EDITORIAL BOARDEditor-in-Chief: Tom Heston, MDContributing Editor: Dr Gulab SinghShekhawat, India
TABLE OF CONTENTSFrom the EditorClinicalIntrauterine insemination versus Fallopiantube sperm perfusion in non-tubal infertilityA case report: treatment of a medialcondylar humeral fracture in an adult withosteopetrosisReview / CommentaryStress-only nuclear myocardial perfusionimaging
Can we skip the autopsy?The fundamentals of courageOmega-3 fatty acids, red yeast rice, andsudden cardiac deathNew Android ApplicationsAndroid Apps from the Internet MedicalAssociation
FROM THE EDITORWhat is the price of a medical education?Whether at the start of our career, or nearthe end, we all must pay a constant price inorder to stay up-to-date and well educated.It takes time, energy, and focus to becomean expert.With the goal of helping our readers becomeexperts in their chosen field, the InternetMedical Association is producing a series ofmobile apps. The apps contain the latestnews, research, and publications in thespecialty. A suggested plan to become andexpert, 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 newpublication in your chosen specialty.This system of constant nourishing of themind with important information in yourchosen specialty ultimately will allow thenovice to become an expert, and the expertto continue to be a leader in the field.This month features two clinical articlesfrom India, one on intrauterine inseminationand the other on orthopaedic surgery. This isfollowed by three review articles and anessay on courage. Finally, there is a listing
of new Android Apps that the InternetMedical Association has recently published.We are pleased to welcome Dr. Gulab SinghShekhawat as a contributing editor thismonth.Please send us your article submisstions,comments, or suggestions. We look forwardto hearing from you.Tom Heston, MD, Editor
INTRAUTERINE INSEMINATIONVERSUS FALLOPIAN TUBE SPERMPERFUSION IN NON-TUBALINFERTILITYAUTHORS: Dr. Col (Retd) G SShekhawat, MD(Obst & Gyn) *(Corresponding. Author), Dr Priyanka S,MBBS+PLACE OF RESEARCH WORK:Assisted Reproductive Technology center,Armed Forces Medical College/ CommandHospital (Southern Command), Pune-411040 and 92 Base Hospital PIN -901218C/O 56 APOADDRESS OF THE AUTHORS:
* Associate professor, Dept of Obstetrics &Gynecology, Smt Kashibai Navale MedicalCollege, Narhe, Pune-411041, Maharashtra.Email: firstname.lastname@example.org, Tel :( M) 9372897090,+Medical Officer, Smt Kashibai NavaleMedical College, Narhe, Pune-411041,Maharashtra.INTELLECTUAL CONTRIBUTIONS:Study concept: Dr G S ShekhawatDrafting and Manuscript revision: DrPriyanka S
Statistical analysis: Dr Priyanka SStudy supervision: Dr G S ShekhawatABSTRACT:Background: Controlled ovarian hyperstimulation (COH) combined withintrauterine insemination (IUI), using avolume of 0.5 mail of inseminate iscommonly offered to couples with non tubalinfertility. Another method is Fallopian tubesperm perfusion (FSP) which is based on apressure injection of 4 ml of spermsuspension while attempting to seal thecervix to prevent semen reflux. Thistechnique ensures the presence of higher
sperm density in the fallopian tubes at thetime of ovulation than standard IUI. Theaim of this study was to compare theefficiency of IUI and FSP in the treatmentof infertility.Methods: 200 consecutive patients withinfertility in 404 stimulated cycles wereincluded in the study. Those randomized tostandard IUI included 100 patients in 184cycles [158 Clomiphene citrate/humanmenopausal gonadotrophin cycles and 26Letrozole/FSH cycles exclusively forpolycystic ovarian disease patients] (groupA). Patients subjected to FSP included 100patients in 220 cycles (193 Clomiphenecitrate/human menopausal gonadotrophincycles and 27 Letrozole/FSH cycles
exclusively for polycystic ovarian diseasepatients] (group B). Swim up semenpreparation technique was used in all cases.Insemination was performed in both groups34-37 hours after hCG administration.Standard IUI was performed using 0.5 ml ofinseminate. In FSP 4ml inseminate wasused.Results: In group A (184 IUI cycles in 100patients), 22 clinical pregnancies (presenceof gestational sac with fetal cardiac activity)occurred (11.95% per cycle over fourcycles). In group B, (220 cycles of FSP in100 patients), 48 clinical pregnanciesoccurred (21.81%per cycle over four cycles)and this difference was statisticallysignificant (p<0.05).
