Reproductive Implications and Management of Congenital Uterine Anomalies: Scientific Impact Paper No. 62 November 2019.

Congenital uterine anomalies (CUAs) are malformations of the womb that develop during fetal life. When a baby girl is in her mother's womb, her womb develops as two separate halves from two tubular structures called 'müllerian ducts', which fuse together before she is born. Abnormalities that occur during the baby's development can be variable from complete absence of a womb through to more subtle anomalies, which are classified into specific categories. While conventional ultrasound is good in screening for CUAs, 3D ultrasound is used to confirm a diagnosis. If a complex womb abnormality is suspected, MRI scanning may also be used, with a combination of laparoscopy in which a camera is inserted into the cavity of the abdomen, and hysteroscopy, when the camera is placed in the womb cavity. As there can be a link between CUAs and abnormalities of the kidney and bladder, scans of these organs are also usually requested. Although CUAs are present at birth, adult women typically do not have any symptoms, although some may experience painful periods. Most cases of CUA do not cause a woman to have difficulty in becoming pregnant and the outcome of pregnancy is good. However, these womb anomalies are often discovered during investigations for infertility or miscarriage. Moreover, depending upon the type and severity of CUA, there may be increased risk of first and second trimester miscarriages, preterm birth, poor growth of the baby in the mother's womb (fetal growth restriction), pre-eclampsia and difficult positioning of the baby for birth (fetal malpresentation). Surgical treatment is only recommended to a woman who has had recurrent miscarriages and has a septate uterus, i.e., the womb cavity is divided by a partition. In this case, surgery may improve her chances for a successful pregnancy, although the risks of surgery, especially scarring of the womb should be considered. However, further evidence from randomised controlled trials are required to provide conclusive evidence-based recommendations for surgical treatment for septate uterus. Surgical treatment for other types of CUAs is not usually recommended as the risks outweigh potential benefits, and evidence for any benefits is lacking. Women with CUAs may be at an increased risk of preterm birth even after surgical treatment for a septate uterus. These women, if suspected to be at an increased risk of preterm birth based on the severity of CUA, should be followed up using an appropriate protocol for preterm birth as outlined in UK Preterm Birth Clinical Network Guidance.1 >.

Methods employed to overcome difficult embryo transfer during assisted reproduction treatment.

PURPOSE: Multiple steps, at both scientific and clinical level, are involved in assisted reproduction technology (ART). Optimization of each of these steps contributes to maximize the success of ART. Embryo transfer is one of the vital steps in ART. An easy embryo transfer increases the success of ART. Adequate training is required to undertake embryo transfer, but anatomical difficulties in completing this procedure alter the success of treatment. Difficult embryo transfer is challenging for clinicians but has an overwhelming negative impact on patients. Difficult embryo transfer may cause cervical or endometrial trauma with uterine contractions which can lead to unsuccessful implantation and poor outcome after ART. METHODS: Literature review of published material looking at all interventions that were employed to overcome difficult embryo transfers during ART. RESULTS: We identified 5 methods (17 studies) were employed to overcome difficult embryo transfer which are: Hysteroscopic methods in 4 studies (2 case reports, 2 case series). Malecot catheters after hysteroscopic evaluation were used in 2 studies (1 case report, 1 case series). Dilators including hygroscopic dilators were used in 2 studies (1 case report, 1 case series) and mechanical dilators were used in 3 studies (2 case series, 1 RCT-patients 367). Intrafollopian transfer was reported in 1 case report. Transmyometrial embryo transfers were reported in 5 studies (2 case reports, 2 case series, 1 RCT). CONCLUSION: There were only two randomized controlled studies (RCTs) identified in the review. All other were either case series or case reports. We found that there was no uniform classification or grading of difficulty of embryo transfer in the literature. A grading system has been suggested in this review. We recommend that there should be a consensus guideline formulated for interventions to overcome difficult embryo transfer. A large multicenter randomized controlled study is required to compare different methods for women with difficult embryo transfer.

Improving outcomes for amputees: The health-related quality of life and cost utility analysis of osseointegration prosthetics in transfemoral amputees.

