The Global Track Concept for Assessment of Engaging Hill-Sachs Defects in Anterior Shoulder Instability

BACKGROUND

The glenoid track concept is used to determine preoperatively whether a Hill-Sachs defect is engaging or not. Currently, the glenoid track concept relies on measurements of bony structures as well as on the confines and elasticity of the rotator cuff as a reference point, which varies extensively among individuals and therefore limits the reliability and accuracy of this concept.

PURPOSE

To evaluate the reliability of the global track concept, which determines the angular distance of the Hill-Sachs defect from the center of the articular surface of the humeral head as a new reference point with the help of an automated image analysis software and 3-dimensional analysis of the humeral head.

STUDY DESIGN

Controlled laboratory study.

METHODS

Computed tomography scans of 100 patients treated for anterior shoulder instability with different sizes of Hill-Sachs defects were evaluated manually by 2 orthopaedic surgeons independently using the software OsiriX as well as automatically by using a dedicated prototype software (ImFusion). Obtained manual and automated measurements included the Hill-Sachs length, Hill-Sachs width, and Hill-Sachs depth of the defect; the Hill-Sachs interval (HSI); and the glenoid width for the glenoid track concept, as well as the angular distance of the Hill-Sachs defect from the center of the articular surface of the humeral head (global track concept). The reliability of the different measurement techniques was compared by calculating intraclass correlation coefficients (ICCs).

RESULTS

There was a significant difference for all obtained parameters comparing manual and automatic measurements. For manually obtained parameters, measurements referring to bony boundaries (glenoid width, Hill-Sachs length, and Hill-Sachs width) showed good to excellent agreement (ICC, 0.86, 0.82, and 0.62, respectively), while measurements referring to soft tissue boundaries (HSI and glenoid track; ICC, 0.56 and 0.53, respectively) or not directly identifiable reference points (center of articular surface and global track) only showed fair reliability (ICC middle excursion, 0.42). When the same parameters were measured with the help of an automated software, good reliability for the glenoid track concept and excellent reliability for the global track concept in the middle excursion were achieved.

CONCLUSION

The present study showed that the more complex global track measurements of humeral defects are more reliable than the current standard HSI and glenoid track measurements. However, this is only true when automated software is used to perform the measurements.

CLINICAL RELEVANCE

Future studies using the new proposed method in combination with an automated software need to be conducted to determine critical threshold values for defects prone to engagement.

Reliability of Manual Measurements Versus Semiautomated Software for Glenoid Bone Loss Quantification in Patients With Anterior Shoulder Instability

Background

The presence of glenoid bone defects is indicative in the choice of treatment for patients with anterior shoulder instability. In contrast to traditional linear- and area-based measurements, techniques such as the consideration of glenoid concavity have been proposed and validated.

Purpose

To compare the reliability of linear (1-dimensional [1D]), area (2-dimensional [2D]), and concavity (3-dimensional [3D]) measurements to quantify glenoid bone loss performed manually and to analyze how automated measurements affect reliability.

Study Design

Cohort study (diagnosis); Level of evidence, 3.

Methods

Computed tomography images of 100 patients treated for anterior shoulder instability with differently sized glenoid defects were evaluated independently by 2 orthopaedic surgeons manually using conventional software (OsiriX; Pixmeo) as well as automatically with a dedicated prototype software program (ImFusion Suite; ImFusion). Parameters obtained included 1D (defect diameter, best-fit circle diameter), 2D (defect area, best-fit circle area), and 3D (bony shoulder stability ratio) measurements. Mean values and reliability as expressed by the intraclass correlation coefficient [ICC]) were compared between the manual and automated measurements.

Results

When manually obtained, the measurements showed almost perfect agreement for 1D parameters (ICC = 0.83), substantial agreement for 2D parameters (ICC = 0.79), and moderate agreement for the 3D parameter (ICC = 0.48). When measurements were aided by automated software, the agreement between raters was almost perfect for all parameters (ICC = 0.90 for 1D, 2D, and 3D). There was a significant difference in mean values between manually versus automatically obtained measurements for 1D, 2D, and 3D parameters (P < .001 for all).

