A randomized phase III comparative trial of immediate consolidation with high-dose chemotherapy and autologous peripheral blood progenitor cell support compared to observation with delayed consolidation in women with metastatic breast cancer and only bone metastases following intensive induction chemotherapy.

The prognosis for patients with metastatic breast cancer remains poor. Metastatic breast cancer confined to the bones may have a better prognosis, especially hormone receptor-positive disease. We performed a prospective, randomized clinical trial to compare immediate consolidation with high-dose chemotherapy and hematopoietic support versus observation with high-dose consolidation at the time of disease progression in women with metastatic breast cancer and only bone metastases. The patients received chemotherapy with doxorubicin, 5-fluorouracil and methotrexate before randomization. In all, 85 patients were enrolled and 69 were randomized. The median follow-up is 8.1 years from randomization. The median event-free survival (EFS) for the immediate transplant arm is 12 months and for the observation arm is 4.3 months (P<0.0001). The median overall survival for the immediate transplant arm is 2.97 years and for the observation arm 1.81 years, a difference that is not statistically significant. Immediate high-dose chemotherapy and radiation therapy as consolidation offers a clinically and statistically significant improvement in EFS compared with radiation therapy alone following induction chemotherapy for women with metastatic breast cancer confined to the bones.

Thoracic and lumbar spine trauma.

Complete thoracolumbar trauma evaluation incorporates radiographs, computed tomography, and magnetic resonance imaging. Primarily to localize the level of injury, diagnosis of thoracolumbar spine trauma begins with radiographs. Computed tomography with sagittal reformatted images is more sensitive for identifying the full extent of injury and the degree of involvement of the bony posterior elements. Magnetic resonance imaging is used for evaluating the extent of soft tissue injury, including damage to ligaments, discs, and epidural spaces. Magnetic resonance imaging is most frequently performed when radiographs and computed tomography do not explain the patients' symptoms and when there is a possibility of epidural hematoma, traumatic disc herniation, or spinal cord injury.

Reliability and reproducibility of radiographic interpretation of proximal humeral fracture pathoanatomy.

Recent studies have demonstrated inconsistencies in the use of certain images for classifying proximal humerus fractures. Our purpose was to determine whether three-dimensional computed tomography or the level of expertise of the observers would improve the reliability and reproducibility of identifying specific anatomic fragments in proximal humerus fractures. Two groups of observers, nonexperts and experts in shoulder surgery, were asked to review the radiographs and three-dimensional computed tomography scans of 12 patients with proximal humerus fractures. Observers were asked to identify displaced fracture fragments, dislocation, and articular surface fractures. Both groups of observers displayed suboptimal reliability for the identification of displaced fracture fragments. The addition of three-dimensional computed tomography scans did not improve the reliability or reproducibility. Poor agreement for the purpose of classification seems to occur at the most fundamental level, the pathoanatomic description of the fracture. Inconsistencies may have been due to imprecise identification and measurement of individual fracture fragments, differing interpretations of the pathoanatomy, or both.

Impotence following pelvic fracture urethral injury: incidence, aetiology and management.

OBJECTIVE: To evaluate the potency status of patients undergoing delayed perineal repair following a pelvic fracture urethral injury to determine the incidence and aetiology of impotence. PATIENTS AND METHODS: Long-term potency (> 6 months post-operatively) was subjectively evaluated in 92 patients and correlated with their pre-operative and intra-operative findings. The management of their impotence was aso reviewed. Thirty original pelvic radiographs were assessed independently to determine if the pattern of bony injury was associated with the development of impotence. RESULTS: Fifty-seven patients (62%) remained impotent in the long term with a median follow-up of 48 months (range 12-128) and the operation did not render any potent patient impotent. Self-injection with vasoactive agents was successful in 24 of 27 (89%), suggesting a neurogenic aetiology in the majority. Bilateral pubic rami fracture was also associated with a high incidence of impotence. CONCLUSION: Disruption of the cavernosal nerves lateral to the prostatomembranous urethra behind the symphysis pubis is the most likely cause of impotence in this injury.

