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PubMed2001

First trimester surgical abortion practices: a survey of National Abortion Federation members.

The objective of this study was to survey first trimester surgical abortion practices of North American providers. A survey was mailed to the 310 active member clinics of the National Abortion Federation, the professional organization of abortion providers in North America. The 236 respondents (76%) comprising the study group provided approximately 30% and 33% of all first trimester abortions in the US and Canada, respectively. Of the 529 practitioners who perform most abortions at the clinics, 68% are obstetrician-gynecologists, and 18% are family physicians; 51% are at least 50 years old. The majority of respondents (156 of 236, 66%) confirm gestational age with ultrasonography. Of the 202 clinics that favor one method of anesthesia, 58% use local cervical block with or without oral pre-medication, 32% combine local anesthesia with intravenous sedation, and 10% use general anesthesia. Most clinics open the cervix with tapered dilators (207 of 233, 89%), evacuate the uterus by using curved rigid plastic cannulas (157 of 229, 69%) and an electric vacuum source (191 of 233, 82%), and explore the uterus with a metal curette following aspiration (133 of 232, 57%). A large majority of respondents examine the uterine aspirate on-site (91%), prescribe antibiotics (91%), and offer oral contraceptives (95%) when requested. Although variations exist, surgical techniques and postoperative practices are quite uniform among clinics. Local anesthesia is presently the most frequent method of pain control. Ultrasonographic dating before abortion is common practice. The "graying" of skilled practitioners raises concerns about the future availability of abortion.

Abortion, Legal↗

PubMed1982

Fibrin seal application. Clinical experience.

Clinical experience with fibrin gluing in cardiovascular surgery now extends over 4 years. The adhesive has been employed prophylactically for preclotting of prostheses or sealing of various suture lines including those of the bronchial system of infants. Together with collagen fleece it has turned out to be most effective for control of superficial bleeding due to adhesions or sources of bleeding difficult to reach. Two clinical examples are presented demonstrating the life-saving application of the collagen patch and fibrin gluing method.

Adult↗

PubMed2000

Clinically significant gastrointestinal bleeding in critically ill patients in an era of prophylaxis.

OBJECTIVE: Clinical studies examining stress-related gastrointestinal bleeding in critically ill patients vary in their clinical definitions and assessment of clinical significance. Although there is evidence that routine prophylaxis decreases stress-related gastrointestinal bleeding, recent studies indicate a decreasing incidence, independent of the use of prophylactic medications. The purpose of this study was to determine the incidence of and risk factors for clinically significant, endoscopically proven gastrointestinal bleeding in critically ill patients. METHODS: A database (prospectively collected data) of 8338 patients admitted to the surgical and medical intensive care units at major tertiary care center from July 1988 to April 1995 was examined. All patients with significant upper gastrointestinal bleeding as defined by a drop in hemoglobin of >20 g/L and endoscopic evidence of an upper GI tract source were identified. Risk factors for GI bleeding from stress ulceration were compared in bleeding and nonbleeding patients. A case-control study analyzing risk factors for bleeding in the abdominal aortic aneurysm subgroup was performed. RESULTS: After exclusion criteria, 12/7231 (0.17%) patients had clinically significant, endoscopically proven bleeding. Significant risk factors included age, septic shock, abdominal aortic aneurysm repair, and nutritional support. Intensive care unit stay was prolonged in patients with stress-related bleeding. There was no difference in incidence of hypotension, clamp time, APACHE score, or operating room time in patients with abdominal aortic aneurysm repair as compared with controls. CONCLUSIONS: In an intensive care unit where stress prophylaxis is widely used, clinically important gastrointestinal bleeding is uncommon. Further study is needed to define the optimal prophylaxis regimen and the role for its selective use in high-risk patients.

Aged↗

PubMedDate not supplied

[Analysis of several causes of inadequate surgical treatment of epilepsy].

