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Musculoskeletal radiology: then and now.

Musculoskeletal radiologists, owing to recent advances in imaging technologies and techniques, are playing an increasingly important role in documenting, diagnosing, and treating an increasing variety of bone and soft-tissue lesions. However, improved visualization of anatomic aberrations-"seeing better"-must be paired with "knowing more," on the basis of complete familiarity with all aspects of the biology, physiology, pathophysiology, and static anatomy of the musculoskeletal system. Only with foreknowledge of the latter can the musculoskeletal radiologist fully maximize the benefits of the former.

Biology↗

Microscopic polyarteritis: presentation, pathology and prognosis.

We have described 34 patients with microscopic polyarteritis, all of whom had clinical evidence of a systemic small vessel vasculitis predominantly affecting the skin and musculoskeletal systems accompanied by a focal necrotising glomerulonephritis with renal impairment. Thirty three patients received immunosuppressive treatment, comprising prednisolone, azathioprine, cyclophosphamide and plasma exchange in various combinations. The five-year actuarial patient and kidney survival rates were 65 and 55 per cent respectively, suggesting that aggressive immunosuppressive therapy in these patients is beneficial.

Adolescent↗

Descriptive profile of birth defects among livebirths in Singapore.

A case-control study of birth defects was carried out in Kandang Kerbau Hospital in Singapore for a three-year period from January 1986 until December 1988. This paper presents the descriptive profile of birth defects among livebirths seen in that hospital. Out of 44,842 livebirths, 678 babies were found to have birth defects, giving a prevalence of 15.13 per 1000 livebirths (95% CI 14.0-16.2). The musculoskeletal system was the most frequently affected system accounting for 161 cases with a prevalence of 3.59 per 1,000 livebirths (95% CI 3.06-4.19), followed by 111 cases with defects of the gastrointestinal system (2.47 per 1,000 livebirths 95% CI 2.04-2.98), 88 cases of chromosomal disorders (prevalence of 1.96 per 1,000 livebirths 95% CI 1.57-2.42), 78 cases with defects of the cardiovascular system (1.74 per 1,000 livebirths 95% CI 1.38-2.17), 73 cases with defects of the urogenital system (1.63 per 1,000 livebirths 95% CI 1.28-2.05), and 52 cases with defects of the central nervous system (1.16 per 1,000 livebirths 95% CI 0.87-1.52). The prevalence of cleft lip, cleft palate in isolation, and cleft lip and palate combined was 1.72 per 1,000 livebirths and the occurrence of Down's syndrome was 1 in 700 livebirths. When reviewed 6 weeks postpartum, the rate of false positives at birth was 4%. In a control group of 709 "normal" cases at birth, the rate of cases not detected at birth but detected at 6 week follow-up, false negatives was 0.84%.

Case-Control Studies↗

The occurrence, nature and distribution of flares in a cohort of patients with systemic lupus erythematosus: a rheumatological view.

This study examines the occurrence, nature and distribution of disease flares in systemic lupus erythematosus (SLE) according to organ involvement. One-hundred-and-fourteen patients were seen in the Lupus Clinic of the Bloomsbury Rheumatology Unit over a 3-yr period. At each visit a data sheet was completed to assess their disease activity in eight separate organs/systems according to the British Isles Lupus Assessment Group (BILAG) activity index. This information was entered into a computer and a score for each organ system was obtained. The record of each individual patient was examined to identify flares in the individual organs; 458 flares occurred in 107 patients. The majority of patients (69%) experienced more than one flare during the study period. Fifty-four per cent of patients had flares in more than one system simultaneously, but the majority (70%) of flares involved only one system. The most severe organ involvement (A score) was most commonly observed in the musculoskeletal system, whereas severe renal disease occurred only three times. These results indicate that although SLE is a multisystem disease, the flares that occur tend to be confined to one system at a time. Further, these results demonstrate that in our rheumatology practice the most common 'A' flare observed was severe polyarthritis (A score in musculoskeletal).

Adult↗

A hierarchical neural-network model for control and learning of voluntary movement.