Conclusions: For non-tubal sub fertility, theresults indicate clear benefit for FSP(Fallopian tube sperm perfusion) over IUI(Intrauterine insemination).Key Words: Intrauterine insemination,Fallopian tube sperm perfusion, Non-tubalinfertility.IntroductionIntrauterine insemination (IUI) with mildovarian stimulation has been used for manyyears in the treatment of non tubalinfertility. During IUI, pretreated semen isconcentrated in a small volume of 0.5 mland deposited by a catheter into the uterine
cavity. The overall pregnancy rates reportedin the literature ranged from 5.7% to 17.7%per cycle . Although the number ofavailable oocytes can be increased byovarian stimulation, the pregnancy rates inIUI are still not promising, mainly becauseof suboptimal spermatozoa at the site offertilization . An alternative procedure,termed Fallopian tube sperm perfusion(FSP), has been reported with improvedpregnancy rates in comparison with IUI [3,4, and 5]. In FSP, sperm preparation isidentical to that used in IUI, but thespermatozoa are diluted in a larger volumeof medium up to 4 ml . This volume hasbeen considered sufficient for bilateralpassage of the spermatozoa through thefallopian tubes. Theoretically, this would
increase the density of capacitatedspermatozoa near the oocytes and result inhigher pregnancy rates. A prospectiverandomized study was designed todetermine whether FSP resulted in higherpregnancy rates than IUI.Material & MethodsTwo hundred infertile patients, aged 17 to39 years, undergoing 404 consecutive cyclesof ovarian stimulation were studied fromJune 2007 to Jan 2009. Institutional boardapproval was obtained. These patientsunderwent a basic infertility workupincluding confirmation of tubal status byhysterosalpingogram or laparoscopy andhormone profile including serum follicle
stimulating hormone (FSH), luteinizinghormone (LH), prolactin and thyroidhormone tests. Menstrual cycle day 3 basaltransvaginal ultrasonography was done inall cases to rule out ovarian cysts prior toovulation stimulation. Exclusion criteriawere age > 39 years, obstructed fallopiantubes and cases with marked oligospermiasperm count<10X106per ml).The patients were classified for purpose ofetiology of infertility as having mild andmoderate endometriosis; ovulatory disorders(hormonal profile and transvaginalsonography characteristic of polycysticovarian syndrome); cervical hostility (poorproperly timed post-coital test); male subfertility (as per WHO criteria) ;
unexplained infertility (where no infertilitycauses were found).These patients underwent ovulationinduction with either Clomiphene citrateand Human menopausal gonadotrophin (351cycles in 174 patients) or Letrozole andFSH used exclusively for polycystic ovariandisease patients (53 cycles in 26 patients).The ovarian stimulation protocol ofclomiphene and hMG (Human menopausalgonadotrophin) was used in 170 patients. Itconsisted of clomiphene citrate 100 mgdaily on days 3-7 of the cycle, and 75 IUdaily of hMG (Human menopausalgonadotrophin) on days 6-9 of the cycle.For some of the women, hMG wasincreased to 150 IU in subsequent cycles,
depending on the previous ovarian response.Rotterdam ESHRE consensus workshopcriteria (2003) was used for diagnosis ofPCOS. In all PCOS patients (26 patients),who had been on Metformin 500 mg t.i.d ,Letrozole was given orally in a dose of2.5mg/day for 5 days starting from day 3 ofa spontaneous or progesterone inducedmenstrual bleeding . Inj purified FSH 75 IUadministered on 6-9 day of menstrual cycle.Cycles were monitored from day 9 onwardsby transvaginal ultrasound measurement ofthe number and diameter of the growingfollicles along with the thickness andmorphology of the endometrium. A dose of10,000 IU human chorionic gonadotrophin(hCG) was administered when at least one
leading follicle had reached a diameter of 18mm and at least 8 mm endometrial thicknesswith tri laminar ‘halo’ appearance seen.Patients were called 34 to 36 hours later,and either standard IUI (group A: 184 cyclesin 100 patients) or FSP (group B: 220 cyclesin the 100 patients) was performed. Thepatients were counseled about the twoalternative procedures and informedconsents were obtained beforerandomization. Patients were allocatedrandomly to standard IUI or FSP on the dayof insemination in the first cycle itself,according to even or odd serial number inthe register. Maximum of four cycletreatments of IUI or FSP were consideredfor those patients who could not conceive inprevious attempts. However those who
failed to conceive with IUI were offered IUIonly and vice versa.132 male partners were normozoospermicwith count > 20X106 sperm per ml, >50%motile with forward progression (categoriesa and b) within 60 min of ejaculation and >60% morphologically normal spermatozoa(WHO criteria) . Male partners withsperm count ranging from 10X106 to20X106 were asked to produce a secondsemen sample within 2 hours of the firstsample on the day of insemination. Sixty-eight males having sub fertility as per WHOcriteria did consent to the study. However04 could not produce a second sample at thetime of IUI, and 1 patient had total spermimmotility and was excluded from the study.
