Comparison between innominate osteotomy and arthrodistraction as a primary treatment for Legg-Calve-Perthes disease: a prospective controlled trial

Legg-Calv,-Perthes (LCP) disease is currently managed by mechanical containment of the femoral head in the hip socket. As evidence suggests that hip distraction may offer a new treatment strategy, we used arthrodistraction as a primary treatment for active forms of LCP disease and prospectively compared the results with the Salter innominate osteotomy. A total of 54 children, six years or older of both genders with severe forms of LCP disease in the stages of necrosis or revascularisation, were enrolled. Patients were submitted to either Salter innominate osteotomy (n = 28) or hip arthrodistraction (n = 26). Final radiographs were used to evaluate the Mose index, Wiberg angle, extrusion index and the Stulberg et al. classification. There were no significant differences in gender, age, lateral pillar classification and average follow-up time between the two groups. The osteotomy group progressed without major complications, but children in the joint distraction group experienced episodes of pin tract pain and infection, leading to the early removal of the external device in one case. Two patients developed joint stiffness, treated by physiotherapy or manipulation, and one child developed subluxation of the femoral head. The average time in distraction was 4.44 months (2.53-7.23 months). In the final evaluation the osteotomy group showed better containment of the femoral head. The Mose index and the Stulberg et al. classification were statistically similar between the two groups. Despite similar final radiological results, arthrodistraction was associated with a higher morbidity. Consequently, we do not recommend hip distraction as a primary treatment for the early stages of LCP disease.

Assessment of integration of the Leprosy Program into primary health care in Aracaju, State of Sergipe, Brazil

Introduction: The aim of this study was to assess the epidemiological and operational characteristics of the Leprosy Program before and after its integration into the Primary Healthcare Services of the municipality of Aracaju-Sergipe, Brazil. Methods: Data were drawn from the national database. The study periods were divided into preintegration (1996-2000) and postintegration (2001-2007). Annual rates of epidemiological detection were calculated. Frequency data on clinico-epidemiological variables of cases detected and treated for the two periods were compared using the Chi-squared (chi(2)) test adopting a 5% level of significance. Results: Rates of detection overall, and in subjects younger than 15 years, were greater for the postintegration period and were higher than rates recorded for Brazil as a whole during the same periods. A total of 780 and 1,469 cases were registered during the preintegration and postintegration periods, respectively. Observations for the postintegration period were as follows: I) a higher proportion of cases with disability grade assessed at diagnosis, with increase of 60.9% to 78.8% (p < 0.001), and at end of treatment, from 41.4% to 44.4% (p < 0.023); II) an increase in proportion of cases detected by contact examination, from 2.1% to 4.1% (p < 0.001); and III) a lower level of treatment default with a decrease from 5.64 to 3.35 (p < 0.008). Only 34% of cases registered from 2001 to 2007 were examined. Conclusions: The shift observed in rates of detection overall, and in subjects younger than 15 years, during the postintegration period indicate an increased level of health care access. The fall in number of patients abandoning treatment indicates greater adherence to treatment. However, previous shortcomings in key actions, pivotal to attaining the outcomes and impact envisaged for the program, persisted in the postintegration period.

Ambulatory blood pressure monitoring in children with obstructive sleep apnea and primary snoring

Objective: To evaluate the systemic blood pressure (BP) during daytime and nighttime in children with sleep breathing disorders (SBD) and compare parameters of BP in children with diagnosis of obstructive sleep apnea syndrome (OSA) to those one with primary snoring (PS). Methods: Children, both genders, aged from 8 to 12 years, with symptoms of SBD realized an overnight polysomnography followed by a 24 h recording of ambulatory BP. Results: All subjects presented with a history of snoring 7 nights per week. Children who have apnea/hipoapnea index >= four or a apnea index >= one presented a mean BP of 93 +/- 7 mmHg and 85 +/- 9 mmHg diurnal and nocturnal respectively whereas children who have a apnea/hipoapnea < four or a apnea index < one presented 90 +/- 7 mmHg and 77 +/- 2 mmHg. Eight children out of fourteen, from OSA group, lost the physiologic nocturnal dipping of the blood pressure. Among OSA children 57% were considered non-dippers. Two (16%) have presented absence of nocturnal dipping among children with primary snoring. The possibility of OSA children loosing physiologic blood pressure dipping was 6.66 higher than the possibilities of patients from PS group. Discussion: Our results indicate that children with sleep apnea syndrome exhibit a higher 24 h blood pressure when compared with those of primary snoring in form of decreased degree of nocturnal dipping and increased levels of diastolic and mean blood pressure, according to previous studies in literature. OSA in children seems to be associated to the development of hypertension or other cardiovascular disease. (C) 2012 Elsevier Ireland Ltd. All rights reserved.