Conclusion

While more advanced measurement techniques that take glenoid concavity into account are more accurate in determining the biomechanical relevance of glenoid bone loss, our study showed that the reliability of manually performed, more complex measurements was moderate.

Explanatory models and help-seeking for symptoms of PTSD and depression among Syrian refugees

OBJECTIVE

This study investigates how Syrian refugees explain and prefer to seek help for symptoms of post-traumatic stress disorder (PTSD) and depression.

METHODS

We conducted five semi-structured focus group interviews based on a vignette-technique with Syrian refugees (n = 21 men, n = 10 women). The vignettes describe a fictional person suffering from symptoms of PTSD or depression in line with DSM-5 and ICD-10 criteria.

RESULTS

Despite never mentioning PTSD, participants in the PTSD-interviews recognized the symptoms. They perceived them as a common reaction to extreme situations, mainly the war, the flight, and post-migratory stressors. Depression was labeled as either depression or feelings caused by social problems, and the participants were more hesitant to identify with these symptoms. Despite some differences, both the PTSD and depression vignettes were explained in terms of situational explanatory models and externally caused stress. The main finding is how participants described changing stressors resulting from migration and resettlement leading to a difference in how they would seek help in Syria and in Norway. Specifically, we found that preferred help-seeking and coping strategies are contextual.

CONCLUSIONS

These findings point to the need to consider transformations following forced migration when studying aspects of explanatory models, preferred help-seeking, and coping strategies in refugee groups.

[Gestational surrogacy - sin, whim or necessity]

The authors propose the gestational surrogacy to be permitted but only for medical indications and under exact requirements. The surrogate mother if married, her husband, too, sign with the commissioning adopting couple a legal agreement at the beginning of the procedures.

["Flare up" and modified natural cycle IVF for patients with expected poor response]

The aim of this study is to compare the efficiency of the "flare up" protocol (mini-dose GnRH-ag, macro-dose FSH, GnRH-ant, HCG)-gr. A, with a modified natural cycle IVF (GnRH-ant, HCG)-gr. B.

RESULTS

In gr. A 140 and in gr. B 17 patients were assessed. The average age is 35.5 in gr. A and 35 years in gr. B. The embryo transfer is realized 48-72 hours after ovarian puncture in 98 cases (70%) in gr. A and 11 cases (64.7%) in gr. B. Clinical pregnancy is registered in 32 cases (22.8% per cycle, 32.6% per transfer) in gr. A and 4 cases (23.5% per cycle, 36.3% per transfer) in gr. B. In gr. A the cancellation rate is 30%-42 cases and in gr. B--35.3%--6 cases.

CONCLUSION

The preliminary results indicate that the 2 methods are equal as regards cancellation and success rate. The natural and modified natural cycle IVF have the following advantages: minimization of severe early and late complications and multifetal pregnancies as well as cost-effectiveness and better chance for pregnancy cumulation rate. There is no doubt that the "mild" and natural, resp. modified natural protocols will displace the conventional hyperstimulation regimens.

[Oocyte and embryo donation and surrogacy. Religious, medico-social, ethical, financial and legal problems]

The authors quote and discuss the postulates of the Orthodox, Jewish, Catholic and Islamic religions towards ART as well as worldwide legislations and standards and the attitude of female students of medicine in Varna. Indications of oocyte and embryo donation and surrogacy are proposed but all kinds or surrogacy should be permitted. The ART legislation and standards in Bulgaria should be thoroughly revised.

[Ovulation induction in high risk IVF patients: GnRH-agonist, diminished dose of urinary or recombinant chorion gonadotropin]

In high risk IVF patients the ovulation triggering was done with agonist (0.2 mg), 1.gr., Pregnyl 5000 IE, 2. and 4.gr., Ovitrelle 0.250 mg, 3.gr., and Pregnyl 10000 IE in the fifth--non-risk group. The protocol of the first and fourth group included antagonist, the second and third group was with short and the fifth group with long agonist protocol. There was no grave OHSS in the first group, one case in each second, third and fourth group and 4 cases in the fifth group, as a whole 7 patients (3.3%). In all of them an abdominal drainage lasting 4 to 30 days was performed and all pregnancies were preserved. The average success rate was 50%, 71.4% in the fourth and 43.1% in the fifth group. A protocol with antagonist and ovulation triggering with agonist or reduced dose ChG in order to diminish OHSS in high risk IVF patients is recommended.

