Atypical Femoral Fractures: Transverse Morphology at Lateral Cortex Is a Critical Feature

In 2010, the American Society for Bone and Mineral Research (ASBMR) task force defined major and minor features to assist in the case finding and reporting of atypical femoral fractures (AFFs). One major feature that was proposed was a “transverse or short oblique configuration.” Our primary aim was to compare the conventional overall fracture morphology (OFM) with its associated angle (OFMA) and our proposed lateral cortical fracture angle (LCFA) in the assessment of fracture configuration in suspected AFFs and non‐AFFs. The radiographs of 79 patients with AFFs and 39 patients with non‐AFFs were each analyzed by two blinded reviewers to obtain the OFM, OFMA, and LCFA. Using the overall fracture morphology to assess the suspected AFFs resulted in discordance between reviewers in 18 cases (22.8%), of which 5 (6.3%) were discordant between short oblique (>30° to 60°) and long oblique (>60° to 90°) configurations, therefore affecting their classifications as AFFs. By assessing only the critical component within the lateral cortex, all the suspected AFFs fell well within the classification as transverse fractures with a mean LCFA of 4.8° (range 0.3 to 18.0, SD = 4.23). The inter‐reader variability was also lower for LCFA versus OFMA (4.1° versus 6.9°, p = 0.001) when used to assess AFFs. Fracture angles were significantly different in AFFs versus non‐AFFs regardless of whether the OFMA or LCFA methodology was employed, but the greater difference associated with LCFA suggests its greater discriminating power. When LCFA was used in conjunction with 0° to 30° as the criteria for transverse morphology, all the AFFs and non‐AFFs were correctly classified. By using a standardized and precise method in measuring the fracture angle, specifically using only the component of the lateral cortex and limiting to truly transverse fractures, ie, between 0° and 30°, the LCFA is a robust and accurate method to assess the fracture morphology in suspected AFFs. © 2014 American Society for Bone and Mineral Research.     

The impact of the Calman-Hine report on the processes and outcomes of care for Yorkshire's breast cancer patients.

BACKGROUND: The 1995 Calman-Hine plan outlined radical reform of the UK's cancer services with the aim of improving outcomes and reducing inequalities in National Health Service cancer care. Its main recommendation was to concentrate care into the hands of site-specialist multidisciplinary teams. This study aimed to determine whether these teams improved processes and outcomes of care for breast cancer patients. PATIENTS AND METHODS: All patients diagnosed and treated with breast cancer in the Yorkshire region of the UK from 1995 to 2000 were identified within the Northern and Yorkshire Cancer Registry and Information Service database. Changes in the use of breast-conserving surgery, adjuvant radiotherapy following breast-conserving surgery and 5-year survival were assessed among these patients in relation to their managing breast cancer team's degree of adherence to the manual of cancer service standards (which outlines the specification of the 'ideal' breast cancer team) and the extent of site specialisation of each team's surgeons. RESULTS: Variation was observed in the extent to which the breast cancer teams in Yorkshire had conformed to the Calman-Hine recommendations. Increases in adherence to the recommendations in the manual of cancer service standards were associated with a reduction in the use of breast-conserving surgery [odds ratio (OR) = 0.83, 95% confidence interval (CI) = 0.70-0.98, P < 0.01]. Increases in both surgical specialisation (OR = 1.23, 95% CI = 1.00-1.55, P = 0.06) and adherence to the manual of cancer service standards (OR = 1.22, 95% CI = 0.97-1.52, P = 0.05) were associated with the increased use of radiotherapy following breast-conserving surgery. There was a trend towards improved 5-year survival (hazard ratio = 0.93, 95% CI = 0.86-1.01, P = 0.10) in relation to increasing surgical site specialisation. All these effects were present after adjustment for the casemix factors of age, stage of disease, socio-economic background and year of diagnosis. CONCLUSIONS: The extent of implementation of the Calman-Hine report has been variable and, on the basis of limited clinical and organisational information available, its recommendations appear to be associated with improvements in processes and outcomes of care for breast cancer patients.     

An obstetric analysis of fifty consecutive pregnancies after transfer of cryopreserved human embryos

This report describes the obstetric outcome in 50 pregnancies resulting from the transfer of human embryos that had been cryopreserved for up to 2 years. The duration of cryopreservation did not influence the pregnancy rate after thawed embryo transfer. Thirty-one babies have been born from 28 pregnancies and a further seven pregnancies are currently in the second and third trimesters. Twenty-eight percent of the pregnancies failed to progress beyond the first trimester. One pregnancy was terminated at 22 weeks' gestation because of severe fetal malformation. Important antenatal events included premature uterine activity in six patients although only one patient with a singleton pregnancy ultimately was delivered prematurely. Retroplacental hemorrhage occurred in four patients but was of clinical consequence in only one. There was a high incidence of breech presentation at term in singleton pregnancies (12%). The cesarean section rate in this series was 21%. An international registry of cryopreserved pregnancies would facilitate data collection in this relatively new clinical field.     

