The predictive value of first-trimester embryonic heart rates in infertility patients.

OBJECTIVE: To analyze whether first-trimester embryonic (fetal) heart rates (FHR) are useful in predicting pregnancy outcome for infertility patients. METHODS: Patients in a university-based reproductive endocrinology and infertility practice were studied prospectively. Infertile women who achieved clinical pregnancy underwent first-trimester transvaginal sonographic evaluation, and FHR in patients achieving viable pregnancies were compared with those experiencing fetal loss. RESULTS: Overall, 99 pregnancies reached viability and 17 resulted in fetal loss before 20 weeks' gestation. Patient age, methods of conception, and number of previous fetal losses did not differ significantly between the two groups. A significant correlation (r = .70, P < .001) was found between increasing FHR levels and advancing gestational age in patients with viable pregnancies and, although to a weaker extent, patients who miscarried (r= .52, P < .05). A significantly higher number of viable pregnancies, compared with fetal losses, had FHR falling within one (70.7% compared with 41.2%, P < .025) and two (99.0% compared with 64.7%, P < .001) standard deviations of the mean for viable pregnancies at corresponding gestational ages. The majority of FHR of failing pregnancies fell below the individual reference ranges. CONCLUSION: First-trimester FHR can help predict pregnancy outcome for infertility patients. Women with FHR outside the reference range from the mean for viable pregnancies at corresponding gestational ages may be at risk for eventual pregnancy loss.

Evaluation of serum creatine kinase levels in ectopic pregnancy.

OBJECTIVE: To analyze whether increased serum creatine kinase (CK) levels are useful in early detection of ectopic pregnancy (EP). DESIGN: Prospective cohort study. SETTING: Patients in a university-based reproductive endocrinology and infertility practice. PATIENTS: Infertile women who achieved clinical pregnancy. INTERVENTIONS: Serum CK with isoenzymes levels were drawn after sonographic evaluation in patients achieving clinical pregnancy. MAIN OUTCOME MEASURES: Comparison of serum CK levels in patients with EP versus those with normal and abnormal intrauterine pregnancy (IUP), both separately and together as one group. RESULTS: There was no significant difference in mean total CK levels for patients with EP (82.25 +/- 81.39 IU/L; conversion factor to SI unit, 1.00) versus normal IUP (62.54 +/- 44.79 IU/L), abnormal IUP (55.15 +/- 3.46 IU/L), or all IUP (60.87 +/- 40.72 IU/L). The mean gestational ages were similar in all three groups: EP, 46.78 +/- 6.65 days; normal IUP, 47.56 +/- 8.29 days; and abnormal IUP, 47.86 +/- 13.30 days. CONCLUSION: Serum CK levels do not help to predict EP for infertility patients achieving conception. To assist in preventing maternal morbidity, a more discriminative test is needed to identify this condition early in gestation.

Cortical circulation of long bones.

Intravascular injections of India ink in the femora of adult dogs revealed the existence of two distinct vascular systems in the cortex. One courses through the entire thickness of the cortex and is a regular, longitudinal network of uniform capillaries which is in continuity with the periosteal and endosteal networks. Once the haversian systems form a second network appears, radiating from the bone marrow. That system, primarily transverse, anastomoses in the haversian canals with the capillaries of the first system. Therefore, the merging of the two networks occurs primarily in the middle layer of the cortex. The direction of the arterial blood flow in the mature animal is predominantly centrifugal, while the venous drainage is centripetal. In the immature animal, the contribution of the periosteal network is much greater. Because the two cortical systems are profusely anastomosed with each other and with the periosteal and endosteal circulatory networks, the blood can flow in either direction, depending on physiological conditions.

Pulmonary function studies in Friedreich's ataxia.

Pulmonary function tests were carried out on 20 patients with Friedreich's ataxia. The lung volume, diffusing capacity, flow rate, flow-volume curve, and blood gases were measured. In each patient the degree of scoliosis was measured and the pulmonary function tests were analyzed in relation to the scoliosis. A control group of 13 subjects with idiopathic scoliosis was used for comparison. In both groups, the degree of scoliosis was similar.

Dynamic loads experienced in correction of idiopathic scoliosis using two types of Harrington rods.

This paper reports the results of a series of tests conducted to evaluate the dynamic loads exerted by the Harrington rod on the vertebral bones during the correction of idiopathic scoliosis. Two types of Harrington rods were tested: the standard stepped rod and a modified threaded rod. The latter had a threaded end replacing the standard stepped end. The tests were conducted on linear and nonlinear springs, the mechanical characteristics of which are similar to those previously obtained from measurements performed on human spines. The results of the tests are reported and the two rod designs are evaluated accordingly. The modified threaded rod shows definite mechanical advantages over the stepped rod; however, the design is still open for modifications to overcome certain functional difficulties. (The Custom Product Services of Zimmer Co. offers a child spinal threaded rod designed by Dr. Kenton Leatherman.)

