20120331 Internet Medical Journal

Published on June 2016 | Categories: Types, Research, Health & Medicine | Downloads: 34 | Comments: 0 | Views: 240
of 88
Download PDF   Embed   Report

Comments

Content

The Internet Medical Journal
March, 2012 Tom Heston, MD Editor

NOTICE: All contents of the Internet Medical Journal is opinion and strictly editorial in nature. Authors take full responsibility for their articles. Please be aware that knowledge is constantly being updated, and mistakes can and will occur. When it comes to your personal health issues, always consult with your doctor or health care provider. © 2012 all rights reserved by the Internet Medical Association. http://medjournal.org

EDITORIAL BOARD Editor-in-Chief: Tom Heston, MD Contributing Editor: Dr Gulab Singh Shekhawat, India

TABLE OF CONTENTS From the Editor Clinical Intrauterine insemination versus Fallopian tube sperm perfusion in non-tubal infertility A case report: treatment of a medial condylar humeral fracture in an adult with osteopetrosis Review / Commentary Stress-only nuclear myocardial perfusion imaging

Can we skip the autopsy? The fundamentals of courage Omega-3 fatty acids, red yeast rice, and sudden cardiac death New Android Applications Android Apps from the Internet Medical Association

FROM THE EDITOR What is the price of a medical education? Whether at the start of our career, or near the end, we all must pay a constant price in order to stay up-to-date and well educated. It takes time, energy, and focus to become an expert. With the goal of helping our readers become experts in their chosen field, the Internet Medical Association is producing a series of mobile apps. The apps contain the latest news, research, and publications in the specialty. A suggested plan to become and expert, and to maintain expert status is this:

1. Daily read the news in your specialty. 2. Weekly read the latest research. 3. Monthly read one best selling or new publication in your chosen specialty. This system of constant nourishing of the mind with important information in your chosen specialty ultimately will allow the novice to become an expert, and the expert to continue to be a leader in the field. This month features two clinical articles from India, one on intrauterine insemination and the other on orthopaedic surgery. This is followed by three review articles and an essay on courage. Finally, there is a listing

of new Android Apps that the Internet Medical Association has recently published. We are pleased to welcome Dr. Gulab Singh Shekhawat as a contributing editor this month. Please send us your article submisstions, comments, or suggestions. We look forward to hearing from you. Tom Heston, MD, Editor

INTRAUTERINE INSEMINATION VERSUS FALLOPIAN TUBE SPERM PERFUSION IN NON-TUBAL INFERTILITY AUTHORS: Dr. Col (Retd) G S Shekhawat, MD(Obst & Gyn) * (Corresponding. Author), Dr Priyanka S, MBBS+ PLACE OF RESEARCH WORK: Assisted Reproductive Technology center, Armed Forces Medical College/ Command Hospital (Southern Command), Pune411040 and 92 Base Hospital PIN -901218 C/O 56 APO ADDRESS OF THE AUTHORS:

* Associate professor, Dept of Obstetrics & Gynecology, Smt Kashibai Navale Medical College, Narhe, Pune-411041, Maharashtra. Email: [email protected], Tel : ( M) 9372897090, +Medical Officer, Smt Kashibai Navale Medical College, Narhe, Pune-411041, Maharashtra. INTELLECTUAL CONTRIBUTIONS: Study concept: Dr G S Shekhawat Drafting and Manuscript revision: Dr Priyanka S

Statistical analysis: Dr Priyanka S Study supervision: Dr G S Shekhawat ABSTRACT: Background: Controlled ovarian hyper stimulation (COH) combined with intrauterine insemination (IUI), using a volume of 0.5 mail of inseminate is commonly offered to couples with non tubal infertility. Another method is Fallopian tube sperm perfusion (FSP) which is based on a pressure injection of 4 ml of sperm suspension while attempting to seal the cervix to prevent semen reflux. This technique ensures the presence of higher

sperm density in the fallopian tubes at the time of ovulation than standard IUI. The aim of this study was to compare the efficiency of IUI and FSP in the treatment of infertility. Methods: 200 consecutive patients with infertility in 404 stimulated cycles were included in the study. Those randomized to standard IUI included 100 patients in 184 cycles [158 Clomiphene citrate/human menopausal gonadotrophin cycles and 26 Letrozole/FSH cycles exclusively for polycystic ovarian disease patients] (group A). Patients subjected to FSP included 100 patients in 220 cycles (193 Clomiphene citrate/human menopausal gonadotrophin cycles and 27 Letrozole/FSH cycles

exclusively for polycystic ovarian disease patients] (group B). Swim up semen preparation technique was used in all cases. Insemination was performed in both groups 34-37 hours after hCG administration. Standard IUI was performed using 0.5 ml of inseminate. In FSP 4ml inseminate was used. Results: In group A (184 IUI cycles in 100 patients), 22 clinical pregnancies (presence of gestational sac with fetal cardiac activity) occurred (11.95% per cycle over four cycles). In group B, (220 cycles of FSP in 100 patients), 48 clinical pregnancies occurred (21.81%per cycle over four cycles) and this difference was statistically significant (p<0.05).