In order to control voluntary movements, the central nervous system (CNS) must solve the following three computational problems at different levels: the determination of a desired trajectory in the visual coordinates, the transformation of its coordinates to the body coordinates and the generation of motor command. Based on physiological knowledge and previous models, we propose a hierarchical neural network model which accounts for the generation of motor command. In our model the association cortex provides the motor cortex with the desired trajectory in the body coordinates, where the motor command is then calculated by means of long-loop sensory feedback. Within the spinocerebellum--magnocellular red nucleus system, an internal neural model of the dynamics of the musculoskeletal system is acquired with practice, because of the heterosynaptic plasticity, while monitoring the motor command and the results of movement. Internal feedback control with this dynamical model updates the motor command by predicting a possible error of movement. Within the cerebrocerebellum--parvocellular red nucleus system, an internal neural model of the inverse-dynamics of the musculo-skeletal system is acquired while monitoring the desired trajectory and the motor command. The inverse-dynamics model substitutes for other brain regions in the complex computation of the motor command. The dynamics and the inverse-dynamics models are realized by a parallel distributed neural network, which comprises many sub-systems computing various nonlinear transformations of input signals and a neuron with heterosynaptic plasticity (that is, changes of synaptic weights are assumed proportional to a product of two kinds of synaptic inputs). Control and learning performance of the model was investigated by computer simulation, in which a robotic manipulator was used as a controlled system, with the following results: (1) Both the dynamics and the inverse-dynamics models were acquired during control of movements. (2) As motor learning proceeded, the inverse-dynamics model gradually took the place of external feedback as the main controller. Concomitantly, overall control performance became much better. (3) Once the neural network model learned to control some movement, it could control quite different and faster movements. (4) The neural network model worked well even when only very limited information about the fundamental dynamical structure of the controlled system was available.(ABSTRACT TRUNCATED AT 400 WORDS)

Animals↗

Role of visual input in nonlinear postural control system.

Stabilometry signals involve irregular and unpredictable components. The purpose of the present study was to investigate these signals with a nonlinear technique to examine how the complexity of the postural control system breaks down under altered visual conditions. We evaluated the dynamical similarities of the postural control system when the eyes were open or closed, or when there was optokinetic stimulation (OKS). A similarity index was calculated by the cross-correlation integral between the two dynamics: eyes open and eyes closed, or eyes open with OKS. Using this technique, dynamical changes were not observed between eyes-open and eyes-closed conditions. This result suggests that the nonvision condition does not produce any striking effect on the postural control system; instead, the eyes-open condition causes a decrease in the stochastic activity of the postural control system, which may originate mainly from the stiffness of the musculoskeletal systems. In contrast, the visual input of OKS affected the dynamics of the postural control system in nearly half of the subjects (group 2) despite showing no significant differences between the eyes-open condition and the other conditions for area as the conventional parameter. However, the other half of the subjects (group 1) did not experience any influence of OKS on their postural dynamics, despite showing significant differences between eyes-open and the other conditions for all traditional parameters. From the results for group 2, we hypothesize that OKS may induce the striking effect on dynamics properties of the multilink network system involving visual and vestibular cortex related to self-motion perception, which acts to decrease the stochastic activity in order to correct disturbed posture.

Adult↗

Nutrition and cardiac cachexia.

PURPOSE OF REVIEW: Congestive heart failure is a leading cause of morbidity and mortality, especially in older persons. In advanced stages of the disease, congestive heart failure can be associated with serious complications such as cardiac cachexia (defined here as weight loss of more than 6% in 6 months). This review will discuss recent insights into the pathophysiology, anthropometric predictors and potential management of cardiac cachexia. RECENT FINDINGS: Cardiac cachexia and the associated progressive weight loss are sometimes overlooked by care providers. A delay in diagnosis often results in further loss of vital tissues, progressive weakness, fall-related injuries and potentially long-term care institutionalization and/or death. Emerging data suggest that congestive heart failure is a dynamic disorder of many organ systems, including the myocardial, neurohormonal, immune, vascular, gastrointestinal, renal and musculoskeletal systems. It is becoming more widely appreciated that it is the deterioration of this interactive multisystem complex that results in the systemic inflammation and progressive wasting and atrophy of muscle and other organ tissues, which is the hallmark of cardiac cachexia. SUMMARY: Cardiac cachexia in congestive heart failure patients may be associated with a low level of physical activity. A high systemic inflammatory state is another marker of cardiac cachexia. Prudent anti-inflammatory nutrition, dietary supplements and exercise can serve to ameliorate and/or potentially prevent progressive wasting. A better understanding of factors contributing to the development of cardiac cachexia will enable us to design preventive strategies and provide improved care for individuals with this debilitating condition.

Aged↗

[Schizoid versus hysterical personality structure. I: Symptoms and diseases].