From the analysis of 100 cases with stereotaxic and "classical" surgical treatment of epilepsy several premises are drawn. The source of possible errors in the topical diagnosis of an epileptic focus may be overestimation in some case of the results of routine neuroradiological examination, and the possibility of the existence of reciprocal interrelationship of the epileptic foci and the activation of one of them in removal of the other. The authors suggests a method of control over the activity of intact foci after removal of the dominating elements of the epileptic systems. Some doubt is expressed concerning the diagnostic value of control (i. e. after removal of the focus) ECG examination and the conviction is stated for the need of widen the volume of single-stage stereotaxic operations by combining the destruction of the most active elements of the epileptic systems.

Adult↗

PubMed1998

Predictors of length of stay for transurethral prostatectomy in Victoria.

BACKGROUND: Transurethral resection of prostate (TURP) is among the top 10 surgical conditions that account for hospital admission in Victoria. Bed utilization for TURP is an increasing concern in current times. This paper describes trends in length of stay (LOS) and identifies predictors of LOS for TURP in Victoria. METHODS: Trends in TURP were studied using ICD-9-CM coded Victorian hospital morbidity data from public hospitals from 1987/88 to 1994/95. Detailed morbidity data from the same source for the financial year 1995/96 were used to study predictors of LOS by logistic regression. RESULTS: Length of stay decreased significantly between 1987 and 1995 from 10.6 to 6.1 days. The strongest predictor of increased LOS was admission through the emergency room (odds ratio (OR) 14.7; 95% confidence interval (CI) 11.8-18.3). Other significant predictors were older age, lower socio-economic status, presence of comorbid conditions, occurrence of procedural morbidity, and hospital type and location. CONCLUSIONS: The trend in decreasing LOS may be explained by increasingly efficient bed management in hospitals who are faced with an increasing need for cost control. Advances in surgical techniques and peri-operative care have also contributed to the decrease in LOS. Other factors that influence LOS can be divided into three categories: intrinsic patient factors, such as co-morbid conditions; procedure-specific factors such as peri-operative morbidity; and intrinsic hospital factors relating to capacity and resources. Such determinants of LOS may be of value to policy makers when considering the effective application of newer methods for treatment of benign prostatic hyperplasia.

Adult↗

PubMed1990

[Financial planning for surgical research. Project portfolio as an instrument for research planning].

Planning of research funding should assure both volume and continuity of economic support. Funding of new research concepts usually depends largely on the internal budget of the research institution (primary economical resources). More mature projects can be funded by governmental and non-profit (secondary) or industrial sources (tertiary economical resources). In general, a balanced proportion of financial support will assure maximal research independence. The respective funding of a research project should be regarded as extrinsic to the quality of the said project. Portfolio analysis of research projects is introduced as a new means of planning and controlling academic and industrial research. In principle, research projects will be evaluated with regard to the inherent potential of development (e.g. potential impact on clinical or scientific concepts) and the current productivity (e.g. output of results and publications). The 2-dimensional portfolio-matrix will be used to analyse these factors, manifesting both the overall activity of a research unit and the development of new research and funding strategies. In addition, repetitive project-portfolio analyses will enable control of both spending and efficiency in research. The application of the current project-portfolio method is exemplified by an analysis of the research activities of the department of surgery at the university of Basel. To date, project-portfolio analysis is not a mature method: Development of more quantitative portfolio strategies and of multidimensional project-portfolios are proposed. However, project-portfolio analysis is a promising means of planning and controlling research. It should be used and developed further in institutions with a number of concurrent research activities.

Animals↗

PubMed2001

Combined chemotherapy and radiotherapy (without surgery) compared with radiotherapy alone in localized carcinoma of the esophagus.