AIM: Some amputees are unable to adequately ambulate using conventional socket prosthetics, osseointegrated prosthetics have been described as an alternative strategy in this patient group. This paper aims to assess the effect of osseointegrated prosthetics, commonly simply referred to as osseointegration, in transfemoral amputees on health-related quality of life and cost analysis. METHODS: Two centre analysis of patients receiving transcutaneous femoral osseointegration using The Osseointegration Group of Australia Osseointegration Prosthetic Limb (OGAP-OPL) implant. Retrospective health utility and cost analysis of prospectively collected patient reported health outcome data. Osseointegration cost was compared with the yearly cost of a poorly fitting conventional prosthetic determining cost/Quality Adjusted Life Year. RESULTS: Eighty amputees received osseointegration. Mean age was 39 years (range 20-57) and 66% were male (n = 53). The majority of subjects underwent unilateral (n = 62, 77.5%) rather than bilateral surgery (n = 18, 22.5%). Trauma was the most common indication (n = 59, 74%). Maximum follow up was 10.5-years. Mean preoperative EQ5D HUV in pooled data was 0.64 (SEM 0.025) increasing to 0.73 (0.036) at 5-years and 0.78 (0.051) at 6 years with continued improvement up to 10.5-years. In subgroup analysis those with a starting EQ5D HUV <0.60 reached a cost/QALY of <£30,000 at 5-years postoperatively and show statistically significant improvement in EQ5D HUV. The UK military experience was wholly positive with a mean starting EQ5D HUV of 0.48 (0.017) with significant (p < 0.05) improvement in EQ5D HUV at each time point and a resultant reducing cost/QALY at each time point being £28,616.89 at 5 years. CONCLUSION: There is both a quality of life and financial argument in favour of osseointegration in select patients with above transfemoral amputations. In those unable to mobilise satisfactorily with traditional prostheses and a pre-intervention score of <0.60, a consistent cost effectiveness and quality of life benefit can be seen. Such patients should be considered for osseointegration as these patients reap the maximum benefit and cost effectiveness of the device. This evidence lends strongly to the debate advocating the use of osseointegration through centrally funded resources, including the NHS.

Metaplastic carcinoma of the breast (carcinosarcoma variant): a case report.

A case of a female patient aged 60 yrs, with metaplastic carcinoma of the breast which is a rare neoplasm is presented. Although it is a tumor of the ductal type, the predominant component of the neoplasm has an appearance other than glandular pattern and more in keeping with other cell types. Metaplastic carcinoma runs a very aggressive course and bears an unfavourable prognosis.

Treatment of anterior fracture-dislocations of the proximal humerus by open reduction and internal fixation.

Over a seven-year period we treated a consecutive series of 58 patients, 20 men and 38 women with a mean age of 66 years (21 to 87) who had an acute complex anterior fracture-dislocation of the proximal humerus. Two patterns of injury are proposed for study based upon a prospective assessment of the pattern of soft-tissue and bony injury and the degree of devascularisation of the humeral head. In 23 patients, the head had retained capsular attachments and arterial back-bleeding (type-I injury), whereas in 35 patients the head was devoid of significant soft-tissue attachments with no active arterial bleeding (type-II injury). Following treatment by open reduction and internal fixation, only two of 23 patients with type-I injuries developed radiological evidence of osteonecrosis of the humeral head, compared with four of seven patients with type-II injuries. A policy of primary treatment by open reduction and internal fixation of type-I injuries is justified, whereas most elderly patients (aged 60 years or over) with type-II injuries are best treated by hemiarthroplasty. The best treatment for younger patients (aged under 60 years) who sustain type-II injuries is controversial and an individualised approach to their management is advocated.

What is a Bristow-Latarjet procedure? A review of the described operative techniques and outcomes.

OBJECTIVES: A variety of operative techniques have been described as under the term 'Bristow-Latarjet' procedure. This review aims to define the original procedure, and compare the variation in techniques described in the literature, assessing any effect on clinical outcomes. MATERIALS AND METHODS: A systematic review of 24 studies was performed to compare specific steps of the technique (coracoid osteotomy site, subscapularis approach, orientation and position of coracoid graft fixation and fixation method, additional labral and capsular repair) and detect any effect this variability had on outcomes. RESULTS: Overall recurrence rate was 5.36% (2.94% to 43%). Half of the studies performed the procedure for recurrent shoulder instability, with only five studies documenting glenoid bone loss as an indication: 12 studies used the procedure as the primary surgical intervention for recurrent instability. No change in outcome was noted when examining variation in the coracoid osteotomy site, the fixation site on the scapular neck, the fixation method or whether a capsular repair was also performed. Performing a horizontal split in subscapularis may preserve external rotation compared with performing a tenotomy. CONCLUSIONS: This is the first review to examine various operative techniques of the Bristow-Latarjet procedure, and their effect on outcome. We found that other than the approach through subscapularis, outcome was independent of the surgical technique, and depended more on patient selection. We would commend future publications on this procedure to provide a detailed description of the surgical technique, and as a minimum present rates of recurrence as an outcome measure. Cite this article: Bone Joint J 2016;98-B:1208-14.