Conclusions: For non-tubal sub fertility, the results indicate clear benefit for FSP (Fallopian tube sperm perfusion) over IUI (Intrauterine insemination). Key Words: Intrauterine insemination, Fallopian tube sperm perfusion, Non-tubal infertility. Introduction Intrauterine insemination (IUI) with mild ovarian stimulation has been used for many years in the treatment of non tubal infertility. During IUI, pretreated semen is concentrated in a small volume of 0.5 ml and deposited by a catheter into the uterine

cavity. The overall pregnancy rates reported in the literature ranged from 5.7% to 17.7% per cycle [1]. Although the number of available oocytes can be increased by ovarian stimulation, the pregnancy rates in IUI are still not promising, mainly because of suboptimal spermatozoa at the site of fertilization [2]. An alternative procedure, termed Fallopian tube sperm perfusion (FSP), has been reported with improved pregnancy rates in comparison with IUI [3, 4, and 5]. In FSP, sperm preparation is identical to that used in IUI, but the spermatozoa are diluted in a larger volume of medium up to 4 ml [6]. This volume has been considered sufficient for bilateral passage of the spermatozoa through the fallopian tubes. Theoretically, this would

increase the density of capacitated spermatozoa near the oocytes and result in higher pregnancy rates. A prospective randomized study was designed to determine whether FSP resulted in higher pregnancy rates than IUI. Material & Methods Two hundred infertile patients, aged 17 to 39 years, undergoing 404 consecutive cycles of ovarian stimulation were studied from June 2007 to Jan 2009. Institutional board approval was obtained. These patients underwent a basic infertility workup including confirmation of tubal status by hysterosalpingogram or laparoscopy and hormone profile including serum follicle

stimulating hormone (FSH), luteinizing hormone (LH), prolactin and thyroid hormone tests. Menstrual cycle day 3 basal transvaginal ultrasonography was done in all cases to rule out ovarian cysts prior to ovulation stimulation. Exclusion criteria were age > 39 years, obstructed fallopian tubes and cases with marked oligospermia sperm count<10X106per ml). The patients were classified for purpose of etiology of infertility as having mild and moderate endometriosis; ovulatory disorders (hormonal profile and transvaginal sonography characteristic of polycystic ovarian syndrome); cervical hostility (poor properly timed post-coital test); male sub fertility (as per WHO criteria) [7];

unexplained infertility (where no infertility causes were found). These patients underwent ovulation induction with either Clomiphene citrate and Human menopausal gonadotrophin (351 cycles in 174 patients) or Letrozole and FSH used exclusively for polycystic ovarian disease patients (53 cycles in 26 patients). The ovarian stimulation protocol of clomiphene and hMG (Human menopausal gonadotrophin) was used in 170 patients. It consisted of clomiphene citrate 100 mg daily on days 3-7 of the cycle, and 75 IU daily of hMG (Human menopausal gonadotrophin) on days 6-9 of the cycle. For some of the women, hMG was increased to 150 IU in subsequent cycles,

depending on the previous ovarian response. Rotterdam ESHRE consensus workshop criteria (2003) was used for diagnosis of PCOS. In all PCOS patients (26 patients), who had been on Metformin 500 mg t.i.d , Letrozole was given orally in a dose of 2.5mg/day for 5 days starting from day 3 of a spontaneous or progesterone induced menstrual bleeding . Inj purified FSH 75 IU administered on 6-9 day of menstrual cycle. Cycles were monitored from day 9 onwards by transvaginal ultrasound measurement of the number and diameter of the growing follicles along with the thickness and morphology of the endometrium. A dose of 10,000 IU human chorionic gonadotrophin (hCG) was administered when at least one

leading follicle had reached a diameter of 18 mm and at least 8 mm endometrial thickness with tri laminar ‘halo’ appearance seen. Patients were called 34 to 36 hours later, and either standard IUI (group A: 184 cycles in 100 patients) or FSP (group B: 220 cycles in the 100 patients) was performed. The patients were counseled about the two alternative procedures and informed consents were obtained before randomization. Patients were allocated randomly to standard IUI or FSP on the day of insemination in the first cycle itself, according to even or odd serial number in the register. Maximum of four cycle treatments of IUI or FSP were considered for those patients who could not conceive in previous attempts. However those who

failed to conceive with IUI were offered IUI only and vice versa. 132 male partners were normozoospermic with count > 20X106 sperm per ml, >50% motile with forward progression (categories a and b) within 60 min of ejaculation and > 60% morphologically normal spermatozoa (WHO criteria) [7]. Male partners with sperm count ranging from 10X106 to 20X106 were asked to produce a second semen sample within 2 hours of the first sample on the day of insemination. Sixtyeight males having sub fertility as per WHO criteria did consent to the study. However 04 could not produce a second sample at the time of IUI, and 1 patient had total sperm immotility and was excluded from the study.