This part examines the symptoms and diseases of neurotics with either a schizoid (38) or a hysterical (70) personality structure, comprising 5% and 10% respectively of the first admissions in 7 years. Compared to the hysterical structure, schizoids more frequently show the following characteristics: they are men and have as their secondary component a mixed character structure, an earlier age of onset, a longer duration of illness but earlier referral for psychotherapy. They suffer mainly from psychic symptoms--depressive states and contact difficulties as the indicating signs. Further complaints are defective concentration, feelings of apprehension and difficulty in working, also bulimia and the inability to breathe deeply. They were mostly born between 1940 and 1959. Their relatives suffered from psychiatric disorders. Compared to the schizoids, hysterically structured individuals are almost exclusively women, their second most important structural component being obsessive-compulsive. They develop their illness later, have it for a shorter time and are referred for psychotherapy later. Their indicating signs manifest themselves more often somatically, less frequently as anxiety states or phobias. The symptoms occur simultaneously in several organ systems, particularly the respiratory tract, the gastrointestinal tract and the musculoskeletal system. Common symptoms are dyspnea and/or hyperventilation tetany, nausea, weight gain, frigidity and fluor as well as crying fits. They formerly suffered from gynecological disorders and had to undergo operations. They were mainly born between 1920 and 1939. Their relatives had cardiac disorders and their symptoms were identical or similar to those of their father.

Adolescent↗

Occupational hazards of dentistry.

Dental professionals are susceptible to a number of occupational hazards. Relying on relevant literature, the present paper discusses selected occupational hazards - occupational biohazards, stressful situations, and latex hypersensitivity, as well as factors leading to the musculoskeletal system diseases and diseases of the peripheral nervous system.

Dentistry↗

Congenital anomalies in black South African liveborn neonates at an urban academic hospital.

STUDY OBJECTIVE: The aim was to study the spectrum of clinical problems and outcomes in infants born at an urban academic hospital. In consequence, as part of the overall study, the incidence of congenital anomalies and the outcomes of affected infants were recorded. DESIGN: This was a prospective, hospital-based study, undertaken on liveborn infants born over a 3-year period, 1 May 1986 to 30 April 1989. SETTING: Kalafong Hospital, Pretoria. MAIN RESULTS: A total of 17,351 liveborn infants was examined and the total congenital anomalies incidence was 11.87 per 1,000 livebirths. The central nervous system was the system most frequently involved (2.30 per 1,000 livebirths), followed by the musculoskeletal system (2.13 per 1,000 livebirths). The commonest individual congenital anomaly was Down syndrome (1.33 per 1,000 livebirths), followed by neural tube defects (0.99 per 1,000 livebirths) and ventricular septal defects (0.69 per 1,000 livebirths). In 11% (2.25 per 1,000 livebirths) of neonatal deaths, infant loss was attributable to congenital anomalies. CONCLUSIONS: The incidence of congenital anomalies in black South African neonates, born in an urban setting, is as high as in other First- and Third-World countries, and the incidence of some individual congenital anomalies is higher. This study indicates the need for further research and the establishment of prenatal, genetics and paediatric facilities to manage these problems.

Academic Medical Centers↗

The spectrum of paediatric and adolescent rheumatology.

A wide range of conditions comes under the umbrella of paediatric rheumatology. These problems are common in childhood and cover a wide variety of presentations and outcomes. Many conditions are benign and self-limiting, others run a chronic relapsing and remitting course; some are fatal. Broadly, rheumatological problems can be subdivided into inflammatory, mechanical, and behaviourally or psychologically driven aetiologies, although these are not mutually exclusive. The majority of patients with rheumatological conditions will present with symptoms that are easily localized to the musculoskeletal system. Sometimes, however, a child with a rheumatological condition may present less specifically: for example with fatigue, deterioration in school performance or growth retardation. In this case a rheumatological aetiology may be overlooked unless it is specifically suspected and a careful assessment for musculoskeletal symptoms and signs is undertaken. In order to arrive at the correct diagnosis and plan appropriate further management, it is therefore important for the clinician both to have an effective system to ensure that musculoskeletal symptoms are appropriately determined and assessed, and to be aware of the wide range of conditions, which can cause such symptoms in childhood and adolescence. The keys to this lie in acquiring the clinical skills necessary to accurately assess such patients and awareness of the changing differential diagnosis with the age of the child. In this chapter, we aim to address these issues, initially by discussing the prevalence of musculoskeletal symptoms in children and adolescents and the various conditions which cause them, and subsequently by looking at common presentations of rheumatic disease in childhood and suggesting an approach to diagnosis in each case.

Adolescent↗

[Diseases of the locomotor system in forestry workers].

