Multicentric giant cell tumor of bone: a case report and review of the literature

Multicentric giant cell tumor of bone is the rare variant of a lesion that is relatively common in a skeletally mature population. An otherwise healthy 13-year-old boy presenting with this entity was followed up for 6 years. During this period, the patient was diagnosed with and treated for six individual lesions. One recurrence required resection, Ilizarov bone lengthening, and subsequent ankle arthrodesis. He remains fully active and free of distant metastasis.     

Comparison of outcomes and direct cost between minimal stimulation and conventional protocols on ovarian stimulation in in vitro fertilization

AIM: To determine whether minimal stimulation with clomiphene and gonadotropin provides outcomes and direct costs comparable with those of a conventional GnRHa-gonadotropin stimulation protocol for infertile patients undergoing in vitro fertilization. METHODS: A non-randomized clinical trial was conducted from 1 July 1996 to 31 March 2003 at the Infertility and Assisted Reproductive Unit, Ramathibodi Hospital, Faculty of Medicine, Mahidol University, Thailand. A total of 192 patients were recruited of whom 96 cases underwent ovarian stimulated cycles with minimal stimulation protocol, and 96 controls underwent ovarian stimulated cycles with GnRHa-gonadotropin protocol, with cases and controls matched for age and infertility cause. RESULTS: The median patient age was 35 years. Endometriosis was the most frequent infertility cause (28.1%). The conventional GnRHa-gonadotropin protocol could give more oocyte numbers than the minimal stimulation protocol (7.3 +/- 4.9 vs 4.5 +/- 3.3 oocytes). The fertilization rate and cleavage rate were similar (73.4 +/- 31.9 and 84.9 +/- 32.6 in minimal stimulation protocol, 69.3 +/- 29.6 and 88.4 +/- 28.0 in GnRHa-gonadotropin protocol, respectively). The pregnancy rate per oocyte retrieval cycle in the GnRHa-gonadotropin protocol was similar to the minimal stimulation protocol. (13.1%vs 13.0%, P = 1.000). However, the cost per pregnancy of minimal stimulation protocol was less than that of GnRHa-gonadotropin protocol. (6021.95 US dollars for minimal stimulation protocol per pregnancy, 10,785.65 US dollars for GnRHa-gonadotropin protocol per pregnancy, P < 0.000). CONCLUSION: Minimal stimulation was less effective than conventional GnRHa-gonadotropin on the ovarian stimulation. However, the total costs of minimal stimulation were cheaper than the conventional GnRHa-gonadotropin protocol. The decreased costs of minimal stimulation justifies further evaluation of its role in the treatment of infertility in selected cases.     

Sperm motility and DNA integrity affected by different g‐forces in the preparation of sperm in urine specimens

Retrograde ejaculation, a common type of anejaculation, is attributable to many causes, some of which can be treated with medication and some of which cannot. For infertility treatment, sperm must be collected from the urine of the patients. Our study attempts to ascertain the effects of different g‐forces on sperm motility, morphology and DNA integrity in sperm preparation by the Sil‐Select? density gradient method of isolating sperm from urine specimens. Forty‐seven semen samples with normal semen analyses according to World Health Organisation (WHO) 1999 criteria were included in this study. Semen samples of 1 ml were mixed with 20 ml alkalinised normal urine and then divided equally into tubes A and B. The two samples were prepared by the Sil‐Select? density gradient centrifugation method at 350 g (tube A) and at 700 g (tube B). Total motile sperm after centrifugation at 700 g was significantly higher than after centrifugation at 350 g [6.7 (0.4–23.0) million versus 3.1 (0.1–13.7) million] (P < 0.001). There was no significant difference between the either the percentage of sperm with normal morphology or with DNA damage between centrifugation at 350 g and 700 g (P > 0.05), although centrifugation at 700 g achieves a higher number of total motile sperm compared with Sil‐Select? sperm preparation at 350 g centrifugation.     