A fresh ejaculate was delivered in a sterile 60 ml jar by masturbation on the day of insemination. Neat semen was left at room temperature for liquefaction for 30 minutes.The liquefied semen samples were analyzed for density and motility using a fixed-depth counting chamber (Makler). The liquefied ejaculate was transferred to a labeled sterile 14 ml round-bottomed disposable centrifuge tube (Falcon No.2095) and 4 ml flushing media (Medicult) added to it. After thorough mixing the sample was centrifuged at 5000 rpm for 10 minutes. Then, the supernatants were discarded and the pellet was resuspended and mixed in 3 ml of fresh flushing media (Medicult) and centrifuged for second wash again at 5000 rpm for 10 minutes. Once again the

supernatants were discarded. Each pellet was now gently layered with 0.5 ml for IUI and 4 ml for FSP of universal IVF media (Medicult), and incubated at 37oC in a humidified incubator with 5% Carbon dioxide for 1 hour. Post wash semen analysis was done in all cases using Makler’s counting chamber before insemination. Intrauterine insemination was performed with conventional catheter using 0.5 ml of inseminate. To eliminate dead space problem, IUI catheter was first attached to syringe and then inseminate was aspirated. In FSP 4ml inseminate was used and backflow of inseminate was occluded at the cervical opening by the long size Allis

clamp (Figure-1), which was suitably modified by attaching cervical occluding prongs with rubber cushions to avoid trauma to the cervix and was kept in place for about 3 to 4 minutes after insemination. In both groups, the patient rested for 30 minutes after insemination and received oral micronized progesterone 100 mg, two tablets per day for luteal-phase support. Values were recorded as mean ± SD using Microsoft Excel version 4. Statistical analysis were performed using student’s ttest for testing significance of difference between the means and the X2test to compute p-values for testing the agreement between proportions. MedCalc statistical software (Meriakerke, Belgium) version

9.5.0.0 was used for all statistical analysis. The significance was defined as p < 0.05. Results The patient characteristics for group A and B were not significantly different concerning patient’s age (28.42 ± 2.78 years and 28.19 ± 2.80 years), type of sterility (primary infertility 74% versus 72% respectively) and duration of infertility (5.6 ± 2.1 and 5.3 ± 1.9 years respectively). The clinical indications for IUI or FSP were also not significantly different for the two groups (endometriosis 12% versus 12%, polycystic ovarian syndrome 34% versus 36%, cervical 4% versus 4%, unexplained 18% versus 12% and male factor sub fertility 32%

versus 36% respectively). The ovarian stimulation protocol for group A and B were not significantly different (clomiphene citrate/hMG 85% versus 87% and Letrozole/FSH 15% versus 13% respectively). The parameters of cycle monitoring for group A and B including number of follicles=18 mm diameter(3.93±1.37 versus 3.90±1.17), endometrial thickness on the day of hCG administration (9.19±0.58mm versus 9.14±2.1mm) and the number of spermatozoa(38.83±16.57X106 versus 36.68±13.44X106) inseminated were not significantly different. However the day of hCG administration (12.8±3.4 versus 11.1±2.1) was significantly different between the two groups as shown in table-1

and 2. Clinical pregnancy was defined by the presence of fetal cardiac activity, detected by ultrasound examination. Pregnancy rates were similar when compared for the etiology of infertility: for ovarian (PCOS) cause (17.7% versus 21.8%), endometriosis cause (8.4% versus 10.1%), male infertility (12.8% versus 16.4%) and unexplained infertility (14.4% versus 24%) for the two groups, respectively as shown in table-3. There was statistically significant difference (p<0.05) in the overall pregnancy rate per cycle over four treated cycles (11.95% per cycle for IUI versus 21.81% per cycle for FSP over four cycles) as shown in table-4. Two missed abortions and one twin

pregnancy occurred among the patients in group A (IUI). Three missed abortions and two twin pregnancies occurred among the patients in group B (FSP). However, this limited number of abortions and multiple pregnancies are too low to allow testing for statistical significance. Three cases of mild ovarian hyper stimulation syndrome (OHSS) occurred in both groups. Discussion The purpose of this prospective, randomized study was to study pregnancy rates in couples with nontubal infertility when treated with FSP (inseminate volume 4 ml), in comparison with standard IUI (inseminate volume 0.5 ml). Pregnancy

rates were 21.81 and 11.95% respectively over four treatment cycles. The same protocols for ovarian stimulation were used in both groups. There was no statistically significant difference regarding the age of the patients treated, mean number of follicles, endometrial thickness on the day of hCG administration and the total number of motile spermatozoa inseminated. However the day of hCG(12.8±3.4 for FSP versus 11.1±2.1 for IUI) administration was statistically different between the two groups (p value <0.05). Kahn et al. reported the first clinical experience with FSP. In their study, they used a Frydman catheter for FSP and reported a pregnancy rate per cycle of

26.9% in patients with unexplained infertility and of 2.7% to 7.7% in patients with other etiologies. These excellent results, particularly in patients with unexplained infertility, were confirmed by other studies [8]. Some investigators used a paediatric Foley catheter or cervical clamp double-nut bivalve speculum and very encouraging results were reported by Fanchin et al, in which FSP using an auto blocking device (FAST system) doubled their pregnancy rates from 20% to 40% [1].The different types of catheters used for IUI have been compared but no study reports a significantly higher rate of pregnancy with any one type of catheter [9, 10].