Enoxacin in the treatment of typhoid fever.

Enoxacin 400 mg twice daily was given orally to 40 patients who had Salmonella typhi- or Salmonella paratyphi-positive blood or bone marrow cultures. One patient was switched to parenteral therapy within 48 hours of study enrollment, but the remaining 39 patients were given enoxacin for 10 to 14 days. All 39 patients were cured by enoxacin, even though 23 (58.9%) strains were resistant to cotrimoxazole and 16 (41%) strains were multiply resistant to ampicillin, chloramphenicol, and cotrimoxazole. No adverse events necessitated the interruption of therapy. In this study, enoxacin was well tolerated and efficacious in the treatment of typhoid fever.

Quantitation of pharmacologically-induced penile erections: the value of radionuclide phallography in the objective evaluation of erectile haemodynamics.

This study combines the pharmacologically-induced penile erection (PIPE) technique with radionuclide phallography (RNP) for the non-invasive study of penile haemodynamic changes during erection. Penile erections produced by the intracavernosal injections of two different vasoactive drugs, prostaglandin E1 (PGE1) and papaverine HCl (PPV) were assessed by quantitation of the dynamic RNP and parameters of erection were defined and compared. PGE1 intracavernosal injections were seen to elicit a better erectile response than PPV. Dynamic radionuclide phallography was performed using 99Tcm-labelled autologous RBCs in five normally potent volunteers, sixteen patients with psychogenic impotence, seven patients with vasculogenic impotence (three arteriogenic, four venous leakage) and one patient with neurogenic impotence. Physical parameters of erection including the penile length and circumference changes during erection and the erectile angle were compared with the indices of penile blood flow and volume derived through quantitation of the RNP. There was a close correlation between the penogram index (an index of penile blood volume) and penile circumference increase during erection (r = 0.77, p less than 10(-6). The erectile angle, a measure of penile rigidity, correlated strongly (r = 0.82, p less than 10(-6) with the flow index, a measure of penile blood volume. Patterns specific to various categories of impotence were observed and these aided in the diagnosis, especially in equivocal cases with a suboptimal clinical response to the intracavernosal injection. Quantitative RNP offers a non-invasive method which allows direct objective assessment of the erectile response providing several quantitative parameters for analysis.

Burns in pregnancy: effect on maternal and fetal outcomes.

Burn injury during pregnancy is known to have adverse effects on fetal and maternal survival. Any hope of reducing the high mortality lies in identifying the risk factors responsible for the poor maternal and fetal outcome. A prospective study cohort of 50 pregnant burned patients, a comparison cohort of 50 uncomplicated singleton pregnancies and another comparison cohort of 50 non-pregnant burned females were followed up for fetal and maternal survival or death at the Government Medical College & Hospital, Nagpur, India. The effect of maternal factors on the maternal and fetal survival were assessed. Most of the patients (64 per cent) were severely burned, i.e. > 60 per cent TBSA with 100 per cent fetal and maternal mortality. There was 50 per cent maternal and fetal loss in the 40-59 per cent TBSA group. A fetal loss of 11.1 per cent was noted in the 20-39 per cent TBSA group with no maternal loss. Survival analyses using the Kaplan-Meier survival analysis and the Cox Proportional Hazards model showed that TBSA burned was the only factor found to be statistically significantly (P < 0.0001) responsible for the adverse fetal and maternal outcome. Pregnancy did not alter the maternal survival. Adequate shock management and early excision with grafting could reduce the mortality figures. Prevention of injury during pregnancy still appears to be the best option.

Effect of irradiation and germination on trypsin inhibitor and protein content of chickpea (Cicer arientinum L.).

