radiation exposure than single-photon absorptiometry (SPA), dual-photon absorptiometry (DPA), and quantitative computed tomography (CT) scanning. To evaluate application of QDR to a pediatric population, the bone mineral density (BMD) of both proximal femurs and lumbar spine was determined in 20 normal children aged 4-15 years. Duplicate measures indicated a precision less than 2%. A small left side/right side difference was sometimes found in the BMD of the proximal femurs. This difference was not related to age, sex, or handedness, and there was no history of significant injury to, or problems with, either lower extremity. QDR will greatly enhance early evaluation and treatment of many conditions that adversely affect the immature skeleton.

Posttraumatic necrosis of the talus: the Hawkins sign versus magnetic resonance imaging

Magnetic resonance imaging (MRI) is reported to be more sensitive than plain radiographs, computed tomography, or radionuclide bone scanning in detecting osteonecrosis. Few cases of MRI scans falsely negative for osteonecrosis have been reported. A 36-year-old man with posttraumatic necrosis of the body of the talus proven by biopsy had three serial MRI scans that were interpreted as showing the talus to be viable. Eight weeks after injury, the plain radiographs did not show subchondral resorption of bone in the talus (Hawkins sign) and, thus, did correctly indicate necrosis. Most likely a non-union of the talus neck fracture resulted in the false-negative MRI scans.

Assessment of the mechanical axis in adolescent tibia vara

To assess precision of measurement, the mechanical axis was determined by two independent observers on 52 radiographs of 15 obese patients with adolescent tibia vara. Special, but simple, modifications in radiographic technique are described that allow simultaneous exposure of the hip, knee, and ankle joints. Even in this challenging population, assessment of the alignment of the lower extremity is possible with excellent precision using the mechanical axis. In 42 of the 52 radiographs, the two independent observers differed by less than or equal to 1 degree. The mechanical axis is superior to measurement of the tibial-femoral shaft angle for evaluation of lower extremity alignment.

Bilateral simultaneous fractures of the femoral neck: case report

A case of bilateral fractures of the femoral neck resulting from high-voltage electric injury is reported. Surgeons caring for patients with electrical injuries must be aware of the possibility of this injury as well as other skeletal injuries which may result from muscle contraction or falls related to electric shock. Without vigilance for these injuries, diagnosis may be delayed.

Postarthroscopy analgesia with bupivacaine. A prospective, randomized, blinded evaluation

The analgesic effect of intraarticular bupivacaine injected at the conclusion of knee arthroscopy done under general anesthesia was investigated in a prospective, randomized, and blinded fashion. Pain scores, the use of analgesic medications, crutch use, weight-bearing, activity level, and difficulty sleeping the night after surgery were all unaffected by the use of bupivacaine. The apparent lack of effect is most likely due to rapid clearance from the knee, leaving only a transient, 1 to 2 hours of potential benefit. In this study, the patients were already quite comfortable during this time period due to the routine use of intraoperative narcotics. The preoperative level of knee discomfort was found to be a major determinant of postoperative discomfort. Other much less important factors were synovial and chondral shaving, sex of the patient, and experience of the surgeon.

Variability in radiographic measurement of bowleg deformity in children

The tibial metaphyseal-diaphyseal (MD) and tibial-femoral (TF) angles were measured on the radiographs of 33 knees in young children (aged 12-36 months) with bowleg deformity. Four observers of differing experience measured the films in a blinded fashion to determine the intraobserver and interobserver variability of these measurements. The clinical implications of these variabilities are described. Very little instruction and experience is necessary to make these measurements correctly and precisely. Measurement of the MD angle was superior to measurement of the TF angle. Contrary to published opinion, rotation can have a small but potentially significant effect on the measured MD angle.

Evaluation of magnetic resonance imaging in Legg-Perthes disease: a prospective, blinded study

Twenty-two patients (24 hips) with Legg-Perthes disease received 49 magnetic resonance (MRI) scans. The scans and corresponding radiographs were independently evaluated in a blinded fashion to assess the capabilities of, and indications for, MRI in Legg-Perthes disease. Early in the disease process, MRI often more clearly delineated the extent and location of areas of involvement than did plain radiographs. In one patient, MRI failed to indicate necrosis early in the course of the disease, but it was detected on plain radiographs. MRI can also be used to give a rough estimate of sphericity, which in some phases of the disease process is better than plain radiographs. For serially following the disease process through the natural healing course, plain radiographs were as good or better than MRI and considerably less costly.

Salmonella septic and aseptic arthritis in sickle-cell disease. A case report

A 26-year-old black male with sickle-cell disease developed a Salmonella septic arthritis in one knee and an acute, aseptic arthritis in the other knee. Salmonella is showing increasing resistance to many antibiotics. In this patient, optimal antibiotic treatment of his uncommon infection was delayed by a rare resistance to trimethoprim-sulfamethoxazole. Two pathophysiologic mechanisms could account for his acute, aseptic arthritis: sickle-cell disease with presumed synovial ischemia from sickling and reactive arthritis precipitated by a remote Salmonella infection elsewhere in the body. The authors could find no previous discussion of either of these processes in the orthopedic literature. Acute arthritis in a patient with sickle-cell disease can be a complex diagnostic and therapeutic problem.

The long-term results of nonoperatively treated major pelvic disruptions

Twenty-six patients with major anterior-posterior pelvic disruptions not involving the acetabulum were reevaluated an average of 8 years (minimum 5 years) after injury. All pelvic injuries were treated nonoperatively. Subjective complaints at the time of follow-up included frequent or daily low back discomfort (50%), localized distal dysesthesias (46%), and some degree of work disability (38%). Objective neurologic deficit (42%) and a limp (32%) were often detected on examination. The amount of residual vertical displacement was measured on plain AP radiographs and graded as none, displaced less than 1 cm, or displaced greater than 1 cm. The long-term outcome correlated exceptionally well with both the amount of residual vertical displacement and the stability of the fracture.

Histofluorescence techniques provide evidence for dopamine-containing neuronal elements in canine kidney

Changes induced by hydrochloric acid in the excitation spectrum of catecholamine fluorophores associated with the innervation of the canine renal vasculature show that there are neuronal elements at the glomerular vascular poles containing predominantly dopamine. In contrast, the catecholamine fluorescence in the periadventitial layer of the arcuate arteries is derived from norepinephrine. The dopamine-containing structures may represent the prejunctional counterpart to the pharmacologically identified dopamine receptors in the renal vasculature. As such, this system may be involved in the normal regulation of renal blood flow and renin release.