Evaluation of FRAX® score use in Maltese osteoporosis management guidelines

Objectives: Recent years have brought a shift towards evidence-based fracture risk engines. Fracture Risk Assessment Tool (FRAX®) is one such diagnostic tool used to evaluate the ten-year probability of osteoporotic fracture risk. The aim of this study was to evaluate the Maltese FRAX® score-based osteoporosis management guidelines and identify the suitability of using such a risk factor engine-based protocol. Study design: Data from 702 patients presenting for bone mineral density (BMD) estimation in 2010- 2011 were collected. In this period, local guidelines were devised but not yet put into practice so all referred patients underwent BMD estimation. These patients were below 65 years of age and above the minimum age for FRAX® use: 40 years. Data included Age, Weight, Height, BMI and the presence of any risk factor components of the FRAX® score tool. BMD was assessed using Norland/Hologic densitometers. FRAX® scores (excluding BMD) for each patient were calculated using the online tool www.shef.ac.uk/FRAX as accessed in 2014. The resulting major osteoporotic fracture risk was compared to age-specific assessment thresholds as set by Kanis et al. (2013). Thus the appropriateness (or otherwise) of densitometry measurements as dictated by local guidelines was determined. Main outcome measures: The main outcome measures in this study were the femoral neck and vertebral body BMD. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of using the FRAX®-based guidelines in under 65 year olds were calculated. Results: Local guidelines for managing <65 year olds were found to have a PPV of 11.26% and a NPV of 94.38 % Conclusion: FRAX®-guided local guidelines are well suited at excluding non-osteoporotic patients (False omission rate of 5.62 %). Positive likelihood ratio for the protocol was found to be 1.27. This means that 1 in every 8.8 patients that would have been referred for BMD estimation were actually osteoporotic.peer-reviewe

Linkage to chromosome 11p12 in two Maltese families with a highly penetrant form of osteoporosis

Osteoporosis is a metabolic bone disease with a strong genetic component. Family-based linkage studies were performed by a number of investigators to try to identify loci that might contain genes responsible for an increased susceptibility to osteoporosis. A whole-genome linkage scan using 400 microsatellite markers was performed in 27 members from two Maltese families with a highly penetrant form of osteoporosis. The phenotype was defined by lumbar and femoral z-scores calculated after measurement of bone mineral density by DEXA. Both males and females were among the affected individuals. Multipoint parametric and non-parametric linkage analyses were performed by EasyLinkage v4.01 using GENEHUNTER v2.1, assuming dominant and recessive modes of inheritance with variable penetrance. Evidence of linkage was observed to a marker at 11p12 where a non-parametric LOD score of 5.77 (P¼0.0006) was obtained. A maximum heterogeneity LOD score of 2.55 for this region was obtained for the dominant mode of inheritance with 90% penetrance and a phenocopy rate of 1%. Following fine mapping, the critical interval was narrowed to a region that is 52.94cM from 11p-telomere. In this region, the gene for tumour necrosis factor receptor-associated factor 6 (TRAF6) is located approximately 1 cM away from the indicated marker. Sequencing of the promoter region and exons of the TRAF6 gene revealed three sequence variants, one of which was found in three affected members within one family.peer-reviewe

Extensive Pulmonary Embolism in late pregnancy associated with Anticardiolipin Antibodies

The leading cause of morbidity and mortality during pregnancy and the puerperium is venous thromboembolism. Though uncommon, the risk is five times higher in a pregnant woman than in a non-pregnant woman of similar age.1,2 In pregnancy, all three underlying factors for venous thrombosis are present: hypercoagulability, venous stasis and vascular damage (Virchow's triad). Of these, the most constant predisposing factor is increasing venous stasis due to the pressure of the gravid uterus on the pelvic vasculature. In addition the presence of a thrombophilia, (congenital or acquired) will increase this risk substantially. During pregnancy hypercoagulability is a physiological preparation for the haemostatic challenge of delivery. There are increases in procoagulant factors, such as von Willebrand factor, factor VIII, factor V, and fibrinogen together with an acquired resistance to activated protein C and a reduction in protein S. Increases in plasminogen activator inhibitors impair fibrinolysis. The third factor of this triad, vascular damage, is a possible complication of trophoblastic invasion of the uterine spiral arterioles or of delivery.peer-reviewe

Household decision-making about delivery in health facilities: evidence from Tanzania.

