New horizons for the in vivo assessment of major aspects of bone quality

The Biomechanically founded individualised osteoporosis Assessment and treatment (BioAsset) consortium pursues experimental and clinical studies in the context of skeletal effects of bisphosphonate treatment. Here, first results using newly developed diagnostic methods in a set of vertebral bone specimen obtained from donors with documented bisphosphonate history ranging from 0 to more than 5 years of treatment are presented. A new thoracolumbar quantitative computed tomography (QCT) protocol covering T6 to L4 plus high-resolution QCT (HRQCT) assessment of T12 were compared with high-resolution peripheral QCT (HRpQCT) and micro-CT scans of excised specimens serving as gold standard techniques. Finite element (FE) modelling was performed. Material, ultrastructural, and micromechanical properties were tested on a set of single trabeculae obtained from the donor specimens. A newly developed quantitative ultrasound (QUS) device for measuring the anisotropy of cortical material properties at the tibia was designed and built. The thoracolumbar QCT protocol permitted in situ imaging with good image quality and automated segmentation of vertebral bodies in the whole range from T6 to L4. The duration of bisphosphonate treatment was significantly associated with increased levels of mineralization and this effect could be measured with HRQCT performed on excised specimens. Microstructural parameters contributed to vertebral bone strength modelled by FE analysis independently of bone mineral density. The new QUS tibia scanner permitted measuring the acoustical anisotropy of reference materials. Taken together, these results document that new methods developed in BioAsset permit a more comprehensive assessment of bone fragility. The set of donor specimens with a documented history of bisphosphonate treatment allows for the assessment of the effects of long-term treatment from the organ down to the tissue and material level. These results will ultimately be linked to the parallel clinical study to provide guidance for determining the optimum duration of bisphosphonate treatment to reduce the incidence of osteoporotic fractures.

Exercise addiction: Links, risks and challenges faced

Introduction

Exercise addiction is a condition described by a craving for physical training resulting in excessive exercise behaviour and withdrawal symptoms. It has not been accepted as a mental disorder and further research is needed to examine the pathology of the condition.

Objectives

Exercise addiction is suggested to have links to other mental disorders and risks in terms of negative consequences such as injuries. Treatment for exercise addiction faces several challenges as the condition is associated with ambivalence, and studies based on controlled interventions are missing.

Aims

The aim of this study was to examine and interpret the existing research on links, risks and challenges faced in treatment interventions.

Methods

A literature review was conducted in the databases PubMed, PsycINFO and Scopus with the terms: “exercise addiction, excessive exercise” and/or “comorbidity, eating disorder, depression, anxiety, personality, pain, injury, illness, social isolation, stress, intervention, treatment”.

Results

Exercise addiction seems to be associated with eating disorder pathology, obsessive-compulsive behaviour and personality traits characterized by perfectionism, narcissism and neuroticism. Overload injuries (e.g. stress fractures) and impaired interpersonal relations are reported. In a treatment context, low compliance is described as a challenge. Thus, motivational interviewing is recommended, and also cognitive behavioural therapy is suggested for treatment. None of these interventions have yet been scientifically evaluated in addicted exercisers.

Conclusion

This review concludes that exercise addiction has links to psychopathology and increases the risk of injuries. More research is needed to estimate the level of psychosocial and physiological distress in these athletes. Controlled treatment interventions have to be conducted.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Efficacy and safety of the ZSI375 artificial urinary sphincter for male stress urinary incontinence: lessons learned

PURPOSE

To analyze efficacy and safety for the ZSI375 artificial urinary sphincter in a multicenter case series.

METHODS

Thirteen male patients with stress urinary incontinence underwent implantation of a ZSI375 artificial urinary sphincter device between 2010 and 2012 in three international continence reference centers. Perioperative characteristics and postoperative complications were analyzed using the Clavien-Dindo scale. Re-hospitalization and explantation rates, and functional outcome were assessed. Inner-group and between-group differences were analyzed using Wilcoxon, Mann-Whitney U, and Fisher's exact test whenever indicated. Kaplan-Meier analysis was performed to assess device survival. A p value below 0.05 was considered statistically significant.