The most common hazards in the forestry that may induce disorders of the musculoskeletal system are vibrations, unfavorable microclimatic conditions, noise, over-time working hours, work load and long-term repeated movements. The objective of this study was to analyze the prevalence of musculoskeletal diseases and its difference among workers engaged in various jobs in the forestry. Two groups of workers were selected: woodcutters operating with chain-saw (N=33) and other loggers (N=32). Selected workers were of the similar age and had similar total length of employment as well as the length of service in the forestry. Both groups of workers employed in the forestry had the high prevalence of musculoskeletal diseases (woodcutters 69.7% and other loggers 62.5%, respectively). Degenerative diseases of spinal column were very frequent, independently of the type of activity in the forestry. Non-significantly higher risk of carpal tunnel syndrome was found in woodcutters with chain-saw compared to workers having other jobs in the forestry (OR=3.09; 95%CI=0.64-19.72). The lateral epicondylitis was found only in woodcutters operating with chain-saw with the prevalence of 18.2%.

Adult↗

Tai chi for treating rheumatoid arthritis.

BACKGROUND: Rheumatoid arthritis (RA) is a chronic, systemic inflammatory autoimmune disease that results in the destruction of the musculoskeletal system. The major goals of treatment are to relieve pain, reduce inflammation, slow down or stop joint damage, prevent disability, and preserve or improve the person's sense of well-being and ability to function. Tai Chi, interchangeably known as Tai Chi Chuan, is an ancient Chinese health-promoting martial art form that has been recognized in China as an effective arthritis therapy for centuries. OBJECTIVES: To assess the effectiveness and safety of Tai Chi as a treatment for people with RA. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register (CCTR), MEDLINE, Pedro and CINAHL databases up to September 2002, using the Cochrane Collaboration search strategy for randomised controlled trials. We also searched the Chinese Biomedical Database up to December 2003 and the Beijing Chinese Academy of Traditional Medicine up to December 2003. SELECTION CRITERIA: Randomized controlled trials and controlled clinical trials examining the benefits and harms of exercise programs with Tai Chi instruction or incorporating principles of Tai Chi philosophy were selected. We included control groups who received no therapy, sham therapy or another type of therapy. DATA COLLECTION AND ANALYSIS: Two reviewers determined the studies to be included in this review, rated the methodological quality and extracted data using standardized forms. MAIN RESULTS: Four trials including 206 participants, were included in this review. Tai Chi-based exercise programs had no clinically important or statistically significant effect on most outcomes of disease activity, which included activities of daily living, tender and swollen joints and patient global overall rating. For range of motion, Tai Chi participants had statistically significant and clinically important improvements in ankle plantar flexion. No detrimental effects were found. One study found that compared to people who participated in traditional ROM exercise/rest programs those in a Tai Chi dance program reported a significantly higher level of participation in and enjoyment of exercise both immediately and four months after completion of the Tai Chi program. REVIEWERS' CONCLUSIONS: The results suggest Tai Chi does not exacerbate symptoms of rheumatoid arthritis. In addition, Tai Chi has statistically significant benefits on lower extremity range of motion, in particular ankle range of motion, for people with RA. The included studies did not assess the effects on patient-reported pain.

Arthritis, Rheumatoid↗

Three-dimensional spatial tuning of neck muscle activation in humans.

The complex structure of the neck musculoskeletal system poses challenges to understanding central nervous system (CNS) control strategies. Examining muscle activation patterns in relation to musculoskeletal geometry and three-dimensional mechanics may reveal organizing principles. We analyzed the spatial tuning of neck muscle electromyographic (EMG) activity while subjects generated moments in three dimensions. EMG tuning curves were characterized by their orientation (mean direction) and focus (spread of activity). For the four muscles that were studied (sternocleidomastoid, splenius capitis, semispinalis capitis and trapezius), EMG tuning curves exhibited directional preference, with consistent orientation and focus among 12 subjects. However, the directional preference (orientation) of three of the four neck muscles did not correspond to the muscle's moment arm, indicating that maximizing a muscle's mechanical advantage is not the only factor in determining muscle activation. The focus of muscle tuning did not change with moment magnitude, demonstrating that co-contraction did not increase with load. Axial rotation was found to have a strong influence on neck muscle spatial tuning. The uniform results among subjects indicate that the CNS has consistent strategies for selecting neck muscle activations to generate moments in specific directions; however, these strategies depend on three-dimensional mechanics in a complex manner.

Adult↗

Skin is the most frequently damaged system in recent-onset systemic lupus erythematosus in a tropical region.