This study investigated how partners' perceptions of the healthcare system influence decisions about delivery-location in low-resource settings. A multistage population-representative sample was used in Kasulu district, Tanzania, to identify women who had given birth in the last five years and their partners. Of 826 couples in analysis, 506 (61.3%) of the women delivered in the home. In multivariate analysis, factors associated with delivery in a health facility were agreement of partners on the importance of delivering in a health facility and agreement that skills of doctors are better than those of traditional birth attendants. When partners disagreed, the opinion of the woman was more influential in determining delivery-location. Agreement of partners regarding perceptions about the healthcare system appeared to be an important driver of decisions about delivery-location. These findings suggest that both partners should be included in the decision-making process regarding delivery to raise rates of delivery at facility

Comparison of visual and objective quantification of elbow and shoulder movement in children with obstetric brachial plexus palsy

BACKGROUND: The Active Movement Scale is a frequently used outcome measure for children with obstetric brachial plexus palsy (OBPP). Clinicians observe upper limb movements while the child is playing and quantify them on an 8 point scale. This scale has acceptable reliability however it is not known whether it accurately depicts the movements observed. In this study, therapist-rated Active Movement Scale grades were compared with objectively-quantified range of elbow flexion and extension and shoulder abduction and flexion in children with OBPP. These movements were chosen as they primarily assess the C5, C6 and C7 nerve roots, the most frequently involved in OBPP. Objective quantification of elbow and shoulder movements was undertaken by two-dimensional motion analysis, using the v-scope. METHODS: Young children diagnosed with OBPP were recruited from the Royal Children's Hospital (Melbourne, Australia) Brachial Plexus registry. They participated in one measurement session where an experienced paediatric physiotherapist facilitated maximal elbow flexion and extension, shoulder abduction and extension through play, and quantified them on the Active Movement Scale. Two-dimensional motion analysis captured the same movements in degrees, which were then converted into Active Movement Score grades using normative reference data. The agreement between the objectively-quantified and therapist-rated grades was determined using percentage agreement and Kappa statistics. RESULTS: Thirty children with OBPP participated in the study. All were able to perform elbow and shoulder movements against gravity. Active Movement Score grades ranged from 5 to 7. Two-dimensional motion analysis revealed that full range of movement at the elbow and shoulder was rarely achieved. There was moderate percentage agreement between the objectively-quantified and therapist-rated methods of movement assessment however the therapist frequently over-estimated the range of movement, particularly at the elbow. When adjusted for chance, agreement was equal to chance. CONCLUSION: Visual estimates of elbow and shoulder movement in children with OBPP may not provide true estimates of motion. Future work is required to develop accurate, clinically-acceptable methods of quantifying upper limb active movements. Since few children attained full range of motion, elbow and shoulder movement should be monitored and maintained over time to reduce disability later in life

Influence du couvert végétal sur l'hydrologie des crues, modélisation à validations multiples

La modélisation présentée ici a subi une double validation : expérimentale, par exploitation de bassins fortement contrastés en végétation, et méthodologique, par exploitation simultanée d'un modèle régional (descriptif synthétique) à démarche ascendante (QdF) et d'un modèle conceptuel global à démarche descendante (GR3J). Le bassin versant de l'Ardières à Beaujeu (54,5 km2) est un petit bassin versant montagneux, recouvert sur 90 % de sa superficie d'une forêt de sapins, de feuillus ainsi que de prairies et sur les 10 % restants de vignobles. A proximité de celui-ci, le bassin versant de la Vauxonne à Buyon (49,3 km2), dont 70 % de la superficie sont plantés en vigne et 30 % sont occupés par la forêt et les prairies, présente des crues bien différenciées, de celles de son voisin, en général plus rapides et deux fois plus intenses. Nous pouvons penser que cette différence de comportement hydrologique est liée au mode d'occupation des sols et plus précisément au système sol-végétation. Dans un premier temps, nous montrons que la paramétrisation des modèles, fortement différenciée d'un bassin versant à l'autre, est la "signature" (toutes choses égales par ailleurs) du rôle joué par l'entité végétale sur les crues observées. Dans un deuxième temps, l'exemple de simulation choisi permet de quantifier et de comparer, pour une même pluie "fictive" d'entrée, le comportement hydrologique en crue d'un petit bassin (environ 50 km2) forestier ou vignoble, dans un contexte pluviométrique bien différencié, de type océanique ou continental alpin. (Résumé d'auteur

