Author: Publisher

{Two knee surgeons in Belgium say they have identified a previously unfamiliar ligament in the human knee.}

Writing in the Journal of Anatomy, they suggest the fibrous band could play a part in one of the most common sports injuries worldwide.

Despite glimpses of the ligament in medical history, this is the first time its structure and purpose have been so clearly established, they say.

But experts say more studies are needed to prove its relevance to knee surgery.

Four main ligaments – or thick fibrous bands – surround the knee joint, criss-crossing between the upper and lower leg bones to provide stability and prevent excessive movement of our limbs.

But the anatomy of the knee remains complex, and several international groups have been exploring the less-defined structures of the joint for some time.

The notion of this particular ligament was first made by French surgeon Paul Segond in 1879 but it has evaded definitive surgical classification for many years.

‘Extensive search’
Now building on the work of other surgeons, Dr Claes and Professor Johan Bellemans of the University Hospitals of Leuven, Belgium, say they have closely mapped the band which runs from the outer side of the thigh bone to the shin bone.

And they say this anterolateral ligament could play an important protective role as we twist or change direction.

Mr Joel Melton, a consultant knee surgeon at Addenbrooke’s Hospital, Cambridge, UK, who was not involved in the research said: “If you look back through history there has been a veiled understanding that something is going on on that side of the knee but this work finally gives us a better understanding.

“I think this is very exciting – there is no doubt they have hit upon a very important anatomical structure.”

The Belgian surgeons used macroscopic dissection techniques to examine 41 donated knee joints and pinpointed this ligament in all but one specimen.

And they say the presence of this band could help them better understand and treat a common sports injury that has puzzled doctors for some time – the anterior cruciate ligament (ACL) tear.

An injury to the ACL is typical in people who pivot during sport – from athletes and basketball players and footballers and skiers. A tear can happen when you change direction rapidly or stop suddenly and causes pain, swelling and reduced movement in the knee.

But despite improvements in surgical techniques, between 10-20% of people with a repaired ACL tear are unable to recover fully.

Twist or turn
In particular, some patients say their knees give way as they twist or turn.

Dr Claes and Bellemans think an injury to the anterolateral ligament (ALL) may be partly responsible for this. They hypothesise some people may injure the ALL at same time as the ACL, leaving the knee less stable as the leg rotates.

And their biomechanical studies suggest tears in this ligament may also be to blame for small fractures that have previously been attributed to ACL injuries.

Mr Paul Trikha, a knee surgeon at the Surrey Orthopaedic Clinic, who was also not involved in the research said: “I do around 150 ACL repairs each year. When I saw Dr Claes’ research, it blew me away.

“Knowing about the ALL has given us a better understanding of what other structures may be damaged during this common injury and this will hopefully open up opportunities to improve surgery for our patients.”

But reaction to this work has been mixed.

Gordon Bannister, professor of orthopaedics at Bristol University said: “There is no doubt this is a very interesting paper from the anatomical point of view but at the moment this is not a major clinical breakthrough.

“Its role in knee injuries is a perfectly reasonable hypothesis to test but the most important step is to see whether any intervention to the ligament actually makes a significant difference to patients.”

Dr Claes and Bellemans have already started exploring this possibility and are offering repairs of the new ligament in certain cases.

Their next steps are to refine their techniques and monitor their patients to see if there are lasting improvements to their mobility.

Dr Claes said: “We surgeons may need to rethink what we know about common ACL injuries. Though we have shed light on the purpose of this ligament and its role in common injuries, we now need to find out for certain when it is best to intervene surgically.

“Long-term studies will give us that answer and hopefully allow us to perfect a minimally invasive techniques to give our patients a better recovery.”

Source: BBC

{Depression is the second most common cause of disability worldwide after back pain, according to a review of research.}

The disease must be treated as a global public health priority, experts report in the journal PLOS Medicine.

The study compared clinical depression with more than 200 other diseases and injuries as a cause of disability.

Globally, only a small proportion of patients have access to treatment, the World Health Organization says.

Dr Alize Ferrari,University of Queensland’s School of Population Health led the study.

“Depression is a big problem and we definitely need to pay more attention to it than we are now,” she told BBC News.

Depression was ranked at number two as a global cause of disability, but its impact varied in different countries and regions. For example, rates of major depression were highest in Afghanistan and lowest in Japan. In the UK, depression was ranked at number three in terms of years lived with a disability.

“There’s still more work to be done in terms of awareness of the disease and also in coming up with successful ways of treating it.

“The burden is different between countries, so it tends to be higher in low and middle income countries and lower in high income countries.”

Policy-makers had made an effort to bring depression to the forefront, but there was a lot more work to be done, she added.

“There’s lots of stigma we know associated with mental health,” she explained.

“What one person recognises as disabling might be different to another person and might be different across countries as well, there are lots of cultural implications and interpretations that come in place, which makes it all the more important to raise awareness of the size of the problem and also signs and how to detect it.”

The data – for the year 2010 – follows similar studies in 1990 and 2000 looking at the global burden of depression.

Commenting on the study, Dr Daniel Chisholm, a health economist at the department for mental health and substance abuse at the World Health Organization said depression was a very disabling condition.

“It’s a big public health challenge and a big problem to be reckoned with but not enough is being done.

“Around the world only a tiny proportion of people get any sort of treatment or diagnosis.”

