Controversies relating to the management of acromioclavicular joint dislocations.

The aim of this review is to address controversies in the management of dislocations of the acromioclavicular joint. Current evidence suggests that operative rather than non-operative treatment of Rockwood grade III dislocations results in better cosmetic and radiological results, similar functional outcomes and longer time off work. Early surgery results in better functional and radiological outcomes with a reduced risk of infection and loss of reduction compared with delayed surgery. Surgical options include acromioclavicular fixation, coracoclavicular fixation and coracoclavicular ligament reconstruction. Although non-controlled studies report promising results for arthroscopic coracoclavicular fixation, there are no comparative studies with open techniques to draw conclusions about the best surgical approach. Non-rigid coracoclavicular fixation with tendon graft or synthetic materials, or rigid acromioclavicular fixation with a hook plate, is preferable to fixation with coracoclavicular screws owing to significant risks of loosening and breakage. The evidence, although limited, also suggests that anatomical ligament reconstruction with autograft or certain synthetic grafts may have better outcomes than non-anatomical transfer of the coracoacromial ligament. It has been suggested that this is due to better restoration horizontal and vertical stability of the joint. Despite the large number of recently published studies, there remains a lack of high-quality evidence, making it difficult to draw firm conclusions regarding these controversial issues.

A systematic review of plate versus intramedullary fixation in the treatment of midshaft clavicle fractures.

The best method of fixation for clavicle fractures is not known. The purpose of this review was to examine the evidence comparing plate and intramedullary fixation for midshaft clavicle fractures. A search of MEDLINE in September 2011 identified five papers that compared plate and intramedullary fixation, and fulfilled our eligibility criteria, consisting of; one randomised controlled trial, two quasi-randomised controlled trials, and two retrospective studies. Level of evidence was assessed using the Scottish Intercollegiate Guidelines Network guidance and the Cochrane Bone, Joint and Muscle Trauma Group's quality assessment tool. No attempt at meta-analysis was made due to the heterogeneity of the study populations and interventions. We found no difference between intramedullary fixation and plate fixation. There was a trend towards a lower complication rate with intramedullary fixation. On the basis of the available evidence, we would advocate both techniques for the treatment of midshaft clavicle fractures.

Bilateral pisotriquetral loose bodies.

Case reports detailing diagnosis and effective treatment of pisotriquetral loose bodies are scarce. This article describes an even rarer case of bilateral pisotriquetral joint loose bodies, explores the relative diagnostic roles of magnetic resonance imaging versus computed tomography, and outlines effective strategies used for the management of this condition drawn from the literature and our own experience.

Temporary intra-operative reduction techniques for tibial fracture fixation: A review of the literature.

Accurate intra-operative reduction and maintenance of reduction is essential for successful fixation of tibial fractures. Although many tibial fractures can be reduced with minimal manipulation, numerous techniques have been described to facilitate fixation of more difficult fractures. These include use of a traction table, manual traction techniques, temporary distracters, reduction clamps and temporary unicortical plating. This article reviews the literature and assesses the options available for the temporary reduction and maintenance of reduction of tibial fractures prior to definitive fixation.

Agreement between preoperative core needle biopsy and postoperative invasive breast cancer histopathology is not dependent on the amount of clinical material obtained.

AIMS: To establish the relation between the amount of breast core needle biopsy (CNB) material examined and agreement between preoperative and postoperative histopathology parameters in invasive breast cancer. METHODS: The CNB and surgical specimen histopathology reports of 113 patients with invasive breast carcinoma were reviewed and the total amount of CNB material examined for each case was determined. Agreement was calculated for tumour type, grade, mitoses, nuclear pleomorphism, and tubule formation. Associations between the amount of CNB material and histopathology agreement before and after surgery were explored using binary logistic regression. RESULTS: Tumour type and grade agreed in 65.4% and 61.6% of cases, respectively. The components used to calculate grade--nuclear pleomorphism (57.4%), mitoses (59.4%), and tubule formation (55.6%)--agreed slightly less frequently. The proportion of cases with preoperative and postoperative assessments that agreed did not depend on the number of cores collected or the total amount of material examined. CONCLUSION: Neither tumour type and grade, nor the individual components used to calculate grade agreed consistently between the CNB and surgical specimen. The number of cores collected and the total amount of material reviewed by the pathologist does not influence the likelihood of agreement between preoperative and postoperative histopathology reports.