RESULTS

There were no intraoperative complications. Median follow-up was 13.5 months. In this period, four device defects (30.8 %) could be observed, being the main cause for device explantation, followed by device infection (15.4 %), non-resolvable pain (7.7 %), and urethral erosion (7.7 %). There were no Clavien IV or Clavien V complications. Overall explantation rate was 61.5 %. Mean time-to-explantation was 279 ± 308 days. There was no significant influence of previous irradiation and previous invasive incontinence therapy (p = 0.587 and p = 0.685, respectively). Mean daily pad usage decreased from 5.8 ± 1.5 to 2.4 ± 2.1 (p = 0.066). One patient (7.7 %) did not use any pads. Social continence (0-1 pads) was achieved in 15.4 % of the patients.

CONCLUSION

This is the most current study that is investigating the outcome after ZSI375 implantation in a multicenter case series. Based on our results, explantation rates after ZSI375 implantation are high and efficacy rates seem lower than previously described. Addressing this high failure rate, the system has undergone a two-step modification in the meantime.

Association of osteolytic lesions, bone mineral loss and trabecular sclerosis with prevalent vertebral fractures in patients with multiple myeloma

PURPOSE

In patients with multiple myeloma (MM), computed tomography is widely used for staging and to detect fractures. Detecting patients at severe fracture risk is of utmost importance. However the criteria for impaired stability of vertebral bodies are not yet clearly defined. We investigated the performance of parameters that can be detected by the radiologist for discrimination of patients with and without fractures.

METHODS AND MATERIALS

We analyzed 128 whole body low-dose CT of MM patients. In all scans a QCT calibration phantom was integrated into the positioning mat (Image Analysis Phantom(®)). A QCT-software (Structural Insight) performed the volumetric bone mineral density (vBMD) measurements. Description of fracture risk was provided from the clinical radiological report. Suspected progressive disease (PD) was reported by the referring clinicians. Two radiologists that were blinded to study outcome reported on the following parameters based on predefined criteria: reduced radiodensity in the massa lateralis of the os sacrum (RDS), trabecular thickening and sclerosis of three or more vertebrae (TTS), extraosseous MM manifestations (EOM), visible small osteolytic lesions up to a length of 8mm (SO) and osteolytic lesions larger than 8mm (LO). Prevalent vertebral fractures (PVF) were defined by Genant criteria. Age-adjusted standardized odds ratios (sOR) per standard deviation change were derived from logistic regression analysis and area under the curve (AUC) from receiver operating characteristics (ROC) analyses were calculated. ROC curves were compared using the DeLong method.

RESULTS

45% of the 128 patients showed PVF (29 of 75 men, 24 of 53 women). Patients with PVF were not significantly older than patients without fractures (64.6 ± 9.2 vs. 63.3 ± 12.3 years: mean ± SD, p=0.5). The prevalence of each parameter did not differ significantly by sex. Significant fracture discrimination for age adjusted single models was provided by the parameters vBMD (OR 3.5 [1.4-8.8], AUC=0.64 ± 0.14), SO (sOR 1.6[1.1-2.2], AUC=0.63 ± 0.05), LO (sOR 2.1[1.1-4.2] AUC=0.69 ± 0.05) and RDS (sOR 2.6[1.6-4.7], AUC=0.69 ± 0.05). Multivariate models of these four parameters showed a significantly stronger association with the development of PVF (AUC=0.80 ± 0.04) than single variables. TTS showed a significant association with PVF in men(sOR 1.5 [0.8-3.0], AUC=0.63 ± 0.08), but not in women (sOR 2.3[1.4-3.7], AUC=0.70 ± 0.07). PD was significantly associated with PVF in women (sOR 1.9[1.1-3.6], AUC=0.67 ± 0.08) but not in men (sOR 1.4[0.9-2.3], AUC=0.57 ± .07). EOM were not associated with PVF (sOR 1.0[0.4-2.6], AUC=0.51 ± .05).