[Role of intercellular adhesion molecule-1 and E-selectin in the pathogenesis of ovarian hyperstimulation syndrome]

OBJECTIVE

To explore the ICAM-1 and E-selectin in patients with OHSS and clarifying its role in pathogenesis of the syndrome.

MATERIALS AND METHODS

20 patients were included in the research and 20 control patients with stimulating ovarian cycle for the purposes of ART, during the period from 01.01.2004 till 01.01.2005 years in the center of ART-MU-Varna and Department of Obstetrics and Gynecology-IVF-ward-MU-Ben-Gurion, Israel. The patients were divided into 3 subgroups according to the degree of OHSS by the classification of Golan- mild, moderate, severe. The method of ELISA was used to record the values of the factors under research.

RESULTS

Six patients with severe OHSS, showed increase in the value of the ICAM-1 and somebody of them, showed low level of E-selectin testing in serum and ascitic fluid in comparison with the control group and the rest of the patient with OHSS.

CONCLUSION

OHSS is a life-threatening complication in which the main pathophysiology factor is the increased of capillary permeability. ICAM-1 are expressed on human granulosa cells and by the vascular endothelium after the stimulation by inflammatory cytokines and acts as a mediator of the cohesion with the lymphoid cells. E-selectin is produced by the endothelium after cytokine activation. The soluble forms of these molecules are found in serum, follicular fluid during the COH, as well as in ascitic fluid in severe OHSS. In our research adhesion molecules- ICAM-1 are correlated to the OHSS, especially in the severe forms of the syndrome.

[The importance of the sonographic control for a successful embryotransfer after in vitro fertilization]

Two groups of patients have been assessed for a period from January 2000 till Mai 2004. In the first group of 222 patients the Embryotransfer was performed without sonographic control. In the second group of 253 patients the transfer was sonographically controlled. The results of the second group - 54,1% pregnancy rate per transfer are statistically better than of the first group - 29,3% pregnancy rate. ET performed under sonographic control improves significantly the results.

[Some aspects of ovarian hyperstimulation syndrome]

Ovarian hyperstimulationsyndrome (OHSS) is a serious and potentially life-threatening complication of ovarian stimulation. The clinical picture of severe OHSS, includes ovarian enlargement, ascites, pleural effusion, hypercoagulation and electrolyte disorders. In this study we describe some factors which are linked with pathogenesis of OHSS. We had a case of moderate OHSS with a twin pregnancy after IVF-ET. In this case, because of abdominal pain and discomfort from the ascites, we perform abdominal paracentesis without termination of pregnancy.

[Is there a correlation between the vaginal colonization with group B streptococci and premature deliveries?]

The study covered 110 pregnant females during the period from January 1, 2002 till April 30, 2003. Nine females (8.18%) delivered premature newborns. Samples were taken from the posterior vaginal fornix and canalis cervicalis in the 18th and 24th gestational week. The preparations stained after Gram were examined under light microscope. Microbial cultures on blood agar were examined, too. It was established that 18 or 16.36% of all the cases presented with cultures positive for group B streptococci (Str. agalactiae) and Ureaplasma urealythicum. Some other microbial flora representatives such as Chlamydia trachomatis, Neisseria gonorrhoea and Trichomonas vaginalis were additionally identified. The independent colonization with Str. agalactiae prior to the 18th gestational week does not relate to the spontaneous abortions and premature deliveries at all. On the other hand, the colonization with Group B streptococci or their symbiosis with other microorganisms after the 23rd-24th gestational week displays a certain correlation with the premature births.