Roy-Camille plates in unstable spinal conditions. A preliminary report.

From 1979 to 1982, 21 consecutive patients with posttraumatic or pathologic fractures of the spine were treated at the University of Sherbrooke by Roy-Camille plates to provide stabilization. Ten burst fractures and 11 fracture-dislocations were treated in this manner. Nine patients had complete paraplegia, 6 had various neurologic deficits, and 6 had no neurologic problems before operation. Using the technique described by Roy-Camille, the authors stabilized the spine with two plates in 18 patients and one plate plus fusion in 3. No major complications occurred with surgery nor after a follow-up of 1-3 1/2 years. Sixteen patients had no loss of correction, and 5 lost 10 degrees-12 degrees. This technique was safe and effective and thought to be a valid alternative to conventional forms of spinal fixation, particularly in paraplegic patients, in those with spinal metastasses, and in those necessitating extensive laminectomies impairing spinal stability.

The process of adult living liver donation.

OBJECTIVE: To evaluate both the opinion that living liver donors have of the process and the psychological, economic, and social consequences of donation. MATERIAL AND METHODS: Six months after the donation, an anonymous survey was sent to 22 donors of the right liver lobe between March 2000 and December 2002. RESULTS: 15 surveys were returned with all of the questions answered. Almost all the donors had no prior knowledge of living donation. When they were considered to be suitable donors, all of them felt happy, 21% were scared and 15% felt joy and insecurity. The information provided was well understood and accurately described the experiences of 93% of donors. All donors understood the vital risk, and 93% understood that transplantation is not always completely successful. All donors would repeat the experience. Mean hospital stay was 12.6 days. Mean convalescence was 50.6 days. Salaried donors were on sick leave for a mean of 96.4 days (21-150 days), causing financial problems in six cases (36%), due to no financial compensation and compulsory redundancy in one case. All donors had completely recovered at six months after donation. DISCUSSION: Adult living donation of the right liver lobe is an accepted therapeutic alternative. In order to regulate medical and economic protection to avoid additional disturbances after donation, the public, patients, and physicians require more complete information about living donation.

[Genu valgum secondary to a proximal metaphyseal fracture of the tibia]. / Genu valgum secondaire à une fracture de la métaphyse proximale du tibia chez l'enfant. A propos de 6 cas.

Fractures with moderate displacement in childhood are usually thought to be benign if they are not epiphyseal. Six cases of fractures of the upper tibial metaphysis in childhood with slight or moderate displacement are reported. In 5 cases progressive genu valgum appeared. On 3 occasions osteotomy was necessary to correct the deformity. The possible causes of such complications are discussed.

Femoral osteotomy in Perthes disease.

A subtrochanteric osteotomy was performed on 25 hips of 24 patients affected with Perthes disease. Twelve of these patients have been followed 4 or more years postoperatively. Coxa plana, or "mushroom" deformity, never occurred. Roundness of the head was always achieved. Internal fixation was first secured with a 4 screw plate and later advantageously substituted by Hoffmann external fixation. Post-operative shortening was always present but gradually resolved to less than 1 cm in most cases. A Trendelenburg positive sign was always present postoperatively and usually disappeared within 2 years. Internal rotation of 40-60 degrees was obtained at surgery. The resulting external rotation deformity of the leg corrected spontaneously. Varus deformity, on the other hand, changed little within this follow-up. Varisation of the hip is nevertheless an essential part of the osteotomy. The overall results were directly related to the amount of epiphysis involved. The fate of the epiphyseal plate seems to play a major role in the neck deformities and the resulting coxa vara. The absence of metaphyseal changes in the face of significant epiphyseal involvement is an ominous sign.

Synovial chondrometaplasia: review of world literature and a study of 18 Canadian cases.

A retrospective study of synovial chondro-metaplasia in Canada revealed 18 well-documented cases of this condition. Review of these cases together with 137 cases obtained from the literature permitted clarification of the clinical, radiologic and histologic features of the clinical, radiologic and histologic features of the disease. Positive histologic proof of synovial chondrometaplasia is necessary for a true diagnosis. Synovectomy with excision of loose bodies is the treatment of choice in symptomatic cases.

Ultrasonography in the diagnosis of rectus abdominis hematoma.

Because bleeding into the rectus sheath may give a clinical picture simulating an acute abdomen, it is essential that an accurate diagnosis be made so that an unnecessary laparotomy is not performed. Plain films do not give adequate information and computerized axial tomography is not always available, but ultrasonography, which is noninvasive and is readily available, provides an accurate diagnosis as in the case reported in this paper. A 57-year-old woman had bilateral hematomas of the rectus sheath that did not occur simultaneously. She had a chronic debilitating disease as do the majority of such patients. Long-term cortisone therapy with secondary breakdown of connective tissue was probably the predisposing factor. During a blood transfusion that was needed following operation for osteomyelitis the patient had a severe reaction accompanied by sudden onset of severe abdominal pain on the left side. Ultrasonography confirmed the tentative diagnosis of rectus sheath hematoma. The patient was treated conservatively. The pain subsided within a few days leaving an ecchymosis. Two weeks later she experienced a similar pain on the right side which was also diagnosed by ultrasonography as a rectus sheath hematoma. Again, with conservative treatment the pain subsided leaving discolouration of the skin. The authors stress the value of ultrasonography in diagnosing rectus sheath hematoma and the importance of conservative management.