BACKGROUND: Esophageal carcinoma can be managed primarily with either a surgical or radiotherapeutic (non surgical) approach. Strategies to improve the outcome of either modality alone include the use of combined modalities. Combination chemotherapy radiotherapy is one approach that has been explored over the years with increasing application in clinical practice especially in North America. OBJECTIVES: To evaluate the effectiveness of combined chemotherapy and radiotherapy versus radiotherapy alone in the outcome of patients with localized esophageal carcinoma. Outcomes of interest include overall survival, cause specific survival, local recurrence, dysphagia relief, quality of life, acute and chronic toxicities. SEARCH STRATEGY: The Cochrane strategy for identifying randomized trials was combined with MeSH headings including esophageal neoplasms, radiotherapy, chemotherapy combined modality, drug therapy combination. Medline, Cancerlit and Embase were searched using this strategy. In addition, the Cochrane library was also searched. References from relevant articles and personal files were included. SELECTION CRITERIA: Randomized controlled trials in patients with localized esophageal cancer, with one arm employing radiotherapy alone, and one arm employing combination radiotherapy chemotherapy were included. Studies comparing non chemotherapy agents such as pure radiotherapy sensitisers, immunostimulants, planned esophagectomy, were excluded. DATA COLLECTION AND ANALYSIS: Data were extracted by two independent reviewers, and the trial quality was assessed using both the Jadad scoring and Detsky checklist. Sensitivity analysis was planned to explore sources of heterogeneity where heterogeneity existed. The factors hypothesized a priori included combination versus sequential treatment, quality of study, biological effective radiotherapy dose (i.e. Radiotherapy dose) cisplatin versus non cisplatin containing trials, and 5FU versus non 5FU containing trials. Odds Ratio (OR) and 95% confidence limits were used to assess the significance of the difference between the treatment arms. Absolute risk difference and number needed to treat (NNT) were used to express the magnitude of difference where appropriate. MAIN RESULTS: Thirteen randomized trials were included in the analysis. There were eight concomitant and five sequential radiotherapy and chemotherapy (RTCT) studies. The studies were analyzed separately due to observed heterogeneity across all the studies and biological considerations. Concomitant RTCT provided significant overall reduction in mortality at 1 and 2 years. The mortality in the control arms was 67% and 86% respectively. Combined RTCT provided an absolute reduction of mortality by 9% (95% CI 2-17%) and 8% (95% CI 1-17%) respectively. Expressed as NNT, this is 11 and 10 respectively. At longer follow up, the results were heterogeneous, cautioning against pooling of the data. There was a reduction in the overall local recurrence rate. The local recurrence rate for the control arms was in the order of 69%. Combined RTCT provided an absolute reduction of local recurrence rate of 5% (95% CI 4-26%) with a NNT of 7. There was significant increase of severe and life threatening toxicities with a NNH of 6, with this approach. With the sensitivity analysis, there was a suggestion that cisplatin based and 5FU based chemotherapy studies were reasonable regimens to employ when using this strategy. The results from the sequential RTCT studies were heterogeneous and could not be pooled. Factors hypothesized a priori did not identify any single source that could account for a significant component of the heterogeneity. Examining the results individually, there was no data to support clinical benefit. This approach was also accompanied by significant toxicities. REVIEWER'S CONCLUSIONS: When a non-operative approach is selected, then concomitant RTCT is superior to the RT alone. This approach is accompanied by significant toxicities. In patients who are in good general condition, and the risk benefit has been thoroughly discussed with the patient, concomitant RTCT should be considered for the management of esophageal cancer compared with radiotherapy alone.

Combined Modality Therapy↗

PubMed2001

Transmission of hepatitis C virus in a gynecological surgery setting.