The FSP increases the intrauterine pressure(70-200 mmHg) necessary for a flush influx of spermatozoa directly into the fallopian tubes. The high pregnancy rate per cycle for FSP as compared with standard IUI can be due to several causes as follows: firstly, the pressure injection of inseminate can either remove and/or circumvent transitory or partial obstruction of fallopian tubes, such as that created by thick mucus or tubal polyps; secondly, the concentration of motile spermatozoa around the oocytes after FSP is higher than that obtained after standard IUI; and thirdly, FSP leads to inseminate overflowing into the pouch of Douglas. The more accepted hypothesis is the existence of a similar mechanical effect created following a

hysterosalpingography [10]. In this study, we tried to evaluate FSP not only in patients with unexplained infertility but also in patients with other causes of infertility including male causes. Two different stimulation regimes were used; however, the distribution of the two types of stimulation protocols (clomiphene citrate/hMG and Letrozole/FSH) appeared homogenous in both studies groups. Clinical pregnancy was defined by the presence of fetal cardiac activity, detected by ultrasound. When comparing the pregnancy rates in both IUI and FSP in relation to the etiology of infertility, it is found to be statistically similar as shown in

table-3. Though the pregnancy rates of FSP in PCOS and unexplained infertility group of patients is superior to IUI, this finding is statistically not significant. This analysis revealed that couples suffering from any specific etiological sub fertility did not benefit from FSP over IUI. However, there was statistically significant difference in the overall pregnancy rate per cycle over four cycles of treatment (11.95% per cycle over four cycles for IUI versus 21.81% per cycle for FSP over four cycles) as shown in table-4(p value<0.009). Pregnancy rates improved in subsequent attempts with FSP in comparison to IUI. The cumulative pregnancy rates even after the second attempt, over two cycle

treatment, were statistically significant (p value <0.03), however there was no statistical difference when each attempt of treatment cycles was compared between the two groups (p value >0.05). Four studies [2, 4, 6, and 11] mentioned a maximum of three cycles per couple; one study [12] reported a maximum of four cycles. We also allowed maximum of four cycles treatment of IUI or FSP before considering them for In vitro fertilization and embryo transfer (IVF-ET). The type of catheter has no impact on the pregnancy rate after intrauterine insemination [13]. We suitably modified the long size allis clamp, by attaching cervical

occluding prongs with rubber cushions, which was kept in place for about 3 to 4 minutes after insemination to prevent any significant reflux. Mild reflux does not seem to influence the results of the FSP but the significant reflux (> 0.4 ml) may reduce the pregnancy [14]. If more than 1 ml comes back in the catheter, the operator needs to wait for a few minutes and re-inseminate again. All the authors agreed that women tolerated the FSP technique very well. In our study some patients complained of post insemination pelvic transient pain, more so in FSP than in IUI. Other interesting domain of FSP application is the immunological infertility in the presence of anti-sperm antibodies [15, 16].This aspect could not be studied in this study because pre and post

FSP anti-sperm antibody assay was not done. In this study by comparing the overall results, we conclude that FSP over four cycles of treatment offers an advantage over the standard IUI, and can replace the IUI for all its indications because of its better pregnancy rates. However FSP is more expensive than IUI due to the increased media usages. It could be used as an alternative for couples with non tubal infertility before embarking on IVF-ET treatment. References 1. Fanchin R, Oliveness F. A new system for

fallopian tube sperm perfusion leads to pregnancy rates twice as high as standard intrauterine insemination. Fertility and Sterility 1995; 64(3):505–10. 2. Kahn JA, Sunde A, Von During V, et al. Treatment of unexplained infertility. Acta Obstetrica Gynaecologica de Scandinavia 1993; 72(3):193–9. 3. Trout SW. Fallopian tube sperm perfusion versus intrauterine insemination: a randomized controlled trial and metaanalysis of the literature. Fertility and Sterility 1999; 71(5):881–5. 4. Ng EHY, Makkar G. A randomized comparison of three insemination methods

in an artificial insemination program using husbands’ semen. The Journal of Reproductive Medicine 2003; 48(7):542–6. 5. Nuojou-Huttunen S, Tuomivaara L, Juntunen K. Comparison of fallopian tube sperm perfusion with intrauterine insemination in the treatment of infertility. Fertility and Sterility 1997; 67(5):939–42. 6. Gregoriou O, Pyrrgiotis E, Konidaris S. Fallopian tube sperm perfusion has no advantage over intra-uterine insemination when used in combination with ovarian stimulation for the treatment of unexplained infertility. Gynecologic and Obstetric Investigations 1995; 39: 226-8.

