A randomized controlled trial of intra-articular triamcinolone and/or physiotherapy in shoulder capsulitis.

OBJECTIVE: To assess the effectiveness of intra-articular triamcinolone injection and physiotherapy singly or combined in the treatment of adhesive capsulitis of the shoulder. METHODS: Eighty patients with adhesive capsulitis of less than 6 months duration were randomized to one of four groups: Group A, injection of triamcinolone 20 mg and eight sessions of standardized physiotherapy; Group B, injection of triamcinolone 20 mg alone; Group C, placebo injection and eight sessions of standardized physiotherapy; or Group D, placebo injection alone. All subjects were given an identical home exercise programme. Outcome measures were assessed at 6 weeks and 16 weeks. The primary outcome measure was Shoulder Disability Questionnaire (SDQ) score. Secondary outcomes were measurement of pain using a visual analogue scale (VAS), global disability using VAS and range of passive external rotation. A two-way analysis of variance was used to explore the effects of corticosteroid injection and physiotherapy. RESULTS: At 6 weeks, the SDQ had improved significantly more in the groups receiving corticosteroid injection (P = 0.004). Physiotherapy improved passive external rotation at 6 weeks (P = 0.02) and corticosteroid injection improved self-assessment of global disability at 6 weeks (P = 0.04). There was no interaction effect between injection and physiotherapy. At 16 weeks, all groups had improved to a similar degree with respect to all outcome measures. CONCLUSION: Corticosteroid injection is effective in improving shoulder-related disability, and physiotherapy is effective in improving the range of movement in external rotation 6 weeks after treatment.

A study of bone mineral density in women with forearm fracture in Northern Ireland.

A group of Northern Ireland women aged 40-75 years of age with low-trauma forearm fracture were studied to determine the incidence of such fractures and the prevalence of osteoporosis in this fracture population. A total of 1,147 subjects were identified in 1997 and 1998 throughout Northern Ireland following low-trauma forearm fractures, as well as 699 residents in the Eastern Health and Social Services Board (EHSSB), enabling calculation of the annual incidence rate of new low-trauma forearm fractures at 2.69/1,000 population aged 40-75. A total of 375 participants consented to have bone mineral density (BMD) measurements undertaken at the femoral neck, spine, and forearm using a Lunar Expert bone densitometer. Osteoporosis at the femur was present in 14% of women, at the spine in 29%, and at the forearm in 32%. A total of 45% were osteoporotic at one or more measured sites, but only 18% were on treatment for osteoporosis. Additional significant risk factors identified included an early menopause in 24.5% and current or previous corticosteroid use in 13%. Only 1.6% received information on treatment of osteoporosis at the time of fracture. Increased awareness is needed in both primary and secondary care including fracture services to improve treatment of women with low-trauma fracture.

A randomised study of two training programmes for general practitioners in the techniques of shoulder injection.

OBJECTIVES: To evaluate the impact of two different modes of shoulder injection training on the level of confidence and number of injections performed by general practitioners (GPs) METHODS: Demographic details, and information on referrals for shoulder problems, shoulder joint injection activity, and confidence in the six months before training were obtained for 40 GP principals at baseline. Standardised training in the techniques of shoulder joint injection using rubber mannequins was given to all GPs. Twenty of these GPs were randomly allocated to receive additional training on patients in hospital joint injection clinics. Six months after both forms of training the shoulder injection and referral activities of all GPs were reassessed. RESULTS: Both training groups had comparable demographic characteristics and baseline clinical activity. GPs who had additional training with patients reported a marked increase in their level of confidence in performing shoulder injections and the number performed. The number of shoulder referrals did not differ between the groups CONCLUSION: Training on patients in addition to conventional training on mannequins increased GPs' shoulder injection activity and their level of confidence. Hospital injection clinics may provide a suitable setting in which to train GPs interested in developing their shoulder joint injection skills.

Vertical gradients in photosynthetic light response within an old-growth Douglas-fir and western hemlock canopy.

We examined needle-level light response of photosynthesis across a vertical light gradient within 45-55-m-tall western hemlock (Tsuga heterophylla (Raf.) Sarg.) and Douglas-fir (Pseudotsuga menziesii (Mirb.) Franco) trees growing in a 400-500-year-old mixed species stand. We determined: (1) whether light-saturated photosynthetic rates, light compensation points, and respiration rates varied from the upper to the lower canopy, and (2) if light-saturated photosynthetic rates, light compensation points, and respiration rates varied between Douglas-fir and western hemlock. Over a 25-m gradient from the canopy top to the lower canopy, mean light-saturated photosynthetic rates, light compensation points, and respiration rates declined in overstory Douglas-fir and western hemlock needles, paralleling a 65% decline in the mean daily photosynthetic photon flux density (PPFD). At the canopy top, increasing light-saturated photosynthetic rates relative to lower canopy needles increased carbon uptake at high PPFD. In the lower canopy, reduced respiration rates relative to upper canopy needles increased carbon uptake at low PPFD by reducing the light compensation point. At all canopy positions, western hemlock had lower mean light-saturated photosynthetic rates, light compensation points and respiration rates than Douglas-fir. As a result, western hemlock had higher net photosynthetic rates at low PPFD, but lower net photosynthetic rates at high PPFD compared with Douglas-fir.