A fresh ejaculate was delivered in a sterile60 ml jar by masturbation on the day ofinsemination. Neat semen was left at roomtemperature for liquefaction for 30minutes.The liquefied semen samples wereanalyzed for density and motility using afixed-depth counting chamber (Makler).The liquefied ejaculate was transferred to alabeled sterile 14 ml round-bottomeddisposable centrifuge tube (Falcon No.2095)and 4 ml flushing media (Medicult) addedto it. After thorough mixing the sample wascentrifuged at 5000 rpm for 10 minutes.Then, the supernatants were discarded andthe pellet was resuspended and mixed in 3ml of fresh flushing media (Medicult) andcentrifuged for second wash again at 5000rpm for 10 minutes. Once again the
supernatants were discarded. Each pelletwas now gently layered with 0.5 ml for IUIand 4 ml for FSP of universal IVF media(Medicult), and incubated at 37oC in ahumidified incubator with 5% Carbondioxide for 1 hour. Post wash semenanalysis was done in all cases usingMakler’s counting chamber beforeinsemination.Intrauterine insemination was performedwith conventional catheter using 0.5 ml ofinseminate. To eliminate dead spaceproblem, IUI catheter was first attached tosyringe and then inseminate was aspirated.In FSP 4ml inseminate was used andbackflow of inseminate was occluded at thecervical opening by the long size Allis
clamp (Figure-1), which was suitablymodified by attaching cervical occludingprongs with rubber cushions to avoidtrauma to the cervix and was kept in placefor about 3 to 4 minutes after insemination.In both groups, the patient rested for 30minutes after insemination and received oralmicronized progesterone 100 mg, twotablets per day for luteal-phase support.Values were recorded as mean ± SD usingMicrosoft Excel version 4. Statisticalanalysis were performed using student’s t-test for testing significance of differencebetween the means and the X2test tocompute p-values for testing the agreementbetween proportions. MedCalc statisticalsoftware (Meriakerke, Belgium) version
22.214.171.124 was used for all statistical analysis.The significance was defined as p < 0.05.ResultsThe patient characteristics for group A andB were not significantly differentconcerning patient’s age (28.42 ± 2.78 yearsand 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). Theclinical indications for IUI or FSP were alsonot significantly different for the two groups(endometriosis 12% versus 12%, polycysticovarian syndrome 34% versus 36%, cervical4% versus 4%, unexplained 18% versus12% and male factor sub fertility 32%
versus 36% respectively). The ovarianstimulation protocol for group A and B werenot significantly different (clomiphenecitrate/hMG 85% versus 87% andLetrozole/FSH 15% versus 13%respectively). The parameters of cyclemonitoring for group A and B includingnumber of follicles=18 mmdiameter(3.93±1.37 versus 3.90±1.17),endometrial thickness on the day of hCGadministration (9.19±0.58mm versus9.14±2.1mm) and the number ofspermatozoa(38.83±16.57X106 versus36.68±13.44X106) inseminated were notsignificantly different. However the day ofhCG administration (12.8±3.4 versus11.1±2.1) was significantly differentbetween the two groups as shown in table-1
and 2.Clinical pregnancy was defined by thepresence of fetal cardiac activity, detectedby ultrasound examination. Pregnancy rateswere similar when compared for theetiology of infertility: for ovarian (PCOS)cause (17.7% versus 21.8%), endometriosiscause (8.4% versus 10.1%), male infertility(12.8% versus 16.4%) and unexplainedinfertility (14.4% versus 24%) for the twogroups, respectively as shown in table-3.There was statistically significant difference(p<0.05) in the overall pregnancy rate percycle over four treated cycles (11.95% percycle for IUI versus 21.81% per cycle forFSP over four cycles) as shown in table-4.Two missed abortions and one twin
pregnancy occurred among the patients ingroup A (IUI). Three missed abortions andtwo twin pregnancies occurred among thepatients in group B (FSP). However, thislimited number of abortions and multiplepregnancies are too low to allow testing forstatistical significance. Three cases of mildovarian hyper stimulation syndrome(OHSS) occurred in both groups.DiscussionThe purpose of this prospective, randomizedstudy was to study pregnancy rates incouples with nontubal infertility whentreated with FSP (inseminate volume 4 ml),in comparison with standard IUI(inseminate volume 0.5 ml). Pregnancy
rates were 21.81 and 11.95% respectivelyover four treatment cycles. The sameprotocols for ovarian stimulation were usedin both groups. There was no statisticallysignificant difference regarding the age ofthe patients treated, mean number offollicles, endometrial thickness on the dayof hCG administration and the total numberof motile spermatozoa inseminated.However the day of hCG(12.8±3.4 for FSPversus 11.1±2.1 for IUI) administration wasstatistically different between the twogroups (p value <0.05).Kahn et al. reported the first clinicalexperience with FSP. In their study, theyused a Frydman catheter for FSP andreported a pregnancy rate per cycle of
26.9% in patients with unexplainedinfertility and of 2.7% to 7.7% in patientswith other etiologies. These excellentresults, particularly in patients withunexplained infertility, were confirmed byother studies . Some investigators used apaediatric Foley catheter or cervical clampdouble-nut bivalve speculum and veryencouraging results were reported byFanchin et al, in which FSP using an autoblocking device (FAST system) doubledtheir pregnancy rates from 20% to 40%.The different types of catheters used forIUI have been compared but no studyreports a significantly higher rate ofpregnancy with any one type of catheter [9,10].