CONCLUSION

In multiple myeloma, focal skeletal changes in low dose CT scans show a significant association with prevalent vertebral fractures. The combination of large osteolytic lesions and loss in radiodensity as can be detected with simple CT Hounsfield measurements of the os sacrum or BMD measurements showed the strongest association to fractures and may be of value for prospective studies.

Potential interactions between diadromous fishes of U.K. conservation importance and the electromagnetic fields and subsea noise from marine renewable energy developments

The considerable extent of construction and operation of marine renewable energy developments (MRED) within U.K. and adjacent waters will lead, among other things, to the emission of electromagnetic fields (EMF) and subsea sounds into the marine environment. Migratory fishes that respond to natural environmental cues, such as the Earth's geomagnetic field or underwater sounds, move through the same waters that the MRED occupy, thereby raising the question of whether there are any effects of MRED on migratory fishes. Diadromous species, such as the Salmonidae and Anguillidae, which undertake large-scale migrations through coastal and offshore waters, are already significantly affected by other human activities leading to national and international conservation efforts to manage any existing threats and to minimize future concerns, including the potential effect of MRED. Here, the current state of knowledge with regard to the potential for diadromous fishes of U.K. conservation importance to be affected by MRED is reviewed. The information on which to base the review was found to be limited with respect to all aspects of these fishes' migratory behaviour and activity, especially with regards to MRED deployment, making it difficult to establish cause and effect relationships. The main findings, however, were that diadromous species can use the Earth's magnetic field for orientation and direction finding during migrations. Juveniles of anadromous brown trout (sea trout) Salmo trutta and close relatives of S. trutta respond to both the Earth's magnetic field and artificial magnetic fields. Current knowledge suggests that EMFs from subsea cables may interact with migrating Anguilla sp. (and possibly other diadromous fishes) if their movement routes take them over the cables, particularly in shallow water (<20 m). The only known effect is a temporary change in swimming direction. Whether this will represent a biologically significant effect, for example delayed migration, cannot yet be determined. Diadromous fishes are likely to encounter EMFs from subsea cables either during the adult movement phases of life or their early life stages during migration within shallow, coastal waters adjacent to natal rivers. The underwater sound from MRED devices has not been fully characterized to determine its acoustic properties and propagation through the coastal waters. MRED that require pile driving during construction appear to be the most relevant to consider. In the absence of a clear understanding of their response to underwater sound, the specific effects on migratory species of conservation concern remain very difficult to determine in relation to MRED. Based on the studies reviewed, it is suggested that fishes that receive high intensity sound in close proximity to construction may be physiologically affected to some degree, whereas those at farther distances, potentially up to several km, may exhibit behaviour responses; the effect of which is unknown and will be dependent on the properties of the received sound and receptor characteristics and condition. Whether there are behavioural effects on the fishes during operation is unknown but any change to the environment and subsequent response by the fishes would need to be considered over the lifetime of the MRED. It is not yet possible to determine if effects relating to sound exposure are biologically significant. The current assumptions of limited effects are built on an incomplete understanding of how the species move around their environment and interact with natural and anthropogenic EMFs and subsea sound. A number of important knowledge gaps exist, principally whether migratory fish species on the whole respond to the EMF and the sound associated with MRED. Future research should address the principal gaps before assuming that any effect on diadromous species results in a biological effect.

Gold coast seaway smartrelease decision support system: optimising recycled water release in a sub tropical estuarine environment

Gold Coast Water is responsible for the management of the water, recycled water and wastewater assets of the City of the Gold Coast on Australia's east coast. Excess treated recycled water is released at the Gold Coast Seaway, a man-made channel connecting the Broadwater Estuary with the Pacific Ocean, on an outgoing tide in order for the recycled water to be dispersed before the tide changes and re-enters the Broadwater estuary. Rapid population growth has placed increasing demands on the city's recycled water release system and an investigation of the capacity of the Broadwater to assimilate a greater volume of recycled water over a longer release period was undertaken in 2007. As an outcome, Gold Coast Water was granted an extension of the existing release licence from 10.5 hours per day to 13.3 hours per day from the Coombabah wastewater treatment plant (WWTP). The Seaway SmartRelease Project has been designed to optimise the release of the recycled water from the Coombabah WWTP in order to minimise the impact to the receiving estuarine water quality and maximise the cost efficiency of pumping. In order achieve this; an optimisation study that involves intensive hydrodynamic and water quality monitoring, numerical modelling and a web-based decision support system is underway. An intensive monitoring campaign provided information on water levels, currents, winds, waves, nutrients and bacterial levels within the Broadwater. This data was then used to calibrate and verify numerical models using the MIKE by DHI suite of software. The Decision Support System will then collect continually measured data such as water levels, interact with the WWTP SCADA system, run the numerical models and provide the optimal time window to release the required amount of recycled water from the WWTP within the licence specifications.