A new type of dislocation of the first metatarsophalangeal joint: a case report.

We are reporting a case of traumatic dislocation of the first metatarsophalangeal joint that does not correspond to any previously reported type. This new type of dislocation was associated with a rupture of the lateral short sesamophalangeal ligament/plantar plate, partial rupture of the intersesamoid ligament, and separation of a previously bipartite tibial sesamoid. Closed reduction was easily performed; however, the distal portion of the tibial sesamoid remained trapped within the joint. The rationale for and result of surgical treatment are presented.

Bone metastases from breast cancer: value of CT bone windows.

A pilot study was organized to compare the utility of scintigraphy, radiographic bone surveys, and conventional CT bone windows (CTBWs) in judging therapeutic response of bone lesions in patients with metastatic breast carcinoma. Twenty-six patients with stage IV disease and documented bone metastases were evaluated over a 2 year period. Discordance in the assessment of therapeutic response was greatest (56% discordance) between bone scans (BSs) and conventional CTBWs. In 77% of the discordant observations, the assessment by conventional CTBWs agreed with the patients' clinical response to therapy. Our preliminary results suggest that posttherapy review of conventional CTBWs provides useful clinical information about therapeutic response and exceeds the contribution of BSs in this regard.

Coalition of the hallux sesamoids: a case report.

Multiple variations in partition of the hallux sesamoids have been described; however, to our knowledge, a coalition of the hallux sesamoids has never been presented. A case of coalition of the hallux sesamoids is presented and the literature is reviewed with respect to the possible significance of this anomaly.

Radiology of the cervical spine in trauma patients: practice pitfalls and recommendations for improving efficiency and communication.

Trauma constitutes a significant portion of emergency department practice. Such patients often have suspected cervical spine injury necessitating cervical spine radiographs. The importance of detecting cervical spine injury is obvious because failure to do so can lead to tragic consequences for patient and physician alike. Although most cervical spine radiographs are justified, poorly indicated and unnecessary examinations are unfortunately commonplace. Indiscriminate ordering of cervical spine examinations can easily exceed radiology resources assigned to the emergency department. Rational ordering practices are therefore essential for efficient patient management. A risk-tailored approach to performing these examinations, which can improve efficiency, is presented. Once obtained, cervical spine radiographs are presumed to detect injury with consistently high sensitivity. Prevailing conditions of emergency department practice that may lower the "sensitivity" of cervical spine radiographs are reviewed. Overreliance on the initial radiologic examination may lead to inappropriate haste in the evaluation of suspected cervical region injury as exemplified by the commonly voiced mandate to "clear the cervical spine" of injury. This approach is discouraged in patients with significant trauma in favor of a careful, progressive evaluation of the potentially injured cervical spine. Periodic review of these complex issues and close cooperation between clinical services are emphasized.

The relationship of the intrapelvic vasculature to the acetabulum. Implications in screw-fixation acetabular components.

The use of screw-fixation acetabular components in total hip arthroplasty could increase the incidence of vascular injury because of the increased use of drills and screws placed into the acetabulum in close proximity to major vessels. Analysis of two illustrative case studies, anatomic specimen cross sections, and computed tomographic scans demonstrate which vessels are at risk of injury should the inner cortex of the pelvis be penetrated. The iliac vessels are at risk of injury when penetration of the inner cortex of the pelvis occurs in the anterosuperior region of the acetabulum. The obturator vessels are at risk when penetration occurs in the anteroinferior quadrant of the acetabulum. The vessels can be within 0.5 cm of the inner cortex of the pelvis and tend to become closer with advancing age. Damage to the intrapelvic vessels may cause profound blood loss and hypotension when screw-fixation acetabular components are used. Rapid identification and immediate surgical repair of vessel lacerations are essential in the treatment of this complication.

Anaphylactoid reaction to zomepirac.

Circulatory collapse and respiratory arrest occurred in a young woman shortly after taking 200 mg of zomepirac for relief of headache. She had no history of drug hypersensitivity and had tolerated zomepirac without adverse effects 18 months prior to this reaction. The patient was successfully treated and suffered no sequelae.