The FSP increases the intrauterinepressure(70-200 mmHg) necessary for aflush influx of spermatozoa directly into thefallopian tubes. The high pregnancy rateper cycle for FSP as compared with standardIUI can be due to several causes asfollows: firstly, the pressure injection ofinseminate can either remove and/orcircumvent transitory or partial obstructionof fallopian tubes, such as that created bythick mucus or tubal polyps; secondly, theconcentration of motile spermatozoa aroundthe oocytes after FSP is higher than thatobtained after standard IUI; and thirdly, FSPleads to inseminate overflowing into thepouch of Douglas. The more acceptedhypothesis is the existence of a similarmechanical effect created following a
hysterosalpingography .In this study, we tried to evaluate FSP notonly in patients with unexplained infertilitybut also in patients with other causes ofinfertility including male causes. Twodifferent stimulation regimes were used;however, the distribution of the two types ofstimulation protocols (clomiphenecitrate/hMG and Letrozole/FSH) appearedhomogenous in both studies groups.Clinical pregnancy was defined by thepresence of fetal cardiac activity, detectedby ultrasound. When comparing thepregnancy rates in both IUI and FSP inrelation to the etiology of infertility, it isfound to be statistically similar as shown in
table-3. Though the pregnancy rates of FSPin PCOS and unexplained infertility groupof patients is superior to IUI, this finding isstatistically not significant. This analysisrevealed that couples suffering from anyspecific etiological sub fertility did notbenefit from FSP over IUI.However, there was statistically significantdifference in the overall pregnancy rate percycle over four cycles of treatment (11.95%per cycle over four cycles for IUI versus21.81% per cycle for FSP over four cycles)as shown in table-4(p value<0.009).Pregnancy rates improved in subsequentattempts with FSP in comparison to IUI.The cumulative pregnancy rates even afterthe second attempt, over two cycle
treatment, were statistically significant (pvalue <0.03), however there was nostatistical difference when each attempt oftreatment cycles was compared between thetwo groups (p value >0.05).Four studies [2, 4, 6, and 11] mentioned amaximum of three cycles per couple; onestudy  reported a maximum of fourcycles. We also allowed maximum of fourcycles treatment of IUI or FSP beforeconsidering them for In vitro fertilizationand embryo transfer (IVF-ET). The type of catheter has no impact on thepregnancy rate after intrauterineinsemination . We suitably modified thelong size allis clamp, by attaching cervical
occluding prongs with rubber cushions,which was kept in place for about 3 to 4minutes after insemination to prevent anysignificant reflux. Mild reflux does not seemto influence the results of the FSP but thesignificant reflux (> 0.4 ml) may reduce thepregnancy . If more than 1 ml comesback in the catheter, the operator needs towait for a few minutes and re-inseminateagain. All the authors agreed that womentolerated the FSP technique very well. Inour study some patients complained of postinsemination pelvic transient pain, more soin FSP than in IUI. Other interesting domainof FSP application is the immunologicalinfertility in the presence of anti-spermantibodies [15, 16].This aspect could not bestudied in this study because pre and post
FSP anti-sperm antibody assay was notdone.In this study by comparing the overallresults, we conclude that FSP over fourcycles of treatment offers an advantage overthe standard IUI, and can replace the IUI forall its indications because of its betterpregnancy rates. However FSP is moreexpensive than IUI due to the increasedmedia usages. It could be used as analternative for couples with non tubalinfertility before embarking on IVF-ETtreatment.References1. Fanchin R, Oliveness F. A new system for
fallopian tube sperm perfusion leads topregnancy rates twice as high as standardintrauterine insemination. Fertility andSterility 1995; 64(3):505–10.2. Kahn JA, Sunde A, Von During V, et al.Treatment of unexplained infertility. ActaObstetrica Gynaecologica de Scandinavia1993; 72(3):193–9.3. Trout SW. Fallopian tube sperm perfusionversus intrauterine insemination: arandomized controlled trial and meta-analysis of the literature. Fertility andSterility 1999; 71(5):881–5.4. Ng EHY, Makkar G. A randomizedcomparison of three insemination methods
in an artificial insemination program usinghusbands’ semen. The Journal ofReproductive Medicine 2003; 48(7):542–6.5. Nuojou-Huttunen S, Tuomivaara L,Juntunen K. Comparison of fallopian tubesperm perfusion with intrauterineinsemination 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 noadvantage over intra-uterine inseminationwhen used in combination with ovarianstimulation for the treatment of unexplainedinfertility. Gynecologic and ObstetricInvestigations 1995; 39: 226-8.