Characteristics of whistles from the acoustic repertoire of resident killer whales (Orcinus orca) off Vancouver Island, British Columbia

The acoustic repertoire of killer whales (Orcinus orca) consists of pulsed calls and tonal sounds, called whistles. Although previous studies gave information on whistle parameters, no study has presented a detailed quantitative characterization of whistles from wild killer whales. Thus an interpretation of possible functions of whistles in killer whale underwater communication has been impossible so far. In this study acoustic parameters of whistles from groups of individually known killer whales were measured. Observations in the field indicate that whistles are close-range signals. The majority of whistles (90%) were tones with several harmonics with the main energy concentrated in the fundamental. The remainder were tones with enhanced second or higher harmonics and tones without harmonics. Whistles had an average bandwidth of 4.5 kHz, an average dominant frequency of 8.3 kHz, and an average duration of 1.8 s. The number of frequency modulations per whistle ranged between 0 and 71. The study indicates that whistles in wild killer whales serve a different function than whistles of other delphinids. Their structure makes whistles of killer whales suitable to function as close-range motivational sounds.

Failure of total hip arthroplasty with Boneloc bone cement

Early failure of Boneloc cemented total hip arthroplasty is well documented. However, information regarding the long term prognosis is scanty. The aim of this study was therefore to assess the long term failure rate of total hip replacement with Boneloc bone cement. Between January 1991 and March 1992, Boneloc bone cement (Polymers Recontructive A/S, Farum, Denmark) was used in 42 consecutive total hip replacements in 42 patients. The average age of the patients was 75 years. There were 25 women and 17 men. The diagnosis at operation was osteoarthritis in all cases. A cemented Muller Taperloc femoral stem was used with a cemented Muller acetabular cup (Biomet, Warsaw, USA). The follow-up time was 9 years. All patients underwent radiographic control the first postoperative year and annually after 1995. To date 21 patients have been revised for aseptic loosening at a mean of 5 years (range: one year to 8 years). Three other patients have definite radiographic evidence of loosening. The overall failure rate is therefore 24/42 = 57%. Our results confirm the previously reported poor results of Boneloc bone cement for hip arthroplasty and support the recommendation of indefinite follow-up for surviving prostheses. New prosthesis designs and new cements should have documentation, including laboratory tests and randomized clinical studies with radiostereometric evaluation. However, the ethical responsibility rests heavily on the shoulders of the clinician to make a correct analysis of the need for a new product before he begins to use it.

Percutaneous sclerotherapy of hydronephrosis in a non-functioning kidney

A 27-year-old woman was admitted with an abdominal mass in the right hypochondrium. Ultrasound, intravenous urography and scintigraphy revealed a giant non-functioning hydronephrosis. Because she refused surgery, a percutaneous aspiration with instillation of doxycycline was performed. One year thereafter, the patient was still without recurrence of any symptoms or hydronephrosis.

[Aortic dissection demonstrated by ultrasound scanning]

The clinical features of aortic dissection may be nonspecific and confusing. Three patients with different symptomatology diagnosed primarily by ultrasound are reported. In all cases the dissection was confirmed by dynamic CT and arteriography. The sonographic characteristics of aortic dissection are briefly described.

[Computed tomographic detection of air in the portal vein--a case report]

Two cases of portal venous gas (PVG) are presented. One case due to bowel infarction and another due to duodenal ulcer perforation complicated by a subphrenic abscess. The diagnosis was suggested from plain abdominal radiographs and confirmed by unenhanced computed tomography (CT) of the abdomen which is superior to demonstrate gas in the portal venous system. The distinction between PVG and biliary gas is briefly discussed.