7. World Health Organization. WHO laboratory manual for the examination of human semen and sperm cervical mucus interaction. WHO laboratory manual. Cambridge: Cambridge University Press, 1992. 8. Mamas L. Comparison of fallopian tube sperm perfusion and intrauterine tuboperitoneal insemination: a prospective randomized study. Fertility and Sterility 2006; 85(3):735–40. 9. SmithKL, GrowDR, WiczykHP, et al. Does catheter type effect pregnancy rate in intrauterine insemination cycles? Journal of Assisted Reproduction and Genetics 2002; 19(2):49–52.

10. Noci I, Dabizzi S, Evangelisti P, et al. Evaluation of clinical efficacy of three different insemination Techniques in couple infertility. Minerva Ginecologica 2007; 59(1):11–8. 11. Ricci G, Nucera G, Pozzob et al. A simple method for fallopian tube sperm perfusion using a blocking device in the treatment of unexplained infertility. Fertility and Sterility 2001; 7 Suppl 1:1242–8. 12. Biacchiardi CP, Revelli A, Gennarelli G, et al. Fallopian tube sperm perfusion versus intrauterine insemination in unexplained infertility: a randomized, prospective, crossover trial. Fertility and Sterility 2004; 81(2):448–51.

13. Vermeylen AM, D’Hooghe T, Debrock S, et al. The type of catheter has no impact on the pregnancy rate after intrauterine insemination: a randomized study. Human Reproduction 2006; 21(9):2364–7. 14. Kahn JA, von During V, Sunde A, et al. Fallopian tube sperm perfusion. First clinical experience. Hum. Reprod. 1992; 7: 19-24. 15. El Sadek MM, Amer MK, Abdel-Malak G. Questioning the efficacy of fallopian tube sperm perfusion. Human Reproduction 1998; 13 (11):3053–6. 16. Elhelw B, Matar H, Soliman EM. A randomized prospective comparison

between intrauterine insemination and two methods of fallopian tube sperm perfusion. Middle East Fertility Society Journal 2000; 5(1):83–4.

Figure 1

A CASE REPORT: TREATMENT OF A MEDIAL CONDYLAR HUMERAL FRACTURE IN AN ADULT WITH OSTEOPETROSIS Authors: Dr Calvin CHIEN, MBBS. Dr Rajesh BEDI, DNB (Ortho). Dr Richard D. LAWSON, FRACS (Ortho) Abstract Patients with osteopetrosis often present with orthopaedic problems such as frequent fractures. Management of fractures with open reduction and internal fixation is difficult but possible. We report on a 22 year old patient with a medial humeral condyle fracture treated successfully with internal

fixation using a pre-contoured plate. Introduction In 1904 Albers-Schoenberg described a condition characterised by marked radiographic density of the bones (1). Despite the sclerotic radiographic appearance of the thickened cortices and its material hardness, osteopetrotic bone is weak, brittle and prone to fracture after minor trauma (1). Most literature regarding treatment of osteopetrotic patients with fractures concentrates on paediatric patients or on the difficulty of operative intervention in adults (2). We report the case of an adult patient with osteopetrosis and a low medial column fracture (Milch Type I (1)) of the

distal humerus after minor trauma. The fracture was treated operatively utilising internal fixation with a pre-contoured periarticular plate. Case A 22 year old female with known osteopetrosis presented with an elbow injury after bracing herself with the right arm after a fall. The mechanism described suggested a valgus injury to the right elbow resulting in a Milch Type I (3) low medial column fracture of the distal humerus (Fig. 1). There were no neurological deficits. As an adolescent she had previous injuries including one to the radius of the same side limiting elbow extension by twenty degrees.

She was also partially blind and was receiving psychiatric treatment for depression. Two days later, open reduction of the right distal humerus was performed with internal fixation using a pre-contoured medial condylar locking plate (Fig 2). This was done through a posterior approach after identifying the ulnar nerve. Anterior transposition of the ulnar nerve was done before closure. The patient was discharged two days later in a plaster-of-paris back slab with outpatient follow-up. After two weeks the arm was placed in a range of movement elbow brace with unrestricted range of motion. Serial radiographs were performed at four-weekly intervals and complete bony

union with disappearance of the fracture line was evident on the radiographs taken at fourteen weeks (Fig 3). Outpatient as well as a home-based physiotherapy program was arranged and full pre-injury range of motion was achieved by ten weeks. Discussion Osteopetrosis is a rare hereditary disease of the osteoclasts first described by AlbersSchönberg, a German radiologist, in 1904. Defective osteoclastic activity or a reduced number of osteoclasts results in a failure of bone remodelling (4). This is manifested on radiographs as an increase in bone mass and osteosclerotic changes (4).