Chondrosarcoma of the hand.

A case of chondrosarcoma of the hand recurred 4 times over a period of 32 years. Forty-seven cases of hand chondrosarcomas have been found in the literature. Histological diagnosis is difficult in differentiating chondrosarcomas from benign chondromas. Pain and swelling are the main symptoms of recurrence. The diagnosis is established by arteriography and excisional biopsy. Extraskeletal hand chondrosarcomas do not metastasize and other hand chondrosarcomas do so only rarely. Block excision of localized amputation is the treatment of choice.

Late sequelae of infantile meningococcemia in growing bones of children.

Multiple, irregular ball-and-socket deformities at the ends of long bones were noted in four children several years after they had had meningococcemia. Even though these lesions were clinically unsuspected at the time of the fulminant disease, they were probably the result of ischemia secondary to septic emboli to the epiphyseal vessels, which occurred at the same time as soft-tissue necrosis elsewhere. The individual lesions were radiologically identical to the metaphyseal cupping that has been reported following trauma to the growth plate.

Ovulation induction combined with intrauterine insemination in women 40 years of age and older: is it worthwhile?

The use of ovulation induction combined with intrauterine insemination (IUI) as a treatment for subfertility in women with patent Fallopian tubes has increased in recent years. Little is known regarding the efficacy of this treatment in women aged >/=40 years. We reviewed our data in our ovulation induction with IUI programme for 168 consecutive patients aged >/=40 years undergoing a total of 469 cycles of treatment. Either sequential clomiphene citrate and human menopausal gonadotrophins or daily gonadotrophins were utilized along with timed IUI insemination. In 402 completed cycles, 28 clinical pregnancies occurred. The pregnancy loss rate was 34.4%. The overall ongoing/viable pregnancy rates per initiated and completed cycles were 4.47 and 5.22% respectively. No viable pregnancies occurred in 136 cycles in women aged >/=43 years. The ongoing/variable cycle fecundity rates for women aged 40, 41, and 42 years were 9.6, 5.2, and 2.4% per cycle respectively. When utilized in women aged >=40 years, ovulation induction with IUI is most likely to result in successful pregnancy in women 40-42 years of age. Women >/=43 years should consider other alternatives such as adoption or egg donation.

Late sequelae of juvenile rheumatoid arthritis of the hip: a follow-up study into adulthood.

A 4-13 year follow up study of 29 patients with juvenile rheumatoid arthritis into adulthood revealed several structural deformities of the hips: coxa magna, short femoral neck, subluxations associated with large cyst-like erosions of femur and acetabulum near the ligamentum teres and a flattened, wide femoral head (without steroid treatment). The deformities evoke the possibility of ischemia of the femoral head in the presence of active, compressive synovial proliferation during the growth period in a joint with largely intra-articular nutrient vessels.

The orthopedic approach in infected median sternotomy.

A retrospective review of 10 infected median sternotomies revealed that the management may be difficult and several procedures may be required to obtain a satisfactory result. Repeated curettage was successful in four patients. The cavity created by d ebridement was treated by the temporary insertion of gentamicin beads in one patient and by the Papineau bone grafting procedure in two. In two patients the thoracic cage became unstable as a result of extensive d ebridement and was stabilized successfully by inserting Harrington compression rods. One patient died of mediastinitis.

Does the absence or presence of seminal fluid matter in patients undergoing ovulation induction with intrauterine insemination?

Sperm preparations for intrauterine insemination (IUI) generally do not include seminal fluid, and it is not known whether the absence of this component affects pregnancy rates. Therefore we evaluated the effect of high intravaginal seminal fluid deposition on clinical pregnancy rates in patients undergoing ovulation induction and IUI therapy. A prospective, randomized, double-blind study was designed for an infertile population in a university-based infertility practice. Patients were randomized to receive high vaginal deposition of either seminal fluid separated from the husband's ejaculate (study group) or normal saline solution (control group). Intercourse was restricted. A comparison of clinical pregnancy rates per cycle between study and control groups showed no significant difference between them [22/164 (13.4%) and 19/155 (12.3%) respectively]. Furthermore, in non-participants with unregulated intercourse, the pregnancy rate per cycle was not significantly different (40/307; 13.0%). Miscarriage rates between the study and control groups were similar. As high intravaginal deposition of seminal fluid at the time of IUI does not improve the clinical pregnancy rate in patients undergoing ovulation induction and IUI therapy, our study suggests that, after ejaculation, clinically significant biological contributions of seminal fluid to the achievement of pregnancy are bypassed by well-timed IUI.