[Conservative treatment of clavicular fractures]

The outcome of 99 clavicular fractures was examined retrospectively through a questionnaire and, in 20 cases, clinical examination. Primary treatment was in all cases a simple sling or a figure of eight bandage. The aim of the study was to examine prognostic factors in relation to the end-result. The fractures were classified, according to the roentgenograms, and the primary dislocation, primary shortening and secondary shortening of the shoulder were recorded. The end-result was expressed as the degree of pain. Statistically significantly more patients with group two type two fractures had a poor result. No other prognostic factors were found.

Planning change in scheduling practices: a theoretical perspective

The dynamic nature of today's health care environment requires innovation and creativity in organizational structure and management style. Some of the most essential concerns of nursing staff today are related to quality of working life, and perhaps a central focus for most nurse employees is a scheduling system which offers the flexibility necessary for them to respond to an active personal and professional life. This paper describes the utilization of change theory in operationalizing new scheduling practices with four unique nursing groups. The self designed master rotation and a self scheduling process are two examples of innovative change implemented by four nurse managers. Each participative management approach is presented in relation to the phases of Lewin's change process. Strategies include a needs assessment survey, facilitating staff participation in the design, implementation and evaluation of a new scheduling practice and encouraging group responsibility for the process and outcome of the planned change.

Gamma camera renography with 99Tcm-MDP and 131I-Hippuran

Nineteen patients with urologic disorders referred to bone scintigraphy were evaluated with a dual radioisotope technique using simultaneous injection of 99Tcm-MDP and 131I-Hippuran. The MDP and Hippuran renograms showed in general the same pattern and there was no difference between the kidney function determined with the two radionuclides. The peak of the MDP curves occurred later and was less distinct than that of the Hippuran curves. The residual activity of the kidneys 20 min after the injection was higher on the MDP renograms compared with the Hippuran renograms. The early sequential MDP images were superior in quality to the Hippuran images and to the renal images obtained at bone scintigraphy. The early MDP images correlated well with the findings at urography performed in 12 patients, as all cases of radiologically diagnosed hydronephrosis, reduction of renal parenchyma and renal mass lesions became demonstrated. Renal calculi were only diagnosed at urography. In conclusion, MDP cannot replace Hippuran as a renal radionuclide agent, mainly due to its lower extraction ratio and the high bone uptake. However, an increased use of early dynamic renal imaging is recommended in urologic patients referred to bone scintigraphy as valuable information about renal function may be obtained by this procedure.

Hippuran renography and scintigraphy in children with myelomeningocele

Long-term surveillance of the urinary tract is necessary in children with myelomeningocele and neurogenic bladder dysfunction. The results of Hippuran renography and scintigraphy were analyzed in 52 cases and compared to those of intravenous urography. In addition the radionuclide evaluation was correlated to the clinical course. It was concluded that renography is a suitable examination for the monitoring of the kidneys and upper urinary tract in these children. A decrease of renal function and drainage may occur without any changes of the clinical state.

Demonstration of renal mass lesions by early dynamic imaging during bone scintigraphy

The detection of renal abnormalities during bone scintigraphy using 99Tcm-phosphorous complexes is well documented. Three patients with renal carcinoma visible on early but less well on late images during bone scintigraphy are presented. Early dynamic imaging provides improved lesion detectability and information about renal function.

Cimetidine treatment of patients with duodenal ulcer referred to a surgical clinic

Fifty-seven patients with gastroscopically verified duodenal ulcer after being referred to a surgical department were treated with one gram of cimetidine daily for 4 weeks. Within the period of observation 6-16 months (median 9) there was indication for operation in 36 patients, 16 were free from symptoms and five had slight symptoms. Those with freedom from symptoms over a longer period all had gastroscopically verified ulcer healing at control gastroscopy following discontinuation of the treatment. Ulcers localized to the pyloric/pre-pyloric areas had a poorer symptomatic effect of treatment than those situated to the bulb.