Osteopetrosis can be classified into three main forms: a malignant autosomal recessive, intermediate autosomal recessive and benign autosomal dominant form; the vast majority of these cases are the benign autosomal dominant form. The malignant autosomal recessive type, also known as infantile, is characterised by growth retardation, failure to thrive and cranial nerve palsies manifesting as proptosis, deafness and blindness. In addition, pancytopenia and thrombocytopenia may result from bone marrow failure. Many features of the intermediate form of osteopetrosis are similar to those of the malignant form but the intermediate form is less severe and later in onset. It is often diagnosed after a fracture, usually occurring

in the first decade. Benign osteopetrosis has been further subdivided into types I and II. However, recent genetic studies have shown that autosomal-dominant osteopetrosis type I is caused by an increase in osteoblastic activity rather than osteoclastic dysfunction. In this case osteoblasts deposit excessive amounts of bone matrix (4). Type II autosomal dominant osteopetrosis is the form Albers-Schönberg first described and so is often named after him. The onset is in later childhood and is usually diagnosed incidentally during a radiographic examination (4). It is also associated with increased fracture frequency. Other manifestations include coxa vara, osteoarthritis, spondylolysis, back pain, osteomyelitis and cranial nerve palsies.

Radiographic features include skull-base thickening, vertebral end-plate thickening and endobone appearance (4). Isolated medial condylar fractures of the humerus in adults are uncommon and we have not discovered a report of this fracture in an osteopetrotic patient. Medial condylar fractures are intra-articular and like lateral condylar fractures are prone to non-union (1). Usually, the mechanism for this fracture is through a valgus force on an extended elbow where the force is transmitted via the olecranon or coronoid process into the medial condyle (3). The fracture can also arise from an avulsion injury of the condyle through forceful contraction of the forearm flexors. With minimally displaced fractures

of the medial humeral condyle, good fracture healing and functional outcomes can be expected with non-surgical treatment consisting of immobilisation in a splint and a gradually increasing permissible range of motion (7). On the other hand, studies specifically examining displaced medial humeral condylar fractures treated by open reduction internal fixation reported good or excellent outcome in 86% of patients (2). As mentioned earlier, patients with osteopetrosis are prone to infections and the reported incidence of post-operative infection is 12% (2). Furthermore, some authors have reported delayed and nonunion following fractures in osteopetrotic patients (2). A study has shown fracture healing time in osteopetrotic mice to be

more than twice as long (2). Despite the difficulties of surgery, the risk of infection, and the higher incidence of delayed and non-union, the patient achieved an excellent functional outcome with no surgical complications. Open reduction and internal fixation to a fractured medial humeral condyle in a young osteopetrotic patient is certainly an option. References 1. Albers-Schönberg H. Roentgenbilder einer seltenen Knochennerkrankung. Munch Med Wochenschr 1904;51:365. 2. Armstrong DG, Newfield JT, Gillespie R.

Orthopedic management of osteopetrosis: results of a survey and review of the literature. J Pediatr Orthop 1999;19:122– 132. 3. Milch H. Fractures and fracture dislocations of the humeral condyles. J Trauma 1964;15:592-607. 4. Tolar J, Teitelbaum SL, Orchard PJ. Osteopetrosis. N Engl J Med 2004; 351:2839-2849. 5. Abe S, Watanabe H, Hirayama A, Shibuya E, Hashimoto M, Ide Y. Morphological study of the femur in osteopetrotic (op/op) mice using microcomputed tomography. Br J Radiol

2000;73:1078-82. 6. Bollerslev J, Mosekilde L. Autosomal dominant osteopetrosis. Clin Orthop Relat Res. 1993;294:45-51. 7. El Ghawabi MH. Fracture of the medial condyle of the humerus. J Bone Joint Surg Am 1975;57:677-80. 8. Jupiter JB, Neff U, Regazzoni P, Allgower M. Unicondylar fractures of the distal humerus: an operative approach. J Orthop Trauma 1988;2:102-109. 9. Shapiro F. Osteopetrosis: Current clinical considerations. Clin Orthop Relat Res 1993;294:34-44.

10. Marks SC Jr, Schmidt CJ. Bone Remodeling as an Expression of Altered Phenotype: Studies of Fracture Healing in Untreated and Cured Osteopetrotic Rats. Clin Orthop Relat Res 1970;137:259-264.

STRESS-ONLY NUCLEAR MYOCARDIAL PERFUSION IMAGING Author: Tom Heston, MD Inducible myocardial ischemia from coronary artery disease is diagnosed when blood flow to the heart at stress is significantly less than blood flow at rest. The identification of inducible ischemia is important in people with chest pain, because with proper treatment the risk of a major adverse cardiac event is greatly reduced. Many different conditions can cause chest pain, most of which are benign and non-life threatening. However, inducible ischemia can be life threatening, and when left

untreated the consequences are severe. One of the best and most thoroughly validated method of testing for inducible ischemia is stress-rest myocardial perfusion gated SPECT imaging. This involves injecting a patient with a radiotracer at rest and during peak stress. The radiotracer is primarily designed to map blood flow to the heart. However, using a gated SPECT protocol also allows determination of left ventricular size, wall motion, and ejection fraction. Inducible ischemia is suggested by abnormalities in any of these imaging variables at stress, that are not present at rest. Because the objective is to identify abnormalities at stress that are not present at rest, current utilization guidelines for

