Does the PFNA™ nail limit impaction in unstable intertrochanteric femoral fracture? A 115 case-control series.

INTRODUCTION: Femoral neck shortening after dynamic fixation of extra-capsular fracture may impair functional results, but is rarely assessed. The present study measured impaction in stable and unstable fractures (on the Ender classification) treated by PFNA™ nail. The objectives were: 1) to validate the Ender classification to assess fracture stability; 2) to determine whether neck shortening and head purchase quality varied with stability; and 3) to determine the functional impact of femoral neck shortening. HYPOTHESIS: The study hypothesis was that the PFNA™ nail stabilizes unstable as well as stable fractures. MATERIALS AND METHODS: One hundred and fifteen consecutive patients, aged over 70 years, operated on for intertrochanteric fracture using the PFNA™ nail were followed up prospectively for 6 months. Multivariate analysis, including age, gender, assembly quality and body-mass index, was applied to assess the predictive power of the Ender classification with respect to femoral neck shortening. Secondly, patients were grouped according to stable versus unstable fracture (n=70 and 45, respectively), and impaction and femoral head purchase were assessed on a dedicated radiographic protocol. Functional results were assessed on Parker score. RESULTS: In the unstable fracture group, 3 assembly failures required revision by total hip replacement. Ender grade>2 was significantly predictive of>5mm neck shortening. Neck shortening was greater in unstable fracture: 8.1 ± 8.4mm (range, 4-32 mm), versus 2.5 ± 3.7 mm (range, 3-14 mm) (P=0.0004). Mean blade cut-through was 1.2 ± 2.9 mm (range, 1-12 mm) in unstable fracture, versus 0.3 ± 1.3 mm (range, 1-6mm) (P=0.02). Mean cut-out was 2.3 ± 6 mm (range, 2-21 mm) in unstable fracture, versus 0.5 ± 2.6 mm (range, 1-8mm) (P=0.03). Parker scores diminished comparably in the two groups, without significant difference at follow-up: 3.9 ± 2.6 (range, 0-9) in stable and 3.1 ± 1.9 (range, 0-8) in unstable fracture; reduction in Parker score showed no correlation with femoral neck shortening (r=0.013, P=0.88). DISCUSSION: The PFNA™ nail provides poorer stabilization of unstable compared to stable fracture. Femoral neck shortening should be taken into account in assessing internal fixation hardware perfomances. LEVEL OF EVIDENCE: Level III. Prospective case-control study.

Efficacy and tolerability of isradipine and metoprolol in treatment of hypertension: the Finnish Isradipine Study in Hypertension (FISH).

Eight hundred seventy-six men and women with diastolic blood pressure (DBP) of 95-115 mm Hg during a 4-week placebo period were included in a multicenter trial; 479 patients had previously been treated for hypertension. The patients were randomized to receive isradipine or metoprolol; both groups were comparable for age, weight, height, smoking habits, and duration of hypertension. By the end of the placebo period, 79 patients did not fulfill the final entry criteria and were withdrawn. The isradipine group consisted of 398 patients (164 women and 234 men), and the metoprolol group consisted of 399 patients (173 women and 226 men). The initial dose of isradipine was 1.25 mg twice daily (b.i.d.), and the initial dose of metoprolol was 50 mg b.i.d.; the doses were doubled after 4 weeks if DBP had not decreased to less than or equal to 90 mm Hg. After 8 weeks, the isradipine group began combination therapy with metoprolol 50 mg b.i.d. and the metoprolol group began combination therapy with isradipine 1.25 mg b.i.d. if DBP was not less than or equal to 90 mm Hg. After 8 weeks monotherapy, mean BP (MBP) was reduced by 13/11 mm Hg (161/104 to 148/93) in the isradipine group and by 15/12 mm Hg (160/103 to 145/91) in the metoprolol group. Monotherapy with isradipine normalized DBP to less than or equal to 90 mm Hg in 52% with a mean dose of 4.26 mg daily, and monotherapy with metoprolol normalized DBP in 58% with a mean dose of 155 mg daily.1+

Clinical outcome and left ventricular function 23 years after acute coxsackie virus myopericarditis.

The clinical outcome of 18 patients, who presented with a Coxsackie virus myopericarditis in 1965, was evaluated 23 years later. Five patients had died, two of them had had heart failure. Thirteen patients and 23 healthy control subjects underwent exercise testing with gas exchange analysis. Left ventricular (LV) peak filling rate (PFR) was estimated by digitized M-mode echocardiography. Left ventricular ejection fraction was measured at rest and during exercise by radionuclide angiography. All patients were free of cardiac symptoms. Their clinical examination and the chest X-ray were normal. Peak oxygen consumption was not decreased in the patient group compared with the control group. PFR was significantly lower in the patient group than in the control group, 10.2 +/- 0.4 vs 13.2 +/- 0.4 cm s-1, P less than 0.001 (mean +/- SEM). LV ejection fraction was normal at rest in all patients (58 +/- 1%). An abnormal LV ejection fraction response to exercise was observed in two patients. Our data indicate that long-term prognosis after acute Coxsackie virus myopericarditis is good in a majority of patients.