A cluster of hepatitis C virus (HCV) infections among gynecological patients who underwent surgical intervention in the same setting is described. An epidemiological investigation was conducted to identify the cases, the likely source of infection, and the route of transmission. Four recent HCV infections were identified. Based on molecular fingerprinting analysis and epidemiological investigation, transmission between the putative source patient (an HCV-positive woman who was the first patient of the surgical session) and outbreak patients was highly suggestive. All patients, including the source patient, were infected with HCV type 1b. Molecular characterization of HCV clones by sequence analysis of both structural envelope regions (20 clones from the source patient and 58 from the outbreak patients) and the nonstructural NS5 region of the viral genome (12 clones from the source patient and 32 from the outbreak patients) showed close homology between the viral isolates from the source and those from the outbreak patients that was higher than that observed between the viral isolates from the source and those from four unrelated, HCV type 1b-infected patients from the same geographical area (in the latter case, 33 clones were sequenced for the envelope regions and 30 were sequenced for the NS5 region). The mean percent divergence between clones was 4.69 for the envelope and 3.71 for the NS5 region in the source patient and the outbreak patients compared with 6.76 (P = 0.001) and 5.22 (P = 0.01) in the source patient and control patients, respectively. Among the risk factors investigated, only that of having undergone surgery in the morning session of the same day reached statistical significance (P = 0.003). The investigation showed that the source patient and outbreak patients shared only the administration of propofol in multidose vials. The study documents the risk of nosocomial transmission of HCV and the importance of infection control procedures in the operating room and highlights the crucial role of molecular strategies, especially sequence-based phylogenetic analysis of cloned viral isolates, in the investigation of HCV outbreaks.

Adult↗

PubMed1993

Acetylcholinesterase staining and choline acetyltransferase activity in the young adult rat spleen: lack of evidence for cholinergic innervation.

Acetylcholinesterase (AChE) staining in spleens from young adult Sprague-Dawley rats was examined following several denervation paradigms to determine the source of splenic AChE+ nerve fibers. In spleens from all control groups, AChE+ neural-like profiles were present along the vasculature and in the trabeculae. AChE+ reactivity also was present in lymphoid and reticular cells in the spleen, and in neuronal cell bodies in the superior mesenteric-coeliac ganglion (SM-CG). Neurochemical analysis revealed no significant choline acetyltransferase activity in spleens from control animals. Surgical removal of the SM-CG resulted in a total loss of both noradrenergic (NA) and AChE+ nerve profiles, as well as a loss of AChE staining in nonneural compartment in the spleen. On Days 1 and 3 after treatment, chemical sympathectomy with 6-hydroxydopamine also resulted in a loss of both NA and AChE nerve profiles in the spleen, except for a few resistant fibers in the hilar region. AChE reactivity in nonneural compartments also was diminished in chemically denervated regions of the spleen. AChE staining in both neural and nonneural profiles progressively increased from 10 to 56 days after chemical sympathectomy, with a time course and distribution pattern similar to NA fibers reinnervating the spleen. AChE+ staining was preserved following bilateral vagal nerve transection. The miniscule splenic levels of choline acetyltransferase suggest that at best, only a small density of cholinergic nerves distribute to the rat spleen. Further, what cholinergic innervation is present does not arise from the vagus nerve as suggested in the earlier literature. Collectively, the overlapping distribution of AChE+ and NA nerve profiles in spleen and parallel loss of both population of nerve fibers following surgical and chemical sympathectomy support the presence of AChE in NA nerves colocalized with norepinephrine, and thus make AChE+ staining an inappropriate marker for cholinergic innervation in the rat spleen.

Acetylcholinesterase↗

PubMedDate not supplied

Radiotherapy of incompletely resected, moderately differentiated mast cell tumors in the dog: 37 cases (1989-1993).

Thirty-seven dogs with moderately differentiated, cutaneous mast cell tumors had incomplete surgical excisions as determined by histopathology, but no gross evidence of tumor. All dogs were irradiated to a total dose of between 46.2 and 48.0 Gy using either an orthovoltage source (n = 20) or a linear accelerator (megavoltage) (n = 17). Radiation was delivered to an area bordered by margins of 3 cm or greater around the surgical scar. The mast cell tumors had not recurred in 97% of dogs by one year after radiation therapy and had not recurred in 93% of dogs by three years after radiation. Both orthovoltage and megavoltage radiation provide excellent local control of moderately differentiated mast cell tumors in dogs.

Animals↗

PubMed2003

Off-Pump versus on-pump coronary artery bypass: can OPCAB reduce neurologic injury?