Parathyroid adenoma apoplexy as a temporary solution of primary hyperparathyroidism: a case report

Abstract Introduction The natural history of patients with spontaneous parathyroid necrosis is unknown. In this case report we describe the clinical course, laboratory, radiographic, bone densitometry tests, parathyroid ultrasonography and scintigraphy examinations of a patient performed over a period of eight years after she first presented with a sudden episode of spontaneous resolution of primary hyperparathyroidism (PHPT). Case presentation A 24-year-old woman with a clinical history and laboratory and radiographic tests compatible with PHPT suffered a sudden episode of cervical pain and presented with clinical evidence of hypocalcemia. Biopsy of a cervical nodule revealed necrotic material compatible with ischemia of the parathyroid. The follow-up of the patient presented four distinct phases: the first, which lasted two years, was compatible with a period of bone hunger during which it was necessary to introduce calcitriol and calcium carbonate. During this period, the patient showed bone mass gain. The second phase was characterized by normalization of calcium and parathyroid hormone levels and its end was difficult to define. During the third phase there was a recurrence of hypercalcemia associated with elevated parathyroid hormone (PTH) levels and loss of bone mass. The last phase corresponded to the interval after parathyroidectomy, which was characterized by normalization of serum levels of calcium and PTH, as well as bone mass gain. Conclusion This case report indicates that spontaneous resolution of PHPT by adenoma necrosis is potentially temporary. Thus, in cases in which a conservative approach is chosen, clinical and laboratory follow-up is indispensable. Bone mass measurement is a useful tool in the follow-up of these cases. However, this option exposes the patient to a potential roller-coaster ride of bone mass gain and loss, whose long term consequences are still unknown.

Assessment of integration of the leprosy program into primary health care in Aracaju, state of Sergipe, Brazil

INTRODUCTION: The aim of this study was to assess the epidemiological and operational characteristics of the Leprosy Program before and after its integration into the Primary healthcare Services of the municipality of Aracaju-Sergipe, Brazil. METHODS: Data were drawn from the national database. The study periods were divided into preintegration (1996-2000) and postintegration (2001-2007). Annual rates of epidemiological detection were calculated. Frequency data on clinico-epidemiological variables of cases detected and treated for the two periods were compared using the Chi-squared (χ2) test adopting a 5% level of significance. RESULTS: Rates of detection overall, and in subjects younger than 15 years, were greater for the postintegration period and were higher than rates recorded for Brazil as a whole during the same periods. A total of 780 and 1,469 cases were registered during the preintegration and postintegration periods, respectively. Observations for the postintegration period were as follows: I) a higher proportion of cases with disability grade assessed at diagnosis, with increase of 60.9% to 78.8% (p < 0.001), and at end of treatment, from 41.4% to 44.4% (p < 0.023); II) an increase in proportion of cases detected by contact examination, from 2.1% to 4.1% (p < 0.001); and III) a lower level of treatment default with a decrease from 5.64 to 3.35 (p < 0.008). Only 34% of cases registered from 2001 to 2007 were examined. CONCLUSIONS: The shift observed in rates of detection overall, and in subjects younger than 15 years, during the postintegration period indicate an increased level of health care access. The fall in number of patients abandoning treatment indicates greater adherence to treatment. However, previous shortcomings in key actions, pivotal to attaining the outcomes and impact envisaged for the program, persisted in the postintegration period.

Crown dilaceration in permanent teeth after trauma to the primary predecessors: report of three cases

Crown dilaceration of permanent teeth occurs due to the non-axial displacement of the already formed hard tissue portion of the developing crown at an angle to their longitudinal axis due to trauma to the primary predecessors. This is a rare condition, representing only 3% of the total of injuries to developing teeth and usually occurs in permanent maxillary incisors because of the close proximity of their tooth germs to the primary incisors, which are more susceptible to trauma. This alteration frequently results from the intrusion of a primary tooth when the child is around 2 years of age, at which time half of the crown of the permanent successor is already formed. Teeth with dilacerated crowns may either erupt with buccal or lingual displacement or remain impacted. The treatment may involve endodontic, orthodontic, restorative and prosthetic procedures. This paper reports the restorative treatment proposed to reestablish the esthetics and function of the affected teeth in three cases of crown dilaceration in permanent maxillary incisors after trauma to their primary predecessors.