Speedy Techniques to Evaluate Seismic Site Effects in Particular Geomorphologic Conditions: Faults, Cavities, Landslides and Topographic Irregularities

The ground motion that can be recorded at the free surface of a terrain is the final result of a series of phenomena that can be grouped into three fundamental typologies: the source mechanism, the seismic wave propagation till the bedrock interface below the investigated site and the site effects (Fig. 1). The first two features define the kind of seismic input whereas the third represents all modifications that can occur as a consequence of the interaction between seismic waves and local characteristics of the investigated site. The physical and mechanical properties of terrains as well as their morphologic and stratigraphic features appreciably affect the characteristics of the ground motion observed at the surface. The whole process of modifications undergone by a given seismic input in terms of amplitude, frequency content and duration, as a consequence of local characteristics, is generally termed the “local seismic response”. It is indeed well known that the spectral composition of a seismic event is modified first during the source-bedrock path (attenuation function), and second, when the seismic input interacts with the soft terrains layered between the bedrock and the free surface (Fig. 1a). This latter effect, significantly changes the spectral content so that it is extremely important for estimating the final input to which all structures built in the study area will be subjected.peer-reviewe

Feldenkrais Method Balance Classes Improve Balance in Older Adults: A Controlled Trial

The objective of this study was to investigate the effects of Feldenkrais Method balance classes on balance and mobility in older adults. This was a prospective non-randomized controlled study with pre/post measures. The setting for this study was the general community. A convenience sample of 26 community-dwelling older adults (median age 75 years) attending Feldenkrais Method balance classes formed the Intervention group. Thirty-seven volunteers were recruited for the Control group (median age 76.5 years). A series of Feldenkrais Method balance classes (the 33312Getting Grounded Gracefully33313 series), two classes per week for 10 weeks, were conducted. Main outcome measures were Activities-Specific Balance Confidence (ABC) questionnaire, Four Square Step Test (FSST), self-selected gait speed (using GAITRite instrumented gait mat). At re-testing, the Intervention group showed significant improvement on all of the measures (ABC, P = .016, FSST, P = .001, gait speed, P < .001). The Control group improved significantly on one measure (FSST, P < .001). Compared to the Control group, the Intervention group made a significant improvement in their ABC score (P = .005), gait speed (P = .017) and FSST time (P = .022). These findings suggest that Feldenkrais Method balance classes may improve mobility and balance in older adults

Making and shaping endochondral and intramembranous bones

Skeletal elements have a diverse range of shapes and sizes specialized to their various roles including protecting internal organs, locomotion, feeding, hearing, and vocalization. The precise positioning, size, and shape of skeletal elements is therefore critical for their function. During embryonic development, bone forms by endochondral or intramembranous ossification and can arise from the paraxial and lateral plate mesoderm or neural crest. This review describes inductive mechanisms to position and pattern bones within the developing embryo, compares and contrasts the intrinsic vs extrinsic mechanisms of endochondral and intramembranous skeletal development, and details known cellular processes that precisely determine skeletal shape and size. Key cellular mechanisms are employed at distinct stages of ossification, many of which occur in response to mechanical cues (eg, joint formation) or preempting future load‐bearing requirements. Rapid shape changes occur during cellular condensation and template establishment. Specialized cellular behaviors, such as chondrocyte hypertrophy in endochondral bone and secondary cartilage on intramembranous bones, also dramatically change template shape. Once ossification is complete, bone shape undergoes functional adaptation through (re)modeling. We also highlight how alterations in these cellular processes contribute to evolutionary change and how differences in the embryonic origin of bones can influence postnatal bone repair