The WHO recently launched a global mental health action plan to raise awareness among policy-makers.

Source: BBC

{A 3-year-old girl born in Mississippi with HIV acquired from her mother during pregnancy remains free of detectable virus at least 18 months after she stopped taking antiviral pills.}

New results on this child, published online by the New England Journal of Medicine, appear to green-light a study in the advanced planning stages in which researchers around the world will try to replicate her successful treatment in other infected newborns.

And it means that the Mississippi girl still can be considered possibly or even probably cured of HIV infection — only the second person in the world with that lucky distinction. The first is Timothy Ray Brown, a 47-year-old American man apparently cured by a bone marrow transplant he received in Berlin a half-dozen years ago.

This new report addresses many of the questions raised earlier this year when disclosure of the Mississippi child’s case was called a possible game-changer in the long search for an HIV cure.

“There was some very healthy skepticism,” Dr. Katherine Luzuriaga, a professor at the University of Massachusetts in Worcester, tells Shots. She’s part of the team that has been exhaustively testing the toddler’s blood and considering every possible explanation for her apparently HIV-free state.

Luzuriaga is confident the latest tests prove that the child was truly infected with HIV at the time of her birth — not merely carrying remnants of free-floating virus or infected blood cells transferred before birth from her mother, as some skeptics wondered.

The UMass researcher says there’s no way the child’s mother could have contributed enough of her own blood plasma to the newborn to account for the high levels of HIV detected in the child’s blood shortly after birth.

Similarly, Luzuriaga says, new calculations show that the mother “would have had to transfer a huge number of [HIV-infected] white blood cells to the baby in order for us to get the [viral] signal that we got early on.”

Clinching the question as far as the researchers are concerned is the infant’s response to anti-HIV drugs that she began receiving shortly after birth. The remarkable earliness of her treatment is a crucial feature that makes this child different from almost any other.

“There’s a very characteristic clearance curve of viruses once we start babies on treatment,” Luzuriaga says. “The decay of viruses we see in this baby is exactly what we saw in early treatment trials from 20 years ago when we initiated anti-retroviral therapy and shut off viral replication. That’s a very different decay curve than you would expect if it were just free virus transferred to the baby.”

It might be helpful to recap the unusual, if not unique, features of the Mississippi case.

Her mother did not receive prenatal care, so she was not identified as HIV-infected before delivery. If she had been, she would have received drugs that are highly effective in preventing mother-to-child transmission of the virus.

While the mother was in labor, she got HIV testing, as is routine for women without prenatal care. When that came up positive, Dr. Hannah Gay, a pediatrician at the University of Mississippi Medical Center in Jackson, was ready to test the newborn for infection and start anti-retroviral medicines within 30 hours of birth.

The treatment quickly cleared the virus from the baby’s blood. Normally such children would stay on antiviral drugs for a lifetime. But in this case the mother – whose life circumstances were reportedly chaotic – stopped giving the child the medication between 15 and 18 months after birth.

Gay and her colleagues caught up to the child when she was 23 months old and were astonished to discover she was apparently still virus-free despite being off treatment. Five rounds of state-of-the-art testing — at UMass, Johns Hopkins, federal research labs and the University of California San Diego — failed to reveal any trace of the virus in her blood.

That led to last spring’s report and widely reported hope that the child had been cured of HIV.

But Dr. Scott Hammer, an HIV researcher at Columbia University in New York, is not quite convinced. “Is the child cured of HIV infection? The best answer at this moment is a definitive ‘maybe,’ ” Hammer writes in a New England Journal editorial that accompanied the report.

The reason is that a couple of tests done when the child was about 2 years old found indications that her system may contain pieces of RNA or DNA from HIV. This hints that some of the nucleic acid building blocks of the virus are hanging around within her blood cells.

There’s no evidence these “proviral” remnants are capable of assembling themselves into whole viruses that can make copies of themselves. But researchers are concerned about that possibility and how it might be headed off.

“The question is whether those viral nucleic acids have the ability at some point to replicate and allow a rebound of the virus,” Luzuriaga acknowledges. “That’s why it’s important to continue to test the baby over time.” She says that means years.

But for now, the signs from the Mississippi child’s case are encouraging enough to have generated an ambitious global human experiment that Luzuriaga says is in final planning stages.

Women who present in labor without having had prenatal care will be tested for HIV and, if positive, their infants will be intensively treated within a couple of days of birth, as the Mississippi child was. Then they’ll be followed with the most sensitive tests to determine if the virus has been eradicated.

If certain criteria are met, researchers plan to decide whether it would be safe to discontinue HIV treatment deliberately and follow the children closely to see if the virus returns. (If it did, treatment would be restarted.)

If the experiment succeeds, it would be a huge advance in the prevention of childhood HIV and AIDS in many parts of the world. More than 9 out of 10 of the world’s 3.4 million HIV-infected children live in sub-Saharan Africa, where many women deliver without having had prenatal care or HIV treatment. Around 900 children are newly infected every day.

Meanwhile, researchers pursuing an HIV cure will convene next month in San Francisco to consider various strategies — for adults as well as children. One other recent glimmer of hope was provided this summer by Boston researchers who reported that two HIV-infected men with lymphoma remain virus-free without treatment for several months after stopping antiviral treatment.

Source: NPR