Expression of mRNAs for DNA methyltransferases and methyl-CpG-binding proteins in the human female germ line, preimplantation embryos, and embryonic stem cells.

Recent evidence indicates that mammalian gametogenesis and preimplantation development may be adversely affected by both assisted reproductive and stem cell technologies. Thus, a better understanding of the developmental regulation of the underlying epigenetic processes that include DNA methylation is required. We have, therefore, monitored the expression, by PCR, of the mRNAs of DNA methyltransferases (DNMTs), methyl-CpG-binding domain proteins (MBDs), and CpG binding protein (CGBP) in a developmental series of amplified cDNA samples derived from staged human ovarian follicles, oocytes, preimplantation embryos, human embryonic stem (hES) cells and in similar murine cDNA samples. Transcripts of these genes were detected in human ovarian follicles (DNMT3A, DNMT3b1, DNMT3b4, DNMT1, MDBs1-4, MeCP2, CGBP), germinal vesicle (GV) oocytes (DNMT3A, DNMT3b1, DNMT1, MDBs1-4, MeCP2, CGBP), mature oocytes (DNMT3A, DNMT3b1, DNMT1, CGBP), and preimplantation embryos (DNMT3A, DNMT3b1, DNMT1, DNMT3L, MBD2, MDB4, CGBP). Differential expression of DNMT3B gene transcripts in undifferentiated (DNMT3b1) and in vitro differentiated human ES cells (DNMT3b3) further demonstrated an association of the DNMT3b1 transcript variant with totipotent and pluripotent human cells. Significantly, whilst the murine Dnmt3L gene is both expressed and essential for imprint establishment during murine oogenesis, transcripts of the human DNMT3L gene were only detected after fertilisation. Therefore, the mechanisms and/or the timing of imprint establishment may differ in humans.

Alterations of elastin and elastase-like activities in aortae of diabetic rats.

The elastin content of the aortic muscle and the elastase-like activity of the extracts of aortic muscle were studied in spontaneously diabetic BB rats and in rats made diabetic by a single bolus i.v. injection of alloxan. In both modes of diabetes, the total alkaline-insoluble aortic elastin content was significantly reduced in diabetic rats compared to that in the corresponding control rats. This reduction in aortic elastin was also accompanied by a consistent increase in the elastase-like activities of the aortic extracts prepared from the same tissues. Such a reciprocal relationship between aortic elastin content and elastase-like activity has previously been reported in rats with malignant hypertension. Since the rats used in this study were not hypertensive, the altered elastin metabolism observed in this work is likely to be a manifestation of diabetic disease and may in part account for the vascular changes associated with diabetes mellitus.

Mechanism of inhibition by alloxan of ATP-driven calcium transport by vascular smooth muscle microsomes.

The direct in vitro effects of alloxan on the Ca2+ handling by microsomal membranes isolated from dog mesenteric arteries were investigated. Preincubation of the vascular muscle microsomal membranes with alloxan showed a suppressive effect on both binding of Ca2+ (in the absence of ATP) and ATP-driven Ca2+ transport. Such an inhibition was time dependent, dose dependent, and temperature dependent. ATP-driven Ca2+ transport was much more susceptible to the inhibitory action of alloxan than Ca2+ binding under all experimental conditions examined. Alloxan inhibited ATP-driven Ca2+ transport at a comparable level over the entire period of Ca2+ uptake, but had no significant effect on the efflux of Ca2+ from preloaded microsomal membranes. This suggests that alloxan exerts its inhibitory effect on the ATP-driven Ca2+ transport via its action on the Ca-pump protein rather than the membrane permeability to Ca2+. Catalase and mannitol but not superoxide dismutase partially protected against such as inhibition by alloxan. The possible involvement of H2O2 mediating the inhibitory action of alloxan was further supported by the finding of a similar in vitro inhibitory effect of H2O2 on the ATP-driven Ca2+ transport by the vascular smooth muscle microsomes.

Interactions of saponin with microsomal membranes isolated from vascular smooth muscle.