OBJECTIVE: Coronary artery bypass grafting (CABG) with cardiopulmonary bypass is still the gold standard for surgical myocardial revascularization. Despite advances in techniques and technologies, documented evidence indicates that cardiopulmonary bypass remains the major source of intraoperative brain injury. This study was set up to test whether offpump coronary artery bypass (OPCAB) is superior to CABG regarding postoperative neurologic outcome or neurocognitive function. METHODS: Between January 1999 and June 2001, 251 patients scheduled for coronary revascularization were divided into 2 groups, CABG (control) and OPCAB. All patients underwent an extensive neurologic and neurocognitive battery of tests preoperatively and postoperatively at 48 hours, 7 days, and 3 months following surgery. RESULTS: There were no statistically significant differences between the 2 groups regarding the preoperative or intraoperative data. The means for patient age, number of grafts, and number of central anastomoses were, respectively, 65.4 years (CABG) and 64.6 years (OPCAB), 3.0 (CABG) and 2.2 (OPCAB), and 2.0 (CABG) and 1.2 (OPCAB). The occurrence of stroke was 2.3% (CABG) and 0% (OPCAB). CONCLUSION: Neurologic complications and postoperative neurocognitive dysfunction remain major concerns in coronary artery surgery. Besides the occurrence of stroke, which dramatically reduces the success of the heart operation, the importance of neurocognitive disorders for postoperative quality of life is not yet well defined. OPCAB significantly improves postoperative neurocognitive function, which may in turn improve the postoperative quality of life.

Aged↗

PubMed1994

Breast cancer prevention: a summary of the chemoprevention trial with tamoxifen.

PURPOSE/OBJECTIVES: To review the Breast Cancer Prevention Trial, which is testing tamoxifen as a chemoprevention agent. DATA SOURCES: Published articles and books; National Surgical Adjuvant Breast Project protocols. DATA SYNTHESIS: Because tamoxifen has proven to be an effective hormonal agent in the treatment of all stages of breast cancer and because it has a low side effect rate, a national study is under way to determine its effects as a breast cancer preventive agent. CONCLUSIONS: Results of this double-blind, placebo-controlled study will be available at the study's completion in 1997. IMPLICATIONS FOR NURSING PRACTICE: Providing patients with education, informed consent assistance, and help in adjusting to the drug's side effects and influences on quality of life.

Breast Neoplasms↗

PubMed1995

An extended study: protective effects of nerve growth factor in neomycin-induced auditory neural degeneration.

Intracochlear survival of auditory neurons is thought to be a factor contributing to the success of cochlear implantations. Damage to the cochlear end-organ is frequently associated with loss of neurites in the osseous spiral lamina. The authors have previously reported a model for long-term intracochlear administration of pharmacologic agents using a technique and device analogous to a cochlear implant. These studies suggest that nerve growth factor (NGF) protects the auditory nerve from the immediate neurotoxic effects of neomycin. The intent of the present investigation is to determine whether NGF can protect auditory neural elements from neomycin-induced degeneration after several weeks have elapsed between the neomycin perfusion and the administration of NGF. Neomycin was infused over 24 hours through an indwelling, intracochlear cannula attached to a mini osmotic pump to unilaterally destroy the cochlear end-organ. The pump perfused the cochlea with artificial perilymph for 2 weeks. Then, the pump reservoirs were surgically replaced; the new reservoirs delivered either NGF or artificial perilymph for an additional 2 weeks. Spiral ganglion cell densities were measured along Rosenthal's canal in the basal, middle, and apical cochlear turns. This investigation revealed that NGF prevented auditory nerve degeneration over the 2-week period, when compared to controls, and that the protective effect was greatest in the neural elements closest to the source of NGF.

Animals↗

PubMed2003

Irrigated bipolar radiofrequency ablation with transmurality feedback for the surgical Cox-Maze procedure.