Effect of irradiation (0.05-0.20 kGy) and subsequent germination on trypsin inhibitor activity (TIA) and protein content of chickpea, was studied. The results revealed a significant linear relation (r = 0.981 to -0.992) between the loss of TIA and germination time, and the rate of TIA destruction increased with irradiation dose (p less than 0.05). Maximum destruction (43.8%) of the TIA occurred on germination for 120 hr of 0.20 kGy sample (from 330.0 to 185.3 TIU/g). Initially protein content was 21.7% and the value significantly increased to maximum levels of 27.5% and 27.9% in distilled and tap water respectively during germination for 120 hr of 0.10 kGy sample (p less than 0.05). Protein contents were not affected by irradiation.

Biosynthesis of ascorbic acid and riboflavin in radiated germinating chickpea.

Biosynthesis of ascorbic acid and riboflavin in radiated germinating chickpea seeds was studied at ambient room temperature (20-35 degrees C). Synthesis of these vitamins increased significantly with increasing germination time up to 120 hrs depending upon the treatment (P less than 0.05). Maximum amounts of ascorbic acid, 22.32 and 16.84 mg/100 g (wet weight) were found in the 0.10 kGy samples after 120 hrs of germination in tap and distilled waters respectively. Radiation dose of 0.20 kGy resulted in the development of maximum riboflavin, 11.4 and 11.0 micrograms/g (dry weight) on germination in tap and distilled waters respectively. An overall significant linear relation (r = 0.954 to 0.957) was found between vitamin biosynthesis and germination time up to 120 hrs in both the radiated and unradiated chickpea.

Intracavernosal injection of pharmacological agents in the diagnosis and treatment of impotence.

This study details our initial experience with pharmacologically induced penile erections in the diagnosis and therapy of patients with impotence. Intracavernosal injections of papaverine were performed in 5 normal volunteers, 5 patients with psychogenic impotence and 2 patients with penile venous incompetence. The patients were first investigated extensively to determine the etiological basis for their erectile dysfunction. It was observed that the patients with psychogenic impotence and the normal volunteers showed a good response whereas the patients with venous incompetence failed to achieve erection in response to intracavernosal injection. A new drug, Prostaglandin E1 was also tried for the first time for comparison. It appears that this drug has potential advantages over the currently used agent papaverine for the production of pharmacological erections.

Treatment of acute duodenal ulcers with famotidine and its comparison with other H2 blockers.

Famotidine, a new H2 antagonist in a dose of 40 mg qhs was tried in a clinical trial for the treatment of duodenal ulcer in 25 patients and compared with other H2 antagonists. Cimetidine 800 mg qhs and Ranitidine 300 mg qhs were used in a similar number of randomised patients. Patients were evaluated clinically, biochemically and endoscopically. At the end of eight weeks, the healing rate with Famotidine was 96%. Cimetidine was 92% and Ranitidine 96%. No significant side effects were noted with any of these drugs. In conclusion, Famotidine (40 mg qhs) is an effective and generally well-tolerated drug in the treatment of acute duodenal ulcer.

Role of ciprofloxacin in typhoid fever.

A study was conducted to investigate the effects of ciprofloxacin in typhoid fever and to compare its efficacy with chloramphenicol. Eighty patients between 20-45 years with positive blood culture were included in the study. Seventy five percent patients treated with ciprofloxacin became afebrile within 72 hours while with chloramphenicol it took upto 120-144 hours for the same percentage of patients to become afebrile. Four patients resistant to chloramphenicol, cotrimoxazole and ampicillin/amoxycillin, also responded to ciprofloxacin. There were no significant adverse effects indicating that ciprofloxacin is safe and effective drug for resistant and nonresistant cases of typhoid fever.

Adrenocortical reserve in patients with active tuberculosis.