Imprint cytology in immunocytochemical analysis of oestrogen and progesterone receptors of breast carcinoma.

Cytological imprint material from 26 mammary carcinomas was stained with monoclonal antibodies to oestrogen and progesterone receptors in an immunoperoxidase procedure. The staining result was compared with that of parallel stainings of frozen tissue sections of the same tumours. The peroxidase reactions in both techniques were semiquantitatively assessed (histoscore). In both sets of stainings the results agreed in 25 of 26 cases (oestrogen receptor: 19 positive, six negative; progesterone receptor: 14 positive, 11 negative). The histoscores of imprint preparations and cryostat sections showed a significant correlation in linear regression analysis (oestrogen receptor: r = 0.755, p less than 0.001; progesterone receptor: r = 0.740, p less than 0.001). Imprint cytology is simple, does not require expensive instruments, and no separate specimen has to be sequestered. It is especially suitable for immunocytochemical steroid receptor analysis of small breast carcinomas.

Proliferative activity and steroid receptors determined by immunohistochemistry in adjacent frozen sections of 102 breast carcinomas.

Adjacent frozen sections of 102 consecutive female breast carcinomas were examined for the expression of the Ki-67 antibody-reactive proliferation-associated nuclear antigen and of estrogen and progesterone receptors with the use of monoclonal antibodies and peroxidase histochemistry. The results of steroid receptor stainings were semiquantitatively assessed (histoscore) on the basis of nuclear staining intensity and the percentage of positively stained carcinoma cell nuclei. Carcinomas negative for either receptor had significantly higher percentages of Ki-67-positive cells. The highest percentages of Ki-67-positive cells were observed in carcinomas negative for both estrogen and progesterone receptors. There was a highly significant decrease in receptor histoscores with increasing proliferative cell fractions as determined by Ki-67 positivity. No significant (progesterone receptor) or poor negative correlation (estrogen receptor) was observed when proliferative cell fractions were related to receptor concentrations from conventional steroid-binding assays. Immunoperoxidase staining for the Ki-67 antibody-defined proliferation antigen and steroid receptors in tissue sections provides a simple means to gain information of therapeutic and prognostic importance.

Clinical characteristics and coronary anatomy in refractory unstable angina pectoris leading to coronary artery bypass grafting. The Kuopio experience.

One hundred patients with high-risk unstable and medication-resistant angina pectoris underwent coronary artery by-pass grafting. In 35 cases the angina was of early post-infarction type, in 60 it was progressive after previous stability and in five it was of recent onset. All had abnormal ECG in association with anginal attacks (ST depression in 76, ST elevation in 5, T-wave inversion in 15 and left bundle branch block in 4). The left main coronary artery was stenosed in 33 patients, and the respective figures for three-vessel, two-vessel and one-vessel disease were 53, 9 and 5. The average number of inserted peripheral grafts/patient was 4.6. The perioperative mortality rate was 1%. Seven patients had confirmed or probable perioperative myocardial infarction and two had late infarction during the hospital stay, but none had angina pectoris on discharge. Of 60 patients re-examined after 1 year, 47 were angina-free. Five had NYHA class III angina, but all were improved. In refractory unstable angina pectoris there is severe coronary artery involvement, but bypass grafting can give good results.

Immunohistochemical versus biochemical estrogen-receptor and progesterone-receptor analysis: correlation with histological parameters.

Human breast carcinomas were evaluated for estrogen and progesterone receptors by immunohistochemistry using monoclonal anti-receptor antibodies (n = 267) and by cytosol steroid-binding assays (n = 212). The estrogen and progesterone receptor contents of the tumors correlated with histological features of differentiation, such as histological and nuclear grade, and with the amount of tumor necrosis and lymphoid infiltration. The correlation of immunohistochemically determined steroid receptor values with histological characteristics was somewhat better than that of biochemically assessed concentrations.

Immunocytochemical detection of estrogen and progesterone receptors in 124 human breast cancers.