Thoracic pedicle screw instrumentation using the "Funnel Technique": part 2. Clinical experience

This study is a retrospective review of the clinical results of patients treated with thoracic pedicle screws using the "funnel technique." The objective is to report the clinical results of patients treated with thoracic pedicle screws using the funnel technique for screw placement. A total of 115 patients treated with the use of at least one thoracic pedicle screw were retrospectively identified. All patients were treated at a single medical center, under the senior author's supervision. Twenty-five different residents were responsible for placing 50-60% of these screws, and five different fellows and the senior author placed the remainder. The accuracy of screw placement and the complications related to the use of thoracic pedicle screws were analyzed by assessing intraoperative and postoperative charts and radiographs. There were 115 patients (age range 9-82 years) with the average follow-up period of 17 months. The total number of screws used was 348; the screw diameter ranged from 4.0 to 7.75 mm. There were no vascular or pulmonary complications. There was no iatrogenic neurologic injury, except for one patient who developed a transient anterior thigh numbness from intraoperative positioning. In fracture patients, 35% (10 of 28) had documented neurologic improvement postoperatively. There were no obviously misplaced pedicle screws on detailed review of intraoperative and postoperative radiographs. No screws had to be electively removed for complications related to misplacement. There were four broken screws, one broken rod, two loose screws, and three connector disengagements. Two patients had deep infections and four patients had pseudarthrosis requiring additional surgery. The clinical results proved that thoracic pedicle screws can be safely placed with the funnel technique.     

Case Report: Cauda Equina Syndrome Associated With an Interspinous Device

Background  

Although postoperative spinal epidural hematoma (SEH) is not uncommon, hematomas that require surgery are rare. Cauda equina syndrome (CES) may be associated with postoperative SEH. In these cases, early recognition and emergency decompression can prevent further damage and better neurologic recovery.     

Vitamin D and spine surgery

Vitamin D is crucial for musculoskeletal health, maintenance, and function. Vitamin D insufficiency is common among patients undergoing spine surgery and the ideal vitamin D level for spine surgery has yet to be investigated. There is a high prevalence of hypovitaminosis D in patients with musculoskeletal pain regardless of surgical intervention. With the frequency and costs of spine surgery increasing, it is imperative that efforts are continued to reduce the impact on patients and healthcare services. Studies into vitamin D and its associations with orthopaedic surgery have yielded alarming findings with regards to the prevalence of vitamin D deficiency. Importantly, altered vitamin D status also contributes to a wide range of disease conditions. Therefore, future investigations are still essential for better understanding the relationship between vitamin D and spine surgery outcomes. Whilst further research is required to fully elucidate the extent of the effects of hypovitaminosis D has on surgical outcomes, it is strongly advisable to reduce the impacts by appropriate vitamin D supplementation of deficient and at-risk patients.     

A comparison of the effects of clomiphene citrate and the aromatase inhibitor letrozole on superovulation in Asian women with normal ovulatory cycles

Objective. To compare the effect of the aromatase inhibitor letrozole and clomiphene citrate (CC) on superovulation in women with normal ovulation.

Methods. A cross-over randomized study of 22 women with normal ovulation, divided randomly into two equal cohorts, was carried out. Each group of 11 women was randomly allocated to take letrozole or CC for one cycle. After washing out for one cycle, the alternative drug was administered in the subsequent cycle. The number and size of mature follicles, endometrial thickness, and estradiol and progesterone levels were monitored.

Results. The number of mature follicles and estradiol levels on ovulation day were significantly lower in the letrozole group than the CC group (p < 0.05 for both). However, no differences between the two groups in endometrial thickness and pattern were observed. Progesterone levels showed ovulation in all cycles.

Conclusions. The administration of 50 mg CC on days 3–5 was superior to 2.5 mg letrozole for superovulation induction in women with normal ovulation.     

