Bilateral distal fibula fractures in a woman on long-term bisphosphonate therapy.

We report the case of a 53-year-old female, treated by bisphosphonate for 12 years, who presented atraumatic fractures of both fibulas. Her X-rays showed bilateral distal fibula fractures with radiological features similar to atypical femur fractures. The distal fibula should be considered as a potential site for stress fractures in bisphosphonate users. Bisphosphonates are the most widely used drugs in the treatment of osteoporosis. During the last decade, the occurrence of atypical fractures, mostly subtrochanteric and diaphyseal femoral fractures, has been acknowledged in patients with long-term use of bisphosphonates. We report the case of a 53-year-old female on alendronate therapy for the past 12 years who presented with a few months history of atraumatic right, and subsequently left, lateral ankle pain. Her X-rays showed bilateral distal fibula fractures with radiological features similar to atypical femur fractures. She had been treated conservatively with walking boots and her treatment with bisphosphonate had been stopped 5 months prior to the fractures. Callus was progressively seen on serial follow-up X-rays, and both fractures healed completely within a reasonable period of 1 year. Investigations did not reveal any secondary causes of osteoporosis or metabolic bone disorders. To our knowledge, this is the first reported case of bilateral distal fibula fractures in a patient on long-term bisphosphonate therapy.

Stressor exposure of male and female juvenile mice influences later responses to stressors: modulation of GABAA receptor subunit mRNA expression.

Stressors encountered during the juvenile period may have persistent effects on later behavioral and neurochemical functioning and may influence later responses to stressors. In the current investigation, we evaluated the influence of stressor exposure applied during the juvenile period (26-28 days of age) on anxiety-related behavior, plasma corticosterone and on GABA(A) α2, α3, α5 and γ2 mRNA expression within the prefrontal cortex (PFC) and amygdala measured during adulthood. These changes were monitored in the absence of a further challenge, as well as in response to either a social or a non-social psychogenic stressor administered during adulthood. Exposure to an acute adult stressor elicited anxiety in females and was still more pronounced among females that had also experienced the juvenile stressor. Among males, arousal and impulsivity predominated so that anxiety responses were less notable. Furthermore, experiencing the stressor as a juvenile influenced adult GABA(A) subunit expression, as did the adult stressor experience. These changes were differentially expressed in males and females. Moreover, these subunit variations were further moderated among mice that stressed as juveniles and were again exposed to an adult stressor. Interestingly, under conditions in which the juvenile stressor increased the expression of a particular subunit, exposure to a further stressor in adulthood resulted in the γ-aminobutyric acid (GABA) subunit variations being attenuated in both sexes. The current results suggest that juvenile and adult stressor experiences elicit variations of GABA(A) receptor subunit expression that are region-specific as well as sexually-dimorphic. Stressful events during the juvenile period may have pronounced proactive effects on anxiety-related behaviors, but linking these to specific GABA(A) subunits is made difficult by the diversity of GABA changes that are evident as well as the dimorphic nature of these variations. Nevertheless, these GABA(A) sex-specific subunit variations may be tied to the differences in anxiety in males and females.

Evaluation of contraceptive efficacy and cycle control of a transdermal contraceptive patch vs an oral contraceptive: a randomized controlled trial.

CONTEXT: Oral contraceptive (OC) pills are effective, but poor compliance increases rates of pregnancy during treatment. OBJECTIVE: To compare the contraceptive efficacy, cycle control, compliance, and safety of a transdermal contraceptive patch and an OC. DESIGN: Randomized, open-label, parallel-group trial conducted October 1997 to June 1999. SETTING: Forty-five clinics in the United States and Canada. PARTICIPANTS: A total of 1417 healthy adult women of child-bearing potential. INTERVENTIONS: Participants were randomly assigned to receive a transdermal contraceptive patch (n = 812) vs an OC (n = 605) for 6 or 13 cycles. Patch treatment consisted of application of 3 consecutive 7-day patches followed by 1 patch-free week. MAIN OUTCOME MEASURES: Overall and method-failure Pearl Indexes (number of pregnancies/100 person-years of use) and life-table estimates of the probability of pregnancy were calculated. Cycle control, compliance, patch adhesion, and adverse events were also assessed. RESULTS: Overall and method-failure Pearl Indexes were numerically lower with the patch (1.24 and 0.99, respectively) vs the OC (2.18 and 1.25, respectively); this difference was not statistically significant (P =.57 and.80, respectively). The incidence of breakthrough bleeding and/or spotting was significantly higher only in the first 2 cycles in the patch group, but the incidence of breakthrough bleeding alone was comparable between treatments in all cycles. The mean proportion of participants' cycles with perfect compliance was 88.2% (811 total participants, 5141 total cycles) with the patch and 77.7% (605 total participants, 4134 total cycles) with the OC (P <.001). Only 1.8% (300/16 673) of patches completely detached. Both treatments were similarly well tolerated; however, application site reactions, breast discomfort, and dysmenorrhea were significantly more common in the patch group. CONCLUSION: The contraceptive patch is comparable to a combination OC in contraceptive efficacy and cycle control. Compliance was better with the weekly contraceptive patch than with the OC.

Caring in nursing education: reducing anxiety in the clinical setting.

It has been well-documented that the clinical experience is one of the most anxiety-producing aspects of nursing education. When feelings of anxiety become severe, they present a clear threat to the student's success in the program. This article explores the role of "caring" in nursing education as a means of reducing student anxiety. Caring, described at length by Jean Watson, has become one of the most popular trends in the education of young nurses. When caring behaviors are demonstrated in a meaningful way by clinical instructors, the student may experience a sense of comfort and belonging, which may in turn be effective in reducing anxiety and enabling the student to successfully complete a clinical rotation. The aim of this article is to inspire nurses, not only those in the educational setting but in all settings and at all levels of their careers, to reconsider the effects and benefits of displaying a caring attitude.