BACKGROUND: Nonirrigated radiofrequency ablation (RFA) has been used to replicate the surgical scars of the Cox-Maze procedure. This study aimed to demonstrate that an irrigated, bipolar RFA energy source could also effectively replicate Cox-Maze lesions with impedance monitoring to predict the transmurality of ablated tissue. METHODS: A complete Cox-Maze lesion pattern was created ex vivo on fresh porcine atria using an irrigated, bipolar RFA system. Tissues were clamped between opposing electrodes with steady pressure to ensure an intimate tissue-electrode interface during ablation. A proprietary feedback and control algorithm monitored tissue impedance and terminated ablation when lesions were deemed transmural by a plateau in impedance decline. Ablation time and power, lesion width and length, and tissue thickness were recorded. Lesions were stained with 1% triphenyltetrazolium chloride and sectioned for gross assessment of transmurality. RESULTS: One hundred thirty-seven lesions were created on 11 porcine hearts. The total ablation time per lesion was 14.8 +/- 1.2 seconds (range, 10.0-19.0 seconds). Lesions averaged 4.2 +/- 1.3 mm (range, 1.3-10.2 mm) in width. Average tissue thickness was 3.0 +/- 1.7 mm (range, 0.5-9.9 mm). Crosssectional examination revealed that 100% of lesions were transmural (n = 718), and no tissue defects were observed. CONCLUSIONS: These results indicate that irrigated bipolar RFA energy can produce transmural Cox-Maze lesions ex vivo on intact porcine atria and that impedance monitoring is a reliable predictor of lesion transmurality. Additional in vivo studies are under way to further demonstrate the efficacy and safety of irrigated, bipolar RFA technology.

Animals↗

PubMed2002

Prevention of ischemic stroke.

The primary risk factors for stroke are known, and attention to primary care of these disorders should reduce the incidence of stroke significantly. Control of hypertension, diabetes, and hyperlipidemia have all been shown to reduce the rate of stroke. Identification of potential cardioembolic sources of stroke, particularly atrial fibrillation, can prevent stroke with appropriate application of anticoagulation. Duplex Doppler B-mode sonography can establish the extent of carotid artery disease in patients with cervical bruit or risk factors for atherosclerosis, and indicate which conditions should be managed medically or surgically. Patients with a history suggestive of transient ischemic attacks can also be screened noninvasively with duplex sonography to determine if they have a critical carotid stenosis and require carotid endarterectomy. New advances in platelet antiaggregant therapy with ticlopidine, clopidegril, and the combination of aspirin with dipyridamole have also reduced the rate of stroke to a greater degree than standard treatment with aspirin. The incidence of this devastating illness could possibly be reduced by 50% with attentive primary care management. The cardiologist is often involved in the treatment of patients at risk for stroke, and is in an ideal position to provide this care.

Arteriosclerosis↗

PubMed2002

Prevention of Ischemic Stroke.

The primary risk factors for stroke are known, and attention to primary care of these disorders should reduce the incidence of stroke significantly. Control of hypertension, diabetes, and hyperlipidemia have all been shown to reduce the rate of stroke. Identification of potential cardioembolic sources of stroke, particularly atrial fibrillation, can prevent stroke with appropriate application of anticoagulation. Duplex Doppler B-mode sonography can establish the extent of carotid artery disease in patients with cervical bruit or risk factors for atherosclerosis, and indicate which conditions should be managed medically or surgically. Patients with a history suggestive of transient ischemic attacks can also be screened noninvasively with duplex sonography to determine if they have a critical carotid stenosis and require carotid endarterectomy. New advances in platelet antiaggregant therapy with ticlopidine, clopidogrel, and the combination of aspirin with dipyridamole have also reduced the rate of stroke to a greater degree than standard treatment with aspirin. The incidence of this devastating illness could possibly be reduced by 50% with attentive primary care management. The cardiologist is often involved in the treatment of patients at risk for stroke, and is in an ideal position to provide this care.

Journal Article↗

PubMed1994

Abnormal Leydig cell development at puberty in the androgen-resistant Tfm mouse.

