Insertion of distal locking screws of tibial intramedullary nails: a comparison between the free-hand technique and the SURESHOT™ Distal Targeting System.

INTRODUCTION: Positioning of the distal locking screws of an intramedullary nail is often challenging and time consuming because of difficult localisation of the distal locking holes, potential screw malalignment and nail deformation during insertion. The standard free-hand technique under fluoroscopic control involves considerable radiation exposure of both the patient and the surgical team. In this study, we aimed to compare the free-hand technique with a new system that utilises electromagnetic (EM) tracking data (SURESHOT™ Distal Targeting System) to localise distal locking holes. MATERIAL AND METHODS: Patients admitted from March 2010 to January 2013 for tibial fracture that required intramedullary nailing were analysed retrospectively. We compared intraoperative radiation exposure time and distal locking time in patients treated with the standard free-hand technique and distal locking using the EM field-generating device. Intraoperative radiation exposure time and distal locking time were used for comparison. RESULTS: Data from a total of 50 patients were analysed. The standard free-hand technique and the EM field-generating device were used in 25 (group 1) and 25 (group 2) patients, respectively. Mean distal locking time was 1258.6 (450-2289) s in group 1 and 603.5 (360-1140)s in group 2. Mean radiation exposure time was 19.4 (6-33) s in group 1 and 4.6 (1-10) s in group 2. CONCLUSION: The EM field-generating device significantly reduces distal locking time and, more importantly, significantly decreases duration of exposure to ionising radiation.

Large scale association analysis for identification of genes underlying premature coronary heart disease: cumulative perspective from analysis of 111 candidate genes.

BACKGROUND: to date, only three groups have reported data from large scale genetic association studies of coronary heart disease using a case control design. METHODS AND RESULTS: to extend our initial report of 62 genes, we present data for 210 polymorphisms in 111 candidate genes genotyped in 352 white subjects with familial, premature coronary heart disease (onset age for men, 45; for women, 50) and a random sample of 418 population based whites. Multivariate logistic regression analysis was used to compare the distributions of genotypes between cases and the comparison group while controlling for age, sex, body mass, diabetes, and hypertension. Significant associations were found with polymorphisms in thrombospondin-4 (THBS4), thrombospondin-2 (THBS2) and plasminogen activator inhibitor-2 (PAI2), the strongest being with the A387P variant in THBS4 (p = 0.002). The THBS2 and THBS4 associations have since been replicated. We evaluated polymorphisms in 40 genes previously associated with coronary heart disease and found significant (p<0.05) associations with 10: ACE, APOE, F7, FGB, GP1BA, IL1RN, LRP1, MTHFR, SELP, and THPO. For five of these genes, the polymorphism associated in our study was different from that previously reported, suggesting linkage disequilibrium as an explanation for failure to replicate associations consistently across studies. We found strong linkage disequilibrium between polymorphisms within and between genes, especially on chromosome 1q22-q25, a region containing several candidate genes. CONCLUSIONS: despite known caveats of genetic association studies, they can be an effective means of hypothesis generation and complement classic linkage studies for understanding the genetic basis of coronary heart disease.

Single nucleotide polymorphisms in multiple novel thrombospondin genes may be associated with familial premature myocardial infarction.

BACKGROUND: Recent advances in high-throughput genomics technology have expanded our ability to catalogue allelic variants in large sets of candidate genes related to premature coronary artery disease. METHODS AND RESULTS: A total of 398 families were identified in 15 participating medical centers; they fulfilled the criteria of myocardial infarction, revascularization, or a significant coronary artery lesion diagnosed before 45 years in men or 50 years in women. A total of 62 vascular biology genes and 72 single-nucleotide polymorphisms were assessed. Previously undescribed variants in 3 related members of the thrombospondin protein family were prominent among a small set of single-nucleotide polymorphisms that showed a statistical association with premature coronary artery disease. A missense variant of thrombospondin 4 (A387P) showed the strongest association, with an adjusted odds ratio for myocardial infarction of 1.89 (P=0.002 adjusted for covariates) for individuals carrying the P allele. A variant in the 3' untranslated region of thrombospondin-2 (change of thymidine to guanine) seemed to have a protective effect against myocardial in individuals homozygous for the variant (adjusted odds ratio of 0.31; P=0.0018). A missense variant in thrombospondin-1 (N700S) was associated with an adjusted odds ratio for coronary artery disease of 11.90 (P=0.041) in homozygous individuals, who also had the lowest level of thrombospondin-1 by plasma assay (P=0.0019). CONCLUSIONS: This large-scale genetic study has identified the potential of multiple novel variants in the thrombospondin gene family to be associated with familial premature myocardial infarction. Notwithstanding multiple caveats, thrombospondins specifically and high-throughput genomic technology in general deserve further study in familial ischemic heart disease.

Psychosexual aspects of the evaluation and management of vulvar vestibulitis.

OBJECTIVE: This article describes the structure and outcome of a collaboration between a gynecologist and a psychologist in evaluating and treating 45 consecutive women with vulvar vestibulitis. STUDY DESIGN: Women were interviewed by the psychologist in a structured format and also filled out questionnaires. Vulvar lesions were defined by clinical examination and colposcopy, and a conservative local excision was performed, without mobilization of the vagina. Postoperatively, women were offered sexual counseling including Kegel exercises, vaginal dilation, and couple therapy. Follow-up data were gathered a mean of 8 months after treatment. RESULTS: Of the 32 women who had both surgical excision of vulvar lesions and contact with the psychologist, 50% were much improved in perceived pain, 41% were somewhate improved, and 9% were unimproved. Factors predictive of an improved outcome included willingness to have psychologic treatment, higher socioeconomic status, and self-report of specific, localized areas of vulvar pain rather than vague, diffuse pain. Parous women were more likely to improve. Those who reported increased pain intensity premenstrually had poorer outcomes. CONCLUSIONS: Vulvar vestibulitis may be a syndrome that results from interacting pathophysiologic and psychologic factors, so that a comprehensive treatment approach is beneficial. Women who have diffuse genital pain or who refuse psychologic intervention may be poor candidates for surgery.

Circulating lipid and lipoprotein concentrations with oral estrogen-androgen hormone replacement therapy.

The goal of this study was to determine whether the administration of an oral combined estrogen-androgen preparation would influence the lipid and lipoprotein profile of postmenopausal women. There were no pretreatment to posttreatment differences in triglycerides, total cholesterol, or in low density lipoproteins and very low density lipoproteins. However, high density lipoprotein values decreased significantly after treatment. Although further study is warranted, these preliminary findings suggest that the potential beneficial effects of oral estrogen-androgen on sexual and psychological well-being may need to be weighed against the possible cardiovascular risks of adverse lipid changes in postmenopausal women.