The objective of this study was to evaluate the early damage as measured by the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SLICC/ACR DI) in Brazilian systemic lupus erythematosus (SLE) patients with disease duration of 2 and 3 years and to evaluate the possible association between SLICC/ACR DI score and sociodemographic and clinical data. The SLICC/ACR DI was measured in 54 patients with SLE according to the ACR criteria for SLE and a mean (SD) disease duration of 29 (3.8) months. The patients were provided by outpatient clinics and hospitals of the public health network and private clinics in the city of Natal in Brazil. The SLICC/ACR DI scores for each type of organ damage, prevalence of damage within organ systems, and the association with sociodemographic variables were assessed. Disease duration was considered as the time from diagnosis until the study. Organ damage was present in 18 (33%) of the 54 patients while 36 patients (67%) had no damage. The skin (11%), renal (9%), and pulmonary (7.4%) systems were the most frequently involved, followed by the neuropsychiatric and musculoskeletal systems, premature gonadal failure, and diabetes. The most frequent individual items on the SLICC/ACR DI were scarring chronic alopecia and pleural fibrosis. No association was demonstrated between organ damage (SLICC/ACR scores) and sociodemographic and clinical variables. Early organ damage demonstrated in Brazilian patients with SLE was similar to other populations studied in the world, despite a low socioeconomic status. In contrast to reports in other studies, a cutaneous lesion was the most frequent cause of damage in our patients.

Adult↗

Juvenile polyarteritis: results of a multicenter survey of 110 children.

OBJECTIVE: To characterize pediatric patients who had been diagnosed with polyarteritis nodosa (PAN) through necrotizing vasculitis of the small and mid-size arteries or those with characteristic findings on angiograms data were collected. STUDY DESIGN: Pediatricians were asked to classify their patients into one of the four suggested groups for juvenile PAN. Twenty-one pediatric centers worldwide participated with 110 patients. RESULTS: The girl:boy ratio was 56:54, with a mean age of 9.05 +/- 3.57 years. The cases were classified as: 33 (30%) cutaneous PAN; 5 (4.6%) classic PAN associated with hepatitis B surface antigen (HBs Ag); 9 (8.1%) microscopic polyarteritis of adults associated with antineutrophil cytoplasmic antibodies (ANCA); and 63 (57.2%) systemic PAN. Cutaneous PAN was disease confined to the skin and musculoskeletal system. All patients with HBs Ag-associated classic PAN were diagnosed with renal angiograms. Antiviral treatment was administered in most cases. Microscopic PAN patients had pulmonary-renal disease, in combination or separately. ANCA was present in 87%, and 2 patients progressed to end-stage renal failure. Patients classified with systemic PAN had multiple system involvement, almost all had constitutional symptoms, and all had elevated acute phase reactants. Corticosteroids and cyclophosphamide were the first choices of immunosuppressive treatment. The overall mortality was 1.1%. CONCLUSIONS: There were remarkable differences among pediatric patients with PAN, with different clinical manifestations and overall better survival and lower relapse rates when compared with adults.

Adolescent↗

Brucellar spondylitis and meningoencephalitis: a case report.

Brucellosis, a zoonosis with a worldwide distribution, is a systemic infection that can present with involvement of both nervous and musculoskeletal systems. We report a case of spondylitis and meningoencephalitis and describe the clinical features, and difficulties in treatment. Osteoarticular complications of brucellosis are common but involvement of the nervous system is rare and it should be included in the differential diagnosis of any obscure neurologic disorder.

Anorexia↗

Multiple births and congenital anomalies in Tokyo Metropolitan Hospitals, 1979-1990.

The rate of multiple births and the incidence of congenital anomalies in Tokyo Metropolitan Hospitals were studied during the period 1979-1990. The number of twins was 968 pairs (8.23 per 1,000 deliveries) and of triplets 18 sets (15.3 per 100,000 deliveries) among 117,672 deliveries including 1,587 stillbirths after 16 weeks gestation. Multiple birth rates increased yearly. Stillbirth rates in twins and triplets were 5.5% and 16.7% respectively, which were both significantly higher than that in singletons (1.3%). The number of congenital anomalies was 42 in 1,936 twins (2.17%), 2 in 54 triplets (3.7%) and 1721 in 116,686 singletons (1.47%). The most common defects in twins were those of the cardiovascular system (0.72% in twins vs 0.52% in singletons) and of the musculoskeletal system (0.72% in twins vs 0.50% in singletons), followed by upper respiratory tract and/or mouth conditions (0.67% in twins vs 0.35% in singletons), all of which had no significant difference in frequency between twins and singletons. Though some anomalies had a significantly higher frequency in twins than in singletons, the concordance rate in the like-sexed twins was very low.

Congenital Abnormalities↗