myocardial perfusion gated SPECT recommend imaging both at rest and immediately post-stress. Newer research in myocardial perfusion imaging has looked at the possibility of imaging patients only post-stress, and omitting the rest scan. The reasoning for this is that if the stress scan is normal, then the rest scan is medically unnecessary, financially costly, and exposes patients to excess radiation. Although not yet widely validated, stress-only imaging may be reasonable in low-risk patients as long as any abnormal stress study is followed-up with a rest scan. Nevertheless, at the current time, clinical practice guidelines have not fully addressed or endorsed stress-only

imaging, and nearly all nuclear cardiology clinics continue to perform stress-rest imaging. There are several reasons for continuing the practice of stress-rest imaging until more research is done. One reason is that myocardial perfusion imaging is not indicated in low-risk patients, so the research doesn't apply to clinical medicine. The research protocols for stress-only imaging typically involved attenuation correction SPECT, a technique that has not been widely accepted due to a relative lack of solid evidence supporting its use. Another reason is that risk stratification prior to imaging is often inexact, so it is medically safer to assume at least an intermediate risk

and perform a stress-rest study. Finally, the goal of myocardial perfusion imaging is to maximize sensitivity, since the consequences of failing to identify inducible ischemia can be severe. Stress-only imaging is not thought to be as sensitive as stressrest imaging. The current prevailing medical practice to perform stress-rest imaging as a routine appears to be clinically appropriate, with a recent clinical update (2009) from the American Society of Nuclear Cardiology concluding that a stress-only strategy "does not yet have sufficient data to support a widespread utilization." Nevertheless, the research supporting stress-only imaging continues to grow, with one recent paper

finding its use even in high-risk patients to be appropriate in some circumstances. REFERENCES Heller G, Hendel R. Nuclear Cardiology: Practical Applications, Second Edition [2010].

CAN WE SKIP THE AUTOPSY? AUTHOR: Tom Heston, MD The postmortem autopsy is considered the gold standard in the determination of the cause of death. Newer imaging technologies, however, including high resolution computed tomography (CT) and magnetic resonance imaging (MRI), may allow in some cases a virtual autopsy instead, that utilizes medical imaging alone. The benefits of a virtual, imaging autopsy include the potential for conducting more autopsies which could lead to more accurate mortality statistics, and reduced costs. The virtual autopsy may also be more widely accepted by families and religions.

A study published in the January 14th, 2012 issue of the Lancet compared traditional autopsy results with virtual autopsy by both CT and MRI. They randomly enrolled 182 cases that underwent both virtual and full conventional autopsy. The CT and MRI scans were independently interpreted for cause of death, then a combined report was created from both imaging modalities. The radiologists also indicated how confident they were in their diagnosis, which was based entirely upon the scan images. The cases were then dividing into two groups: those with a definite imaging diagnosis, and those without a definite imaging diagnosis. The researchers found that overall, about 1

in 3 virtual autopsies contained a major discrepancy when compared with the full, traditional autopsy. Radiologists considered the imaging diagnosis for cause of death to be definite in about half of the cases. In these cases where the imaging results were considered definite, the major discrepancy rate with full autopsy was about 1 in 6. The researchers also found that CT was more accurate than MRI when using a conventional autopsy as the gold standard. Major common sources of error were when the cause of death was coronary heart disease, pulmonary embolism, bronchopneumonia, and intestinal infarction. As the study progressed, the radiologists improved their interpretation

accuracy, however, major discrepancies continued to exist. The researchers concluded that when conducting a virtual autopsy, CT imaging was better than MRI scanning in providing an accurate cause of death. When the findings on virtual autopsy were considered definite, the major discrepancy rate with full autopsy was 16%. COMMENT: This is a new, emerging application of medical imaging that has tremendous potential. The authors note that when the imaging diagnosis was considered definite, the error rate was comparable to the error rate of a conventional, full autopsy. As physician experience with this relatively

new application of medical imaging improves, it is likely that the accuracy will significantly rise. Because of the relatively low cost and ease of conducting a virtual autopsy, it is likely to become fully integrated into and a routine part of postmortem investigation. REFERENCE Roberts IS, Benamore RE, Benbow EW et al. Post-mortem imaging as an alternative to autopsy in the diagnosis of adult deaths: a validation study. Lancet. 2012 Jan 14;379(9811):136-42

THE FUNDAMENTALS OF COURAGE AUTHOR: Tom Heston, MD "You gain strength, courage, and confidence by every experience in which you really stop to look fear in the face. You must do the thing which you think you cannot do." Eleanor Roosevelt Eleanor Roosevelt faced many challenges during her life. She married Franklin Delano Roosevelt at age 20, then around age 30 she discovered that FDR was having an affair with her own secretary. Shortly thereafter, FDR became paralyzed, and her campaigning on his behalf played a huge role in him winning election to the

Presidency of the U.S. Through her fearless and direct actions, she was able to make the most of things, and ultimately became one of the ten most widely admired people of the 20th century according a poll of the American people. She knew that positive thinking was not courage. Talking to her friends about plans for the future is not courage. Courage is an action. It takes action to overcome a fear, and only through taking action does one become more bold and courageous.Through action directed at fear, the fear is overcome and courage is strengthened. So, in order to become more courageous, it is necessary to embrace the first fundamental element of courage- action.