CONTEXT: In recent years several studies have documented decreased adrenal cortical reserve in patients with active tuberculosis. This reduced adrenal reserve could be an important factor in causing mortality and morbidity in these patients. OBJECTIVE: To study the adrenal cortical reserve and its relationship with disease duration and severity in patients with active tuberculosis. DESIGN SETTING AND PARTICIPANTS: Forty patients with confirmed active tuberculosis (28 pulmonary and 12 extra-pulmonary) without clinical evidence of Addison's disease and 10 healthy, age and sex-matched subjects (controls) participated in this study. The study was conducted at Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir. INTERVENTIONS: Adrenocorticotropic hormone stimulation test performed in both groups. MAIN OUTCOME MEASURES: Basal serum cortisol level and parameters of stimulated cortisol response (maximum increase of cortisol over basal, peak rise of cortisol and area under response curve). RESULTS: The mean basal cortisol levels were comparable between the two groups (P = 0.792). The parameters of stimulated cortisol response including maximum increase of cortisol over basal, the peak rise of cortisol and area under response curves were significantly lower in patients as compared to healthy controls (P < 0.001, 0.002 and 0.049 respectively). However, these parameters were comparable between patients with active pulmonary and extra-pulmonary tuberculosis. Overall 14 (35%) patients exhibited sub-optimal cortisol response (3 negligible and 11 inadequate) to ACTH stimulation. ACTH stimulation revealed significant cortisol rise in patients with active tuberculosis at 4 and 8 hours only, whereas in healthy controls, the cortisol rise was more prolonged and continued up to 24 hours. The adrenocortical reserve was inversely related to the radiological severity of pulmonary tuberculosis (r, -0.41) and chronicity of active tuberculosis (r, -0.59). CONCLUSION: Patients with active tuberculosis have decreased adrenocortical reserve. The adrenocortical reserve seems to be inversely related to the radiological severity of pulmonary tuberculosis and chronicity of active tuberculosis.

Posterior uterine rupture causing fetal expulsion into the abdominal cavity: a rare case of neonatal survival.

Introduction. Uterine rupture is a potentially catastrophic complication of vaginal birth after caesarean section. We describe the sixth case of posterior uterine rupture, with intact lower segment scar, and the first neonatal survival after expulsion into the abdominal cavity with posterior rupture. Case Presentation. A multiparous woman underwent prostaglandin induction of labour for postmaturity, after one previous caesarean section. Emergency caesarean section for bradycardia revealed a complete posterior uterine rupture, with fetal and placental expulsion. Upon delivery, the baby required inflation breaths only. The patient required a subtotal hysterectomy but returned home on day 5 postnatally with her healthy baby. Discussion. Vaginal birth after caesarean section constitutes a trial of labour, and the obstetrician must be reactive to labour events. Posterior uterine rupture is extremely rare and may occur without conventional signs. Good maternal and fetal outcome is possible with a prompt, coordinated team response.

Open reduction and endobutton fixation of displaced fractures of the lateral end of the clavicle in younger patients.

Displaced fractures of the lateral end of the clavicle in young patients have a high incidence of nonunion and a poor functional outcome after conservative management. Operative treatment is therefore usually recommended. However, current techniques may be associated with complications which require removal of the fixation device. We have evaluated the functional and radiological outcomes using a novel technique of open reduction and internal fixation. A series of 16 patients under 60 years of age with displaced fractures of the lateral end were treated by open reduction and fixation using a twin coracoclavicular endobutton technique. They were followed up for the first year after their injury. At one year the mean Constant score was 87.1 and the median Disabilities of the Arm, Shoulder and Hand score was 3.3. All fractures had united, except in one patient who developed an asymptomatic fibrous union. One patient had post-traumatic stiffness of the shoulder, which resolved with physiotherapy. None required re-operation. This technique produces good functional and radiological outcomes with a low prevalence of complications and routine implant removal is not necessary.

Proximal humeral fractures with a severe varus deformity treated by fixation with a locking plate.

We treated 47 patients with a mean age of 57 years (22 to 88) who had a proximal humeral fracture in which there was a severe varus deformity, using a standard operative protocol of anatomical reduction, fixation with a locking plate and supplementation by structural allografts in unstable fractures. The functional and radiological outcomes were reviewed. At two years after operation the median Constant score was 86 points and the median Disabilities of the Arm, Shoulder and Hand score 17 points. Seven of the patients underwent further surgery, two for failure of fixation, three for dysfunction of the rotator cuff, and two for shoulder stiffness. The two cases of failure of fixation were attributable to violation of the operative protocol. In the 46 patients who retained their humeral head, all the fractures healed within the first year, with no sign of collapse or narrowing of the joint space. Longer follow-up will be required to confirm whether these initially satisfactory results are maintained.