Effects of isradipine, a new calcium antagonist, on postpartum uterine activity

The effects of a new calcium antagonist, isradipine (PN 200-110) on postpartum uterine activity and the maternal cardiovascular system were investigated. Uterine activity was recorded by a microtip transducer catheter inserted transcervically within 45 min of normal vaginal delivery. 0.5 mg of isradipine was given as a bolus injection during 5 min to 7 women with spontaneous uterine activity and 1 mg was given during a 15-min period to another 8 women with oxytocin-stimulated uterine activity. Matched controls with similar pre-injection activity (+/- 5%) but not given the drug were selected for comparison. The effects of the drug in 3 women (given 1 mg of isradipine) were compared with those in matched controls and in women given 0.25 mg of terbutalin i.v. as a bolus injection. Isradipine had a marked inhibitory effect on both spontaneous and oxytocin-stimulated uterine activity. The inhibitory effect of 1 mg of isradipine seemed comparable to that of 0.25 mg of terbutalin. The inhibition occurred within 1-2 min after the injection and was sustained throughout the study period (2 h). A transient reduction of the systolic (mean maximum decrease 10-15%) and diastolic blood pressure (mean maximum decrease 15-20%) was seen, particularly during the injection period. Hypotension (systolic blood pressure less than 80 mmHg) was not recorded. A moderate increase in pulse rate (mean maximum increase 22-27%) was seen in all cases. The results show that isradipine given as a bolus injection can inhibit early postpartum uterine activity, with minimal side effects.     

High pregnancy rate after early human embryo freezing

Human embryos produced by in vitro fertilization (IVF) were frozen with 1,2-propanediol as a cryoprotectant. Embryo survival after thawing was related to the presence of a nucleus in frozen cells and decreased with the increasing number of cells in the frozen embryo. None of five embryos frozen 3 or 4 days after IVF survived when thawed. Of 48 early embryos (35 patients) frozen 1 or 2 days after IVF, 42 (87.5%) were transferred in 32 patients. Ten pregnancies were initiated after frozen embryo transfer (ET). If we exclude the three infertile patients who had sexual intercourse in the fertile period, the pregnancy rate for each patient who had 1- or 2-day frozen embryo(s) was 22% (7 of 32). One of the pregnancies was obtained after ET of a 1-cell pronucleated frozen and thawed embryo. The rate of ongoing pregnancies after triple fresh ET was 23%. In patients having four embryos obtained in a single IVF cycle, the expected overall liveborn rate in an IVF-ET program including embryo cryopreservation could theoretically equal that of natural human fertility.     

Potency following conformal neutron/photon irradiation for localized prostate cancer

: To assess the effect of conformal neutron/photon irradiation with or without neoadjuvant hormonal therapy on posttreatment potency.

: Seventy-six patients with localized adenocarcinoma of the prostate, Stage T1 or T2 N0 Mo, Gleason score ≤7, were enrolled on a prospective Phase II study. Each patient received 9–10 Neutron + 38 Photon Gy. Twenty-eight patients received neoadjuvant hormonal therapy in conjunction with radiation therapy. Potency was assessed prior to starting treatment and was assessed at each subsequent follow-up visit.

: Fifty-two of 75 patients (70%) were potent at the start of therapy. Thirty-eight of 52 (73%) had functional erections and 14 of 52 (27%) had erections termed nonfunctional, which were of insufficient strength for intercourse. After treatment, 35 of 52 (67%) retained potency. Twenty-nine of 38 (76%) with functional erections pretreatment maintained this ability. Only 6 of 14 patients (43%) with nonfunctional erection pretreatment maintained their level of potency. Neoadjuvant hormonal therapy did not impact on the ability to maintain erections. Sixty-five percent of those patients receiving hormones retained erectile function, while 69% of those who did not receive hormones maintained erectile function. Age was not a significant factor in posttreatment potency, although a trend towards potency in younger patients was observed . (p = 0.74).

: The majority (67%) of patients maintained their level of erectile function following conformal sequential neutron photon irradiation. This comparable to that achieved with photon irradiation alone. No significant change in potency was seen with neoadjuvant hormonal therapy or with increasing patient age.     

Importance of semen preparation in avoidance of reduced in vitro fertilization results attributable to bacteria

Although the physical treatment of semen for IVF and related procedures is sufficient to remove most organisms present in semen, the pathogenic varieties tend to be more resistant. The supplementation of oocyte culture medium with both penicillin and streptomycin was associated with the eradication of 100% of organisms in the current study. In these circumstances, the presence of pathogenic organisms in the untreated semen is not associated with reduced oocyte fertilization in vitro.     

Human embryo viability related to freezing and thawing procedures

Freezing and thawing procedures did not affect the chances of successful transfer of human embryos. The postimplantation viability of frozen-thawed embryos was equivalent to that of fresh, immediately transferred embryos. Selection of the embryos that were more suitable for freezing did influence the pregnancy rate after transfer of the remaining fresh embryos. The therapeutic efficacy of in vitro fertilization and embryo transfer programs will be greatly increased if only one embryo is transferred in the in vitro fertilization cycle, the others being separately frozen for further embryo transfer in subsequent cycles.