7. World Health Organization. WHOlaboratory manual for the examination ofhuman semen and sperm cervical mucusinteraction. WHO laboratory manual.Cambridge: Cambridge University Press,1992.8. Mamas L. Comparison of fallopian tubesperm perfusion and intrauterinetuboperitoneal insemination: a prospectiverandomized study. Fertility and Sterility2006; 85(3):735–40.9. SmithKL, GrowDR, WiczykHP, et al.Does catheter type effect pregnancy rate inintrauterine insemination cycles? Journal ofAssisted Reproduction and Genetics 2002;19(2):49–52.
10. Noci I, Dabizzi S, Evangelisti P, et al.Evaluation of clinical efficacy of threedifferent insemination Techniques in coupleinfertility. Minerva Ginecologica 2007;59(1):11–8.11. Ricci G, Nucera G, Pozzob et al. Asimple method for fallopian tube spermperfusion using a blocking device in thetreatment of unexplained infertility. Fertilityand Sterility 2001; 7 Suppl 1:1242–8.12. Biacchiardi CP, Revelli A, Gennarelli G,et al. Fallopian tube sperm perfusion versusintrauterine insemination in unexplainedinfertility: a randomized, prospective,crossover trial. Fertility and Sterility 2004;81(2):448–51.
13. Vermeylen AM, D’Hooghe T, DebrockS, et al. The type of catheter has no impacton the pregnancy rate after intrauterineinsemination: a randomized study. HumanReproduction 2006; 21(9):2364–7.14. Kahn JA, von During V, Sunde A, et al.Fallopian tube sperm perfusion. Firstclinical experience. Hum. Reprod. 1992; 7:19-24.15. El Sadek MM, Amer MK, Abdel-MalakG. Questioning the efficacy of fallopiantube sperm perfusion. Human Reproduction1998; 13 (11):3053–6.16. Elhelw B, Matar H, Soliman EM. Arandomized prospective comparison
between intrauterine insemination and twomethods of fallopian tube sperm perfusion.Middle East Fertility Society Journal 2000;5(1):83–4.
A CASE REPORT: TREATMENT OF AMEDIAL CONDYLAR HUMERALFRACTURE IN AN ADULT WITHOSTEOPETROSISAuthors: Dr Calvin CHIEN, MBBS. DrRajesh BEDI, DNB (Ortho). Dr Richard D.LAWSON, FRACS (Ortho)AbstractPatients with osteopetrosis often presentwith orthopaedic problems such as frequentfractures. Management of fractures withopen reduction and internal fixation isdifficult but possible. We report on a 22 yearold patient with a medial humeral condylefracture treated successfully with internal
fixation using a pre-contoured plate.IntroductionIn 1904 Albers-Schoenberg described acondition characterised by markedradiographic density of the bones (1).Despite the sclerotic radiographicappearance of the thickened cortices and itsmaterial hardness, osteopetrotic bone isweak, brittle and prone to fracture afterminor trauma (1). Most literature regardingtreatment of osteopetrotic patients withfractures concentrates on paediatric patientsor on the difficulty of operative interventionin adults (2). We report the case of an adultpatient with osteopetrosis and a low medialcolumn fracture (Milch Type I (1)) of the
distal humerus after minor trauma. Thefracture was treated operatively utilisinginternal fixation with a pre-contoured peri-articular plate.CaseA 22 year old female with knownosteopetrosis presented with an elbow injuryafter bracing herself with the right arm aftera fall. The mechanism described suggested avalgus injury to the right elbow resulting ina Milch Type I (3) low medial columnfracture of the distal humerus (Fig. 1). Therewere no neurological deficits. As anadolescent she had previous injuriesincluding one to the radius of the same sidelimiting elbow extension by twenty degrees.
She was also partially blind and wasreceiving psychiatric treatment fordepression.Two days later, open reduction of the rightdistal humerus was performed with internalfixation using a pre-contoured medialcondylar locking plate (Fig 2). This wasdone through a posterior approach afteridentifying the ulnar nerve. Anteriortransposition of the ulnar nerve was donebefore closure. The patient was dischargedtwo days later in a plaster-of-paris back slabwith outpatient follow-up. After two weeksthe arm was placed in a range of movementelbow brace with unrestricted range ofmotion. Serial radiographs were performedat four-weekly intervals and complete bony
union with disappearance of the fractureline was evident on the radiographs taken atfourteen weeks (Fig 3). Outpatient as wellas a home-based physiotherapy programwas arranged and full pre-injury range ofmotion was achieved by ten weeks.DiscussionOsteopetrosis is a rare hereditary disease ofthe osteoclasts first described by Albers-Schönberg, a German radiologist, in 1904.Defective osteoclastic activity or a reducednumber of osteoclasts results in a failure ofbone remodelling (4). This is manifested onradiographs as an increase in bone mass andosteosclerotic changes (4).