Poor quality of life among untreated Thai and Cambodian children without severe HIV symptoms

There are limited data on quality of life (QOL) 1 in untreated HIV-infected children who do not have severe HIV symptoms. Moreover, such data do not exist for Asian children. Poor QOL could be a factor in deciding if antiretroviral therapy (ART) should be initiated. Thai and Cambodian children (n=294), aged 1-11 years, na?ve to ART, with mild to moderate HIV symptoms and CD4 15-24% were enrolled. Their caregivers completed the Pediatric AIDS Clinical Trials Group QOL questionnaire prior to ART commencement. Six QOL domains were assessed using transformed scores that ranged from 0 to 100. Higher QOL scores indicated better health. Mean age was 6.1 (SD 2.8) years, mean CD4 was 723 (SD 369) cells/mm(3), 57% was female, and%CDC N:A:B was 2:63:35%. One-third knew their HIV diagnosis. Mean (SD) scores were 69.9 (17.6) for health perception, 64.5 (16.2) for physical resilience, 84.2 (15.6) for physical functioning, 77.9 (16.3) for psychosocial well-being, 74.7 (28.7) for social and role functioning, 90.0 (12.1) for health care utilization, and 87.4 (11.3) for symptoms domains. Children with CD4 counts above the 2008 World Health Organization (WHO) ART-initiation criteria (n=53) had higher scores in health perception and health care utilization than those with lower CD4 values. Younger children had poorer QOL than older children despite having similar mean CD4%. In conclusion, untreated Asian children without severe HIV symptoms had relatively low QOL scores compared to published reports in Western countries. Therapy initiation criteria by the WHO identified children with lower QOL scores to start ART; however, children who did not fit ART-initiation criteria and those who were younger also displayed poor QOL. QOL assessment should be considered in untreated children to inform decisions about when to initiate ART.     

First successful trial of preimplantation genetic diagnosis for pantothenate kinase-associated neurodegeneration

Purpose

We aim to present a case of a healthy infant born after intracytoplasmic sperm injection-in vitro fertilization (ICSI-IVF) with a preimplantation genetic diagnosis (PGD) for pantothenate kinase-associated neurodegeneration (PKAN) due to PANK2 mutation.

Methods

ICSI-IVF was performed on a Thai couple, 34-year-old female and 33-year-old male, with a family history of PKAN in their first child. Following fertilization, each of the embryos were biopsied in the cleavage stage and subsequently processed for whole-genome amplification. Genetic status of the embryos was diagnosed by linkage analysis and direct mutation testing using primer extension-based mini-sequencing. Comprehensive chromosomal aneuploidy screening was performed using a next-generation sequencing-based strategy.

Results

Only a single cycle of ICSI-IVF was processed. There were seven embryos from this couple—two were likely affected, three were likely carriers, one was likely unaffected, and one failed in target genome amplification. Aneuploidy screening was performed before making a decision on embryo transfer, and only one unaffected embryo passed the screening. That embryo was transferred in a frozen thawed cycle, and the pregnancy was successful. The diagnosis was confirmed by amniocentesis, which presented with a result consistent with PGD. At 38 weeks of gestational age, a healthy male baby was born. Postnatal genetic confirmation was also consistent with PGD and the prenatal results. At the age of 24 months, the baby presented with normal growth and development lacking any neurological symptoms.

Conclusions

We report the first successful trial of PGD for PKAN in a developing country using linkage analysis and mini-sequencing in cleavage stage embryos.

     

Cost-effectiveness of IVF in women 38 years and older.

OBJECTIVE: To compare the cost per delivery in women younger than 38 years with women equal to or older than 38 years of age attempting IVF. METHODS: All couples undergoing IVF treatment between October 1991 and September 1998 were enrolled in this study. A standard protocol of controlled ovarian hyperstimulation was employed throughout the study. Four hundred and seven cases were allocated to two groups - group I composed of patients younger than 38 years of age and group II of patient equal to or older than 38 years of age. The total cost of each successful outcome was the goal of our study. RESULTS: A total of 407 women underwent 722 stimulated cycles for IVF of which 122 cycles (16.89%) did not proceed to oocyte retrieval. We found statistically significant differences in the cancellation rate, the number of hMG ampoules, the number of oocytes retrieved, the number of oocytes fertilized, the number of embryos transferred, the clinical pregnancy rate, the rate of multiple pregnancy, the delivery per initiated cycle and the cost per delivery between the two groups (P<0.05, significant). The cost per delivery in group II was approximately 3.6 times that of group I. CONCLUSIONS: Women age 38 years or more have less chance of a successful outcome from IVF treatment. Couples contemplating IVF should be provided with accurate information about prognosis for the pregnancy and the financial costs.