Monoclonal antibodies to human estrogen receptor (ER), and rabbit progesterone receptor (PR), also recognizing human PR, were used to detect the receptors by peroxidase immunocytochemistry in frozen sections of 124 primary breast carcinomas. Both ER and PR were almost exclusively located in carcinoma cell nuclei, with heterogeneous distribution and intensity. The staining results were evaluated semiquantitatively (histoscore), based on the percentage of positively stained carcinoma cells and nuclear staining intensity. The receptor status thus determined was as follows: ER+PR+ in 50 patients, ER+PR- in 23, ER-PR- in 26, and ER-PR+ in 3 patients. There was a 79% (ER) or 70% (PR) agreement in the positivity/negativity between the immunocytochemical and steroid-binding assay (in 102 patients) with a highly significant correlation. The histoscore values increased significantly with cytosol receptor levels (ER, r = 0.623, P less than 0.001; PR, r = 0.366, P less than 0.01).

Assessment of the safety margin of vadocaine hydrochloride in man.

Vadocaine hydrochloride (2',4'-dimethyl-6'-methoxy-3-(2-methylpiperidyl)propionanilide+ ++ hydrochloride, OR K-242-HCl; INN: vadocaine) is an anilide derivative with antitussive and local anaesthetic action. The safety of this new compound was studied in 8 healthy male volunteers in a Phase I clinical trial. Vadocaine was administered orally as a single dose of 50, 100, 200, 300, 400 and 500 mg. At the two highest dose levels used, 400 and 500 mg, vadocaine induced side-effects originating in the central nervous system; ECG analysis revealed small prolongations in the P-Q interval and QRS complex after 400 and 500 mg. At a dose of 500 mg the P-Q interval was prolonged by a maximum of 38% (184 ms at 0.5 h; 134 ms pre-dose). The compound had no effect on blood and urinary parameters measured for safety evaluation. On the basis of these results, a 300 mg dose of vadocaine appears to be safe in man in all respects. This dose level is 10 times the therapeutic dose (30 mg). Vadocaine is sufficiently safe for future clinical trials in patients with cough.

Antiarrhythmic efficacy of combined intravenous and oral mexiletine in acute myocardial infarction. A double blind placebo-controlled study.

The antiarrhythmic efficacy of mexiletine in acute myocardial infarction (AMI) was studied in 99 patients randomized to mexiletine or placebo treatment. The loading dose was 250 mg i.v. and 400 mg orally followed by 200 mg orally 2 h later, and thereafter 200 mg t.i.d. up to 42 h. Arrhythmias occurring during 48 h were analysed from continuous electrocardiographic recordings. AMI was verified in 35 of 50 mexiletine patients and in 38 of 49 placebo patients. No deaths or instances of ventricular fibrillation occurred in the AMI patients. The number of patients who had any event of accelerated idioventricular rhythm (AIVR; P less than 0.05) runs of ventricular premature beats (VPBs; P less than 0.01), ventricular tachycardia (P less than 0.01) and Ron T beats (P less than 0.05) was smaller in the mexiletine group than in the placebo group. The number of all VPBs (P less than 0.05), hours with occurrence of AIVR (P less than 0.05), runs (P less than 0.01) and Ron T beats (P less than 0.05) was smaller in the mexiletine than in the placebo group. Serum levels of mexiletine tended to be low throughout the study. The half-life of the elimination was 13.7 +/- 7.2 h (means +/- S.D.). Adverse effects were infrequent, and the treatment was well-tolerated. Combined iv. and oral mexiletine prophylaxis significantly suppressed repetitive ventricular tachyarrhythmias and Ron T beats. However, no clinical benefit from mexiletine treatment could be shown in a coronary care unit with a low frequency of primary ventricular fibrillation.

Pharmacokinetics of intravenous mexiletine in patients with acute myocardial infarction.

Acute myocardial infarction (AMI) is known to alter the pharmacokinetics of several antiarrhythmic agents. To study the effects of AMI on the kinetics of mexiletine (MEX), a single intravenous dose of 200 mg MEX HCl was infused over 30 min in 11 patients with AMI. The study was performed within 24 h of the onset of pain (study I) and repeated about 2 weeks later in seven patients at discharge (study II). MEX was quantitated in plasma and urine samples by a gas-liquid chromatographic method. The decline of MEX in plasma was three-exponential, with a terminal half-life of 14.7 +/- 3.4 (mean +/- SE) h in study I and 11.3 +/- 2.4 h (p less than 0.05) in study II, in the seven patients studied in both phases. The steady-state volume of distribution averaged 578 +/- 97 L in study I and 415 +/- 33 L in study II (p less than 0.05). The total plasma clearance, renal clearance, and recovery of MEX in urine were similar in the two studies, as was the plasma protein binding of MEX (64 +/- 2 vs. 57 +/- 3%, NS). Thus, an increase in the volume of distribution with consequent prolongation of the elimination half-life of MEX occurs in the acute phase of AMI, whereas the rate of elimination remains unchanged.