Osteopetrosis can be classified into threemain forms: a malignant autosomalrecessive, intermediate autosomal recessiveand benign autosomal dominant form; thevast majority of these cases are the benignautosomal dominant form. The malignantautosomal recessive type, also known asinfantile, is characterised by growthretardation, failure to thrive and cranialnerve palsies manifesting as proptosis,deafness and blindness. In addition,pancytopenia and thrombocytopenia mayresult from bone marrow failure. Manyfeatures of the intermediate form ofosteopetrosis are similar to those of themalignant form but the intermediate form isless severe and later in onset. It is oftendiagnosed after a fracture, usually occurring
in the first decade. Benign osteopetrosis hasbeen further subdivided into types I and II.However, recent genetic studies have shownthat autosomal-dominant osteopetrosis typeI is caused by an increase in osteoblasticactivity rather than osteoclastic dysfunction.In this case osteoblasts deposit excessiveamounts of bone matrix (4). Type IIautosomal dominant osteopetrosis is theform Albers-Schönberg first described andso is often named after him. The onset is inlater childhood and is usually diagnosedincidentally during a radiographicexamination (4). It is also associated withincreased fracture frequency. Othermanifestations include coxa vara,osteoarthritis, spondylolysis, back pain,osteomyelitis and cranial nerve palsies.
Radiographic features include skull-basethickening, vertebral end-plate thickeningand endobone appearance (4).Isolated medial condylar fractures of thehumerus in adults are uncommon and wehave not discovered a report of this fracturein an osteopetrotic patient. Medial condylarfractures are intra-articular and like lateralcondylar fractures are prone to non-union(1). Usually, the mechanism for this fractureis through a valgus force on an extendedelbow where the force is transmitted via theolecranon or coronoid process into themedial condyle (3). The fracture can alsoarise from an avulsion injury of the condylethrough forceful contraction of the forearmflexors. With minimally displaced fractures
of the medial humeral condyle, goodfracture healing and functional outcomescan be expected with non-surgical treatmentconsisting of immobilisation in a splint anda gradually increasing permissible range ofmotion (7). On the other hand, studiesspecifically examining displaced medialhumeral condylar fractures treated by openreduction internal fixation reported good orexcellent outcome in 86% of patients (2). Asmentioned earlier, patients withosteopetrosis are prone to infections and thereported incidence of post-operativeinfection is 12% (2). Furthermore, someauthors have reported delayed and non-union following fractures in osteopetroticpatients (2). A study has shown fracturehealing time in osteopetrotic mice to be
more than twice as long (2).Despite the difficulties of surgery, the riskof infection, and the higher incidence ofdelayed and non-union, the patient achievedan excellent functional outcome with nosurgical complications. Open reduction andinternal fixation to a fractured medialhumeral condyle in a young osteopetroticpatient is certainly an option.References1. Albers-Schönberg H. Roentgenbildereiner seltenen Knochennerkrankung. MunchMed Wochenschr 1904;51:365.2. Armstrong DG, Newfield JT, Gillespie R.
Orthopedic management of osteopetrosis:results of a survey and review of theliterature. J Pediatr Orthop 1999;19:122–132.3. Milch H. Fractures and fracturedislocations of the humeral condyles. JTrauma 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 inosteopetrotic (op/op) mice usingmicrocomputed tomography. Br J Radiol
2000;73:1078-82.6. Bollerslev J, Mosekilde L. Autosomaldominant osteopetrosis. Clin Orthop RelatRes. 1993;294:45-51.7. El Ghawabi MH. Fracture of the medialcondyle of the humerus. J Bone Joint SurgAm 1975;57:677-80.8. Jupiter JB, Neff U, Regazzoni P,Allgower M. Unicondylar fractures of thedistal humerus: an operative approach. JOrthop Trauma 1988;2:102-109.9. Shapiro F. Osteopetrosis: Current clinicalconsiderations. Clin Orthop Relat Res1993;294:34-44.
10. Marks SC Jr, Schmidt CJ. BoneRemodeling as an Expression of AlteredPhenotype: Studies of Fracture Healing inUntreated and Cured Osteopetrotic Rats.Clin Orthop Relat Res 1970;137:259-264.