[Diagnostic and clinical status of premature ovarian failure]

Premature Ovarian Failure is a heterogeneous disorder with numerous causes. The exact prevalence of POF is unknown. In this study, we want to make Differentiate diagnosis of hypergonadotropic amenorrhea and to determine the difference between them. Retrospective, we follow up 475 women at which we perform ovarian stimulation and we observe that 6 (1.3%) have Gonadotropin resistant ovary syndrome in IVF-centre--MU--Varna.

Congenital toxoplasmosis: eye manifestations in infants and children

The eye manifestations of congenital toxoplasmosis were investigated in 38 infants and children. Diagnosis of the congenital ocular lesions was established clinically, using also X-ray, computed tomography and ultrasonography, and confirmed by two immunodiagnostic techniques. Infants and children were examined when one or more characteristic manifestations of ophthalmic disorders were present. Typical symptoms and signs can present at birth or appear later in life. The multiplicity of clinical manifestations is characteristic of the disease. The most common symptom was chorioretinitis (92%), associated in 71% of the cases with other ocular lesions, and the second most common symptom was microphthalmia and strabismus. The inflammatory process also involved the anterior segment of the eye: iridocyclitis, cataract, glaucoma. Other rare findings were hydrocephalus, calcification in the brain, paresis, epilepsy and diminished visual acuity. The study showed that transplacental transmission of Toxoplasma to the fetus can have severe clinical consequences and terminate in fatal ocular impairment.

[The basic problems and outlook for assisted reproductive technologies]

In this article the authors discuss some problems in ART:COH, stimulation protocols, culture media, transfer of embryos, luteal phase support, ethical, financial, religious and legal problems etc. Tha main complications are discussed, toosyndrom and pseudosyndrom of the empty follicle, OHSS, multiple pregnancy. In these cases the prophylactic and therapeutical measures are pointed out. Finally the main perspectives and developments of ART in the new millennium are outlined.

LDL-receptor gene polymorphism in patients with early-onset coronary artery disease

Simultaneous amplification of the promoter and 17 (out of 18) exons of the LDL-R gene (along with flanking intron sequences) was performed in 36 patients with hypercholesterolemia and early-onset coronary artery disease. The identification of the PCR-products on denaturing gradient gel electrophoresis (DGGE) revealed 34 cases of heteroduplexes in 24 patients. The heteroduplexes in exons 12, 10, and 2 (31%, 28% and 22%, respectively) probably reflect common polymorphism of LDL-R gene, while heteroduplexes in exons 6, 4 and 13 are less frequent (5.6%, 5.6%, and 2.8%, respectively). Significant association between the genetic variants, or polymorphism with clinical manifestations, could not be established.

Quantitative analysis of the expression of apoptosis-related genes

BACKGROUND

The development and subsequent introduction of current molecular biology techniques allows the elucidation of some of the mechanisms of the programmed cell death (apoptosis). The overexpression of the genes directly (B-cell leukemia/lymphoma-2, BCL-2) or indirectly (multidrug resistance gene-1, MDR1) involved in the suppression of apoptosis, as well as the low-level expression of their antagonists (BCL-2 associated X-protein, BAX) result in longer survival and the development of drug resistance in malignant cells.

AIM

The objective of this study was to design our own appropriate primers and to synthesize internal RNA standards and this way to evaluate the rate of expression of the MDR1, BCL-2 and BAX genes using a competitive reverse transcription and polymerase chain reaction (cRT-PCR).

MATERIAL AND METHODS

Peripheral blood or bone marrow aspirates from 5 patients and 3 healthy controls were used for RNA extraction. Competitive RT-PCR was employed utilizing the constructed specific primers and synthesized internal RNA standards. Following electrophoresis, the PCR products stained with ethidium bromide were evaluated on the "Gel Doc 1000TM" video image system.

RESULTS

The constructed primers specific for each of the three genes and synthesized internal RNA standards with a suitable deletion allow receiving the yield of well-separated competitive amplicons. The measured band's intensity of light and the calculated standard/patient ratio were employed in the analysis of the MDR1, BCL-2 and BAX gene expression.

CONCLUSIONS

Competitive RT-PCR is a non-radioactive and comparatively rapid molecular biology method suitable for everyday laboratory practice. The possibility for simultaneous evaluation of the expression of several genes could help in the elucidation of some of the mechanisms underlying the prolonged survival of malignant cells.