"Conscience is the root of all true courage; if a man would be brave let him obey his conscience." - James Freeman Clarke James Clarke was an early 19th century theologian and author. A graduate of Harvard College in 1829, he then became a minister for the Unitarian church in Louisville, Kentucky. At the time, Kentucky was a slave state, but James Clark stood up against his state's government and advocated strongly for the abolition of slavery. This strength of conviction, coupled with action, made Clarke a courageous person others could follow and respect. Courage comes from this strength to follow one's conscience, even if it goes against popular opinion or as in the case of Clarke,

the government. This is the second fundamental principle of courage. When actions become aligned with the conscience, courage grows and is strengthened. Taking positive action that is in alignment with the conscience is a simple concept. To strengthen courage, one must act upon the things known to be true, just, and right. Is there something the community needs to be improved? What can be done to help? Is there something in the family that can improve? What are some simple actions that will help make things better? Is there something that should be confronted, but fear is getting in the way of acting?

REFERENCES Gallup News Service. Mother Teresa Voted by American People as Most Admired Person of the Century. 31-Dec-1999. Retrieved 24-Feb-2012.Eleanor Roosevelt was #9 on this list. Heston T (ed). Courage Builder. Internet Medical Association, Las Vegas, 2011.

OMEGA-3 FATTY ACIDS, RED YEAST RICE, AND SUDDEN CARDIAC DEATH For people with high cholesterol, or at an increased risk of cardiovascular disease, there are a couple of concentrated nutritional supplements that may be helpful to aid in lowering the risk of a fatal heart attack or disabling heart disease. The first is the unique and natural native product from China - red yeast rice. It has been used in customary medical systems from about 800 A.D. This rice is produced when white rice is fermented with (monascus purpureus) red yeast. It is said to be used first in China (more than 2800 years

in the past) as food coloring agent and food preservative. The first assumed use of the recipe for making red yeast rice was in 1368-1644 - the Ming Dynasty. It was reported even at that time to boost blood circulation. There is careful production of the red yeast rice extract to prevent any citrinin presence, a by-product of the process of fermentation which is sometimes toxic. When CoQ10 is added, there appears to be further enhancement of the product to support the immune system as well as healthy cardiovascular functions. Chinese cuisine has used red yeast rice as cardiac supplements for centuries - that is, to encourage blood circulation and reduce clotting. Asian countries use red yeast rice

as a staple for diets, used in making rice wine, flavour agent, as well as to maintain the colour and flavour of meat and fish. The red yeast rice develops inhibitors referred to as monacolins. These inhibitors (hydroxymethylglutaryl-CoA reductase (HMG-CoA reductase)) occur naturally. The healing properties of the red yeast rice positively affect the lipid reports of patients who are hypercholesterolemic. The second concentrated nutritient that may be of benefit to your heart is omega-3 fatty acid. This appears to be helpful for people that are at risk of heart disease, or are currently experiencing the negative effects of heart disease. Omega-3 fatty acids appear to have an anti-arrhythmic effect, and have

been shown in some research to reduce the risk of sudden death by about a half, and reduce the risk of cardiac death by a third. Modest doses are recommended because of the possible interaction with other supplements or medications a person may be taking, such as aspirin and other bloodthinning medications. The primary side effects of red yeast rice appear to be primarily due to contaminants during production. Selecting a product from a reputable manufacturer is especially important for this supplement. The primary side effects of omega-3 fatty acids likely come from interactions with pharmaceuticals. It is important to let your physician and pharmacist know about what

you are taking, so they can help you minimize any side-effects. Also, keep in mind that supplementation does not replace a healthy diet full of plant foods. Balance supplementation with a moderate and balanced diet. REFERENCE Ong HT, Cheah JS. Statin alternatives or just placebo: an objective review of omega3, red yeast rice and garlic in cardiovascular therapeutics. Chin Med J (Engl). 2008 Aug 20;121(16):1588-94.

NEW ANDROID APPS Cancer Prevention Online | Cancer Prevention App

Am I Ugly? Online Version | Am I Ugly App

Heart Disease Prevention Online Version | Heart Disease Prevention Apps on Android Market

Heart Disease Online Version | Heart Disease - Apps on Android Market

Sponsor Documents

Or use your account on DocShare.tips

Hide

Forgot your password?

Or register your new account on DocShare.tips

Hide

Lost your password? Please enter your email address. You will receive a link to create a new password.

Back to log-in

Close