STRESS-ONLY NUCLEARMYOCARDIAL PERFUSIONIMAGINGAuthor: Tom Heston, MDInducible myocardial ischemia fromcoronary artery disease is diagnosed whenblood flow to the heart at stress issignificantly less than blood flow at rest.The identification of inducible ischemia isimportant in people with chest pain, becausewith proper treatment the risk of a majoradverse cardiac event is greatly reduced.Many different conditions can cause chestpain, most of which are benign and non-lifethreatening. However, inducible ischemiacan be life threatening, and when left
untreated the consequences are severe.One of the best and most thoroughlyvalidated method of testing for inducibleischemia is stress-rest myocardial perfusiongated SPECT imaging. This involvesinjecting a patient with a radiotracer at restand during peak stress. The radiotracer isprimarily designed to map blood flow to theheart. However, using a gated SPECTprotocol also allows determination of leftventricular size, wall motion, and ejectionfraction. Inducible ischemia is suggested byabnormalities in any of these imagingvariables at stress, that are not present atrest. Because the objective is to identifyabnormalities at stress that are not present atrest, current utilization guidelines for
myocardial perfusion gated SPECTrecommend imaging both at rest andimmediately post-stress.Newer research in myocardial perfusionimaging has looked at the possibility ofimaging patients only post-stress, andomitting the rest scan. The reasoning for thisis that if the stress scan is normal, then therest scan is medically unnecessary,financially costly, and exposes patients toexcess radiation. Although not yet widelyvalidated, stress-only imaging may bereasonable in low-risk patients as long asany abnormal stress study is followed-upwith a rest scan. Nevertheless, at the currenttime, clinical practice guidelines have notfully addressed or endorsed stress-only
imaging, and nearly all nuclear cardiologyclinics continue to perform stress-restimaging.There are several reasons for continuing thepractice of stress-rest imaging until moreresearch is done. One reason is thatmyocardial perfusion imaging is notindicated in low-risk patients, so theresearch doesnt apply to clinical medicine.The research protocols for stress-onlyimaging typically involved attenuationcorrection SPECT, a technique that has notbeen widely accepted due to a relative lackof solid evidence supporting its use. Anotherreason is that risk stratification prior toimaging is often inexact, so it is medicallysafer to assume at least an intermediate risk
and perform a stress-rest study. Finally, thegoal of myocardial perfusion imaging is tomaximize sensitivity, since theconsequences of failing to identify inducibleischemia can be severe. Stress-only imagingis not thought to be as sensitive as stress-rest imaging.The current prevailing medical practice toperform stress-rest imaging as a routineappears to be clinically appropriate, with arecent clinical update (2009) from theAmerican Society of Nuclear Cardiologyconcluding that a stress-only strategy "doesnot yet have sufficient data to support awidespread utilization." Nevertheless, theresearch supporting stress-only imagingcontinues to grow, with one recent paper
finding its use even in high-risk patients tobe appropriate in some circumstances.REFERENCESHeller G, Hendel R. Nuclear Cardiology:Practical Applications, Second Edition.
CAN WE SKIP THE AUTOPSY?AUTHOR: Tom Heston, MDThe postmortem autopsy is considered thegold standard in the determination of thecause of death. Newer imagingtechnologies, however, including highresolution computed tomography (CT) andmagnetic resonance imaging (MRI), mayallow in some cases a virtual autopsyinstead, that utilizes medical imaging alone.The benefits of a virtual, imaging autopsyinclude the potential for conducting moreautopsies which could lead to more accuratemortality statistics, and reduced costs. Thevirtual autopsy may also be more widelyaccepted by families and religions.
A study published in the January 14th, 2012issue of the Lancet compared traditionalautopsy results with virtual autopsy by bothCT and MRI. They randomly enrolled 182cases that underwent both virtual and fullconventional autopsy. The CT and MRIscans were independently interpreted forcause of death, then a combined report wascreated from both imaging modalities. Theradiologists also indicated how confidentthey were in their diagnosis, which wasbased entirely upon the scan images. Thecases were then dividing into two groups:those with a definite imaging diagnosis, andthose without a definite imaging diagnosis.The researchers found that overall, about 1
in 3 virtual autopsies contained a majordiscrepancy when compared with the full,traditional autopsy. Radiologists consideredthe imaging diagnosis for cause of death tobe definite in about half of the cases. Inthese cases where the imaging results wereconsidered definite, the major discrepancyrate with full autopsy was about 1 in 6. Theresearchers also found that CT was moreaccurate than MRI when using aconventional autopsy as the gold standard.Major common sources of error were whenthe cause of death was coronary heartdisease, pulmonary embolism,bronchopneumonia, and intestinalinfarction. As the study progressed, theradiologists improved their interpretation
accuracy, however, major discrepanciescontinued to exist.The researchers concluded that whenconducting a virtual autopsy, CT imagingwas better than MRI scanning in providingan accurate cause of death. When thefindings on virtual autopsy were considereddefinite, the major discrepancy rate with fullautopsy was 16%.COMMENT: This is a new, emergingapplication of medical imaging that hastremendous potential. The authors note thatwhen the imaging diagnosis was considereddefinite, the error rate was comparable tothe error rate of a conventional, full autopsy.As physician experience with this relatively
new application of medical imagingimproves, it is likely that the accuracy willsignificantly rise. Because of the relativelylow cost and ease of conducting a virtualautopsy, it is likely to become fullyintegrated into and a routine part ofpostmortem investigation.REFERENCERoberts IS, Benamore RE, Benbow EW etal. Post-mortem imaging as an alternative toautopsy in the diagnosis of adult deaths: avalidation study. Lancet. 2012 Jan14;379(9811):136-42
THE FUNDAMENTALS OF COURAGEAUTHOR: Tom Heston, MD"You gain strength, courage, and confidenceby every experience in which you really stopto look fear in the face. You must do thething which you think you cannot do." -Eleanor RooseveltEleanor Roosevelt faced many challengesduring her life. She married Franklin DelanoRoosevelt at age 20, then around age 30 shediscovered that FDR was having an affairwith her own secretary. Shortly thereafter,FDR became paralyzed, and hercampaigning on his behalf played a hugerole in him winning election to the
Presidency of the U.S. Through her fearlessand direct actions, she was able to make themost of things, and ultimately became oneof the ten most widely admired people ofthe 20th century according a poll of theAmerican people. She knew that positivethinking was not courage. Talking to herfriends about plans for the future is notcourage. Courage is an action.It takes action to overcome a fear, and onlythrough taking action does one becomemore bold and courageous.Through actiondirected at fear, the fear is overcome andcourage is strengthened. So, in order tobecome more courageous, it is necessary toembrace the first fundamental element ofcourage- action.