Rearrangement of T-cell receptor and immunoglobulin heavy chain genes in leukemia and lymphoma

The development of polymerase chain reaction /PCR/ has greatly facilitated the detailed characterization of T-cell receptor /TcR/ and immunoglobulin heavy chain /IgH/ gene rearrangements. The antigen-receptor genes in lymphoid cells undergo rearrangements by combination of variable /V/, diversity /D/ and joining /J/ gene segments, deletion of germline nucleotides and insertion of nontemplate-derived nucleotides /"N-regions"/. In this preliminary study we analysed 12 DNA samples from patients with lymphoproliferative disorders /LPD/ and with acute nonlymphoblastic leukemias /ANLL/. PCR analyses were performed using V and J consensus primers for conserved regions of TcRg and IgH genes. PCR products were evaluated by polyacrilamide gel electrophoresis and denaturing gradient gel electrophoresis. Applying this method, we have detected 3 TcRg and 4 IgH monoclonal rearrangements in all 12 LPD samples. One ANLL sample showed monoclonal rearrangement for TcRg. Because of the clonal rearrangements, the analysis of TcR and IgH gene configuration can be used to track the persistence of malignant cells which are determined at diagnosis. The positive results from ANLL samples will be further evaluated as prognostic criteria.

[The ovarian hyperstimulation syndrome in pregnancy after IVF-ET]

The authors present 3 cases of OHSS in 85 patients (3.5%), treated with long stimulation protocol. They propose an original grading of the severity of the syndrome as well as prophylactic and therapeutic measures.

A case of Friedreich's ataxia confirmed by DNA-analysis

The first case of DNA-confirmed Friedreich's ataxia in Bulgaria is presented. The results from the DNA studies of the index patient revealed two alleles with an expansion between 500 and 1500 repeats of the GAA trinucleotide in the first intron of the X25 gene. The parents had one normal allele with 7-22 repeats and one allele with a similar expansion to that of the patient in the first intron of the X25 gene. These results confirm the homozygous mode of transmission of the abnormal alleles (with an expansion of the GAA trinucleotide in the first intron of the X25 gene) from the two normal heterozygous parents to their affected offspring.

Evaluation of an ion-selective electrolyte analyzer: Microlyte 6

Microlyte 6 (Kone, Finland) is an ion-selective analyzer designed to measure simultaneously the concentration of six important electrolyte parameters--potassium, sodium, chloride, ionized calcium, ionized magnesium and pH in whole blood, serum and plasma. Two values are obtained in analyzing the ionized fractions of magnesium and calcium--one at the actual pH and another at a recalculated measurement for pH = 7.4. Direct determination of ionized calcium and ionized magnesium simultaneously with that of the other electrolytes is of great clinical significance. It is only recently that ion-selective analysis of ionized magnesium has been proposed. The analytical reliability of the results and the operational characteristics of the Microlyte 6 ion-selective analyzer were evaluated for approximately one year. The coefficient of variation of the results in the reference and pathological range was 0.49%-2.23%, and 0.68%-4.42% for the within-run and between-run series, respectively. The inaccuracy of the results expressed by d% was from -4.23% to +4.06%. The comparative evaluation of the results for potassium, sodium, chloride, and ionized calcium between Microlyte-6 and the clinical chemistry analyzer Dynamic (Kone) showed a high correlation (correlation coefficient in the range 0.9868-0.9970). The correlation between the results for the ionized fraction and those obtained for total magnesium was consistent with that generally given in the literature.

[The effect of piracetam on lipid peroxidation in the rat brain]

The effect of piracetam on lipid peroxidation (LPO) in the rat brain was investigated. Piracetam was shown not to catalyze LPO and not to stimulate production of active forms of oxygen but to increase LPO only in the presence of traces of transition of metal ions. In all probability, the reason of this is the capacity of piracetam to chelate these metals. In this case their catalytic activity with respect to LPO increases. The performed studies demonstrate that the observed increase in LPO in the rat brain during the use of piracetam is an artefact due to the presence of traces of transition metal ions.