Leydig cells are the major source of androgens in the male, and it is likely that these cells are also targets for androgen action. The role of androgen action in regulating the development of Leydig cell function has been determined using the testicular feminized (Tfm/Y) mouse, which lacks androgen receptors. In Tfm mice, the testes fail to descend at the normal time (25 days), and testicular descent was, therefore, surgically prevented in control (+/Y) animals. The activity of 3 beta-hydroxysteroid dehydrogenase increased during development from 5-40 days in control and Tfm mice, with no significant difference between the groups. In control animals, 17 alpha-hydroxylase activity was low from 5-25 days, at which time there was a 26-fold increase up to 40 days. In the Tfm group, 17 alpha-hydroxylase activity was 4-fold higher than that in controls on day 5, but showed no change in activity after 25 days and remained at neonatal levels up to 40 days. The activity of 17-ketosteroid reductase in the control animals showed a developmental pattern similar to that of 17 alpha-hydroxylase, with a marked increase in activity after 25 days. In the Tfm group, 17-ketosteroid reductase was normal on day 5, but failed to show any significant change thereafter and remained at neonatal levels on day 40. Serum LH levels in control animals increased from 5 days to a peak at 30 days. In Tfm mice, LH levels were significantly increased on days 20 and 40, but did not differ from controls on days 5, 25, and 30. In control +/Y animals, in which normal testicular descent was allowed to proceed at 25 days, the pattern of development was similar to that in the cryptorchid +/Y animals, although the increase in 17 alpha-hydroxylase activity at 30 and 40 days was significantly greater. The results show 1) that fetal Leydig cell steroidogenesis is enhanced in the absence of androgen receptors, but 2) that adult Leydig cells require receptor-mediated androgen activity around day 25 for normal functional development. In addition, 3) the lack of testicular descent at 25 days reduces the pubertal rise in 17 alpha-hydroxylase activity.

3-Hydroxysteroid Dehydrogenases↗

PubMed2002

Bone density and metabolism in children and adolescents with moderate to severe cerebral palsy.

OBJECTIVES: Diminished bone density and a propensity to fracture with minimal trauma are common in children and adolescents with moderate to severe cerebral palsy (CP). The purpose of this study was to provide a detailed evaluation of bone mineral density (BMD) and metabolism in this population and to assess the relationship of these measures to multiple other clinical, growth, and nutrition variables. METHODS: The study group consisted of 117 subjects ages 2 to 19 years (mean: 9.7 years) with moderate to severe CP as defined by the Gross Motor Functional Classification scale. Population-based sampling was used to recruit 62 of the participants, which allows for estimations of prevalence. The remaining 55 subjects were a convenience sampling from both hospital- and school-based sources. The evaluation included measures of BMD, a detailed anthropometric assessment of growth and nutritional status, medical and surgical history, the Child Health Status Questionnaire, and multiple serum analyses. BMD was measured in the distal femur, a site specifically developed for use in this contracted population, and the lumbar spine. BMD measures were converted to age and gender normalized z scores based on our own previously published control series (n > 250). RESULTS: Osteopenia (BMD z score <-2.0) was found in the femur of 77% of the population-based cohort and in 97% of all study participants who were unable to stand and were older than 9 years. BMD was not as low in the lumbar spine (population-based cohort mean +/- standard error z score: -1.8 +/- 0.1) as in the distal femur (mean z score: -3.1 +/- 0.2). Fractures had occurred in 26% of the children who were older than 10 years. Multiple clinical and nutritional variables correlated with BMD z scores, but interpretation of these findings is complicated by covariance among variables. In stepwise regression analyses, it was found that severity of neurologic impairment as graded by Gross Motor Functional Classification level, increasing difficulty feeding the child, use of anticonvulsants, and lower triceps skinfold z scores (in decreasing order of importance) all independently contribute to lower BMD z scores in the femur. CONCLUSIONS: Low BMD is prevalent in children with moderate to severe CP and is associated with significant fracture risk. The underlying pathophysiology is complex, with multiple factors contributing to the problem and significant variation between different regions of the skeleton.

Adolescent↗