"Conscience is the root of all true courage;if a man would be brave let him obey hisconscience." - James Freeman ClarkeJames Clarke was an early 19th centurytheologian and author. A graduate ofHarvard College in 1829, he then became aminister for the Unitarian church inLouisville, Kentucky. At the time, Kentuckywas a slave state, but James Clark stood upagainst his states government andadvocated strongly for the abolition ofslavery. This strength of conviction, coupledwith action, made Clarke a courageousperson others could follow and respect.Courage comes from this strength to followones conscience, even if it goes againstpopular opinion or as in the case of Clarke,
the government. This is the secondfundamental principle of courage. Whenactions become aligned with the conscience,courage grows and is strengthened.Taking positive action that is in alignmentwith the conscience is a simple concept. Tostrengthen courage, one must act upon thethings known to be true, just, and right.Is there something the community needs tobe improved? What can be done to help? Isthere something in the family that canimprove? What are some simple actions thatwill help make things better? Is theresomething that should be confronted, butfear is getting in the way of acting?
REFERENCESGallup News Service. Mother Teresa Votedby American People as Most AdmiredPerson of the Century. 31-Dec-1999.Retrieved 24-Feb-2012.Eleanor Rooseveltwas #9 on this list.Heston T (ed). Courage Builder. InternetMedical Association, Las Vegas, 2011.
OMEGA-3 FATTY ACIDS, RED YEASTRICE, AND SUDDEN CARDIACDEATHFor people with high cholesterol, or at anincreased risk of cardiovascular disease,there are a couple of concentratednutritional supplements that may be helpfulto aid in lowering the risk of a fatal heartattack or disabling heart disease.The first is the unique and natural nativeproduct from China - red yeast rice. It hasbeen used in customary medical systemsfrom about 800 A.D. This rice is producedwhen white rice is fermented with(monascus purpureus) red yeast. It is said tobe used first in China (more than 2800 years
in the past) as food coloring agent and foodpreservative. The first assumed use of therecipe for making red yeast rice was in1368-1644 - the Ming Dynasty. It wasreported even at that time to boost bloodcirculation. There is careful production ofthe red yeast rice extract to prevent anycitrinin presence, a by-product of theprocess of fermentation which is sometimestoxic. When CoQ10 is added, there appearsto be further enhancement of the product tosupport the immune system as well ashealthy cardiovascular functions.Chinese cuisine has used red yeast rice ascardiac supplements for centuries - that is,to encourage blood circulation and reduceclotting. Asian countries use red yeast rice
as a staple for diets, used in making ricewine, flavour agent, as well as to maintainthe colour and flavour of meat and fish. Thered yeast rice develops inhibitors referred toas monacolins. These inhibitors(hydroxymethylglutaryl-CoA reductase(HMG-CoA reductase)) occur naturally. Thehealing properties of the red yeast ricepositively affect the lipid reports of patientswho are hypercholesterolemic.The second concentrated nutritient that maybe of benefit to your heart is omega-3 fattyacid. This appears to be helpful for peoplethat are at risk of heart disease, or arecurrently experiencing the negative effectsof heart disease. Omega-3 fatty acids appearto have an anti-arrhythmic effect, and have
been shown in some research to reduce therisk of sudden death by about a half, andreduce the risk of cardiac death by a third.Modest doses are recommended because ofthe possible interaction with othersupplements or medications a person maybe taking, such as aspirin and other blood-thinning medications.The primary side effects of red yeast riceappear to be primarily due to contaminantsduring production. Selecting a product froma reputable manufacturer is especiallyimportant for this supplement. The primaryside effects of omega-3 fatty acids likelycome from interactions withpharmaceuticals. It is important to let yourphysician and pharmacist know about what
you are taking, so they can help youminimize any side-effects. Also, keep inmind that supplementation does not replacea healthy diet full of plant foods. Balancesupplementation with a moderate andbalanced diet.REFERENCEOng HT, Cheah JS. Statin alternatives orjust placebo: an objective review of omega-3, red yeast rice and garlic in cardiovasculartherapeutics. Chin Med J (Engl). 2008 Aug20;121(16):1588-94.
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