The effects of the plant glycosides extract, saponin, on various biochemical properties of microsomal fractions isolated from dog aortae and mesenteric arteries were investigated. These properties include binding and transport of Ca2+, ouabain-sensitive K+ activated p-nitrophenyl phosphatase (hereafter termed K+-pNPPase) and binding of radiolabelled antagonists to adrenoceptors. We found that saponin inhibited both Ca2+ binding and transport by the vascular muscle microsomes in a dose-dependent manner, but it caused marked enhancement of the K+-pNPPase activity. Saponin only slightly reduced the Bmax, but not the Kd of [125I]-iodocyanopindolol binding to the beta-adrenoceptors of the dog mesenteric artery microsomes. A similar finding on the [3H]-prazosin binding to the alpha 1-adrenoceptor in dog aortic microsomes was also observed. Our findings are consistent with the "skinning" action of saponin on the smooth muscle and provide direct evidence that saponin does not attenuate the recognition properties of the adrenoceptors in the cell membranes.

In vitro inhibition of calcium binding by alloxan and of calcium transport by isolated vascular smooth muscle microsomes.

The primary purpose of this study was to investigate the possible direct toxic effect of alloxan on the Ca2+ handling by microsomal membranes isolated from rat mesenteric arteries. It was found that preincubation of the vascular muscle microsomal membranes with alloxan had a suppressive effect on both binding of Ca2+ (in the absence of ATP) and ATP-supported Ca2+ transport. Such an inhibition was time, dose, pH, and temperature dependent. ATP-supported Ca2+ transport was more susceptible to the inhibitory action of alloxan than Ca2+ binding. Unlike alloxan, another commonly used diabetogenic drug, streptozotocin, was not effective in causing such an in vitro inhibition of Ca2+ handling.

Application of a real-time microcomputer monitoring system: surveillance of induced labour by uterine activity quantitation.

The uterine activity of women during induced labour was analysed with a real-time Commodore PET 2001 series microcomputer. The active contraction area was measured in torr-min (1 torr = 0.133 kPa) per 10 min epochs [uterine activity unit (UAU)/10 min]. Surgical induction was followed immediately by administration of a geometric oxytocin infusion and all patients received epidural analgesia. Twenty-eight primigravidae for whom inductographic and partographic progress were normal had a mean 'stable phase' uterine activity of 118 +/- 2 SD 43 UAU/10 min (identical to 942 +/- 2 SD 343 kPas/10 min) whereas 15 multiparae had a mean 'stable phase' of 83 +/- 2 SD 34 UAU/10 min (identical to 662 +/- 2 SD 271 kPas/10 min). This difference was significant (P less than 0.01). The construction of uterine activity charts is described and their clinical application discussed.

Feto-maternal surveillance in labour: a new approach with an on-line microcomputer.

A new method of real-time computer surveillance during labour is described with a commercially available "low-cost' microcomputer and integral video display unit (VDU). The fetal monitoring program gives accurate and reliable information on eight parameters of fetal and maternal wellbeing, four of which may be displayed simultaneously, with the facility of instant data recall. Emphasis is on simplicity of operation, and clarity of data display in the form of horizontal bar graphs updated at 5-min intervals, with most recent information in numerical form. Flexibility of the system enables program modification with relative ease, and adaptation to two unmodified commercial electronic fetal monitors.

Comparative study of oestradiol and prostaglandin E2 vaginal gel for ripening the unfavourable cervix before induction of labour.

Oestradiol 150 mg and prostaglandin E2 (PGE2) 4 mg suspended in viscous gel and applied intravaginally were compared with regard to ripening the unfavourable cervix of patients randomly allocated to two study groups. In primigravidae no significant difference was observed in the efficacy of the two substances. Some multiparous patients, however, had considerably more uterine sensitivity to PGE2 quickly developed decelerative cardiotocographic tracings after insertion of the gel. In the group given oestradiol there was a significant absence of uterine activity after gel application. The findings suggest that oestradiol applied vaginally is a safe, comfortable, cheap, and equally effective alternative to PGE2 for ripening the cervix, without the disadvantages of uterine stimulation frequently encountered with PGE2.

Uterine activity plotted on an inductograph as an aid to management of labour.

By combining uterine activity data with an "inductograph" it is possible to distinguish between normal progress and at least three different types of delayed progress during the early stage of stimulated labour. Delayed progress may be associated with optimal, insufficient or, sometimes, excessive uterine activity. The patterns described facilitate early recognition and management of clinical problems such as cephalopelvic disproportion, undue cervical resistance, inadequate myometrial activity, and impending fetal distress.