15N natural abundances and N use by tundra plants.

Plant species collected from tundra ecosystems located along a north-south transect from central Alaska to the north coast of Alaska showed large and consistent differences in 15N natural abundances. Foliar δ15N values varied by about 10% among species within each of two moist tussock tundra sites. Differences in 15N contents among species or plant groups were consistent across moist tussock tundra at several other sites and across five other tundra types at a single site. Ericaceous species had the lowest δ15N values, ranging between about -8 to -6‰. Foliar 15N contents increased progressively in birch, willows and sedges to maximum δ15N values of about +2‰ in sedges. Soil 15N contents in tundra ecosystems at our two most intensively studied sites increased with depth and δ15N values were usually higher for soils than for plants. Isotopic fractionations during soil N transformations and possibly during plant N uptake could lead to observed differences in 15N contents among plant species and between plants and soils. Patterns of variation in 15N content among species indicate that tundra plants acquire nitrogen in extremely nutrient-poor environments by competitive partitioning of the overall N pool. Differences in plant N sources, rooting depth, mycorrhizal associations, forms of N taken up, and other factors controlling plant N uptake are possible causes of variations in δ15N values of tundra plant species.

Human blood and synovial fluid neutrophils cultured in vitro undergo programmed cell death which is promoted by the addition of synovial fluid.

OBJECTIVE: To assess the influence of inflammatory synovial fluid (SF) on apoptosis of joint and blood neutrophils with particular reference to levels of colony stimulating factors (CSF) contained therein. METHODS: Neutrophils were separated from fresh synovial fluid and from peripheral blood by density gradient centrifugation. Apoptosis was assayed by light microscope morphology and DNA degradation. CSFs were assayed using bone marrow bioassay and enzyme linked immunosorbent assays for granulocyte (G-) and granulocyte macrophage (GM-) CSF. Separated neutrophils were cultured in vitro and exposed to: varying concentrations of SF in which CSF levels were measured, recombinant G-CSF and GM-CSF, and hyaluronic acid control solutions. Numbers of apoptotic neutrophils and CSF levels were also measured in fresh SF samples. RESULTS: The addition of autologous or heterologous inflammatory SF to blood or joint cavity neutrophils cultured in vitro caused a significant dose dependent increase in the percentage of cells becoming apoptotic with time as measured morphologically and confirmed by DNA degradation. The effect bore no relationship to levels of CSF in joint fluid, despite our finding that GM-CSF produced inhibition of neutrophil apoptosis in vitro. CONCLUSION: These data suggest that SF contains a factor or factors capable of directly or indirectly promoting neutrophil apoptosis and normally powerful enough to overcome the apoptosis inhibiting effects of cytokines such as GM-CSF at concentrations usually found in inflammatory synovial fluids.

Motor vehicle driving among diabetics taking insulin and non-diabetics.

OBJECTIVE: To determine whether rates of road traffic accidents were higher in diabetics treated with insulin than in non-diabetic subjects. DESIGN: Controlled, five year retrospective survey. SETTING: Diabetic, dermatology, and gastroenterology outpatient clinics. PATIENTS: 596 Diabetics treated with insulin (354 drivers) aged 18-65 attending two clinics and 476 non-diabetic outpatients (302 drivers). MAIN OUTCOME MEASURES: Rates of accidents in diabetic and non-diabetic subjects. RESULTS: A self completed questionnaire was used to record age, sex, driving state, and rates of accidents and convictions for motoring offences among diabetic and non-diabetic volunteers. For the diabetic volunteers further information was obtained on treatment, experience of hypoglycaemia, and declaration of disability to the Driving and Vehicle Licensing Centre and their insurance company. Accident rates were similar (81 (23%) diabetic and 76 (25%) non-diabetic drivers had had accidents in the previous five years). A total of 103 diabetic drivers had recognised hypoglycaemic symptoms while driving during the previous year. Only 12 reported that hypoglycaemia had ever caused an accident. Overall, 249 had declared their diabetes to an insurance company. Of these, 107 had been required to pay an increased premium, but there was no excess of accidents in this group. CONCLUSIONS: Diabetic drivers treated with insulin and attending clinics have no more accidents than non-diabetic subjects and may be penalised unfairly by insurance companies.