Does long in vitro culture promote large for gestational age babies?

STUDY QUESTION: Does the length of time during which embryos are cultured in vitro affect the birthweight of the infants? SUMMARY ANSWER: The duration of the embryo culture period is a significant factor in determining the birthweight of the infants. WHAT IS ALREADY KNOWN: IVF children show adverse perinatal outcome when compared with the general population and increased incidence of preterm birth and low birthweight is commonly observed. STUDY DESIGN, SIZE, DURATION: A retrospective cross-sectional cohort study including 1079 infants born after treatment at the Family Federation of Finland Fertility Clinic in Helsinki, between 2000 and 2010. PARTICIPANTS, SETTING, METHODS: All singleton IVF children were included. The gestation- and gender-adjusted birthweights of the babies were analyzed according to mother's age, BMI, and parity, type of treatment (IVF or ICSI), main cause of infertility and embryo culture period. Two outcomes were investigated: the birthweight and the proportion of small and large for gestational age (SGA and LGA) infants. Multiple linear regression analysis was performed to show the significance of each individual factor on determining the birthweight of the babies born. MAIN RESULTS AND THE ROLE OF CHANCE: In the study group as a whole, the distribution of the SGA and LGA babies showed no deviation from the growth charts of the general population. However, when the birthweight of the children was analyzed according to the length of embryo culture from Day 2 to Days 5-6, an increase in the proportion of LGA babies was found (D2 9.4%, D3 11.5%, D5-6 18.8%; D2 n = 871, D3 n = 139, D5-6 n = 69). Multiple linear regression analysis showed that BMI (P < 0.001) and parity (P < 0.001) of the mother, as well as the embryo culture period (P = 0.007) had a significant effect on the birthweight. The value of the adjusted R(2) was 0.437. LIMITATIONS, REASONS FOR CAUTION: Small number of D5-6 infants and a lack of pregnancy-associated factors contributing to birthweight. WIDER IMPLICATIONS OF THE FINDING: This study warrants larger studies to analyze the birthweight of the IVF children, particularly after blastocyst culture. STUDY FUNDING/COMPETING INTEREST: The study was funded by the Family Federation of Finland, Fertility Clinic Helsinki. No competing interests.

The profile of leg symptoms, clinical disability and reflux in legs with previously operated varicose disease.

PURPOSE: It is difficult to assess the severity and location of venous insufficiency in legs with recurrent varicose disease. This present purpose was to evaluate the distribution of reflux and the diagnostic role of current classifications in a consecutive series of legs with previously operated varicose disease. METHODS: A total of 90 legs in a cohort of 66 patients were included. The examination comprised CEAP clinical class, clinical disability score (CDS) and leg symptoms. Colour-flow duplex imaging (CFDI) was used to observe reflux in deep and superficial veins. Details of prior surgery were assessed. RESULTS: The site of superficial reflux was at the groin in 58% (recurrent or residive vein trunk or unoperated great saphenous vein), and the rate in the popliteal fossa was 11% (unoperated short saphenous vein). In 58% of the legs presenting superficial reflux at groin level, previous surgery at the saphenofemoral junction was noted. A sensation of pain was observed in 74% of the legs, sensation of oedema in 64%, itching in 26 %, and night cramps in 8%, respectively. Only itching was significantly infrequent in uncomplicated (CEAP C 2-3) legs, and in legs with local reflux was restricted to vein tributaries. Higher CDS (classes 2-3) were significantly more frequent among complicated legs (CEAP clinical class C2-3: 22% versus CEAP clinical class C4-6: 77%; p < 0.005). A similar situation was noted when legs with only local reflux were compared to those with more severe reflux (local reflux: 7% versus severe reflux: 48%; p < 0.005). CONCLUSIONS: Superficial reflux is frequently detected at groin level despite prior surgery. Unstructured evaluation of leg symptoms is not beneficial. Clinical disability scores associate well with the severity of the venous disease.

Breast lesions: evaluation with dynamic contrast-enhanced T1-weighted MR imaging and with T2*-weighted first-pass perfusion MR imaging.

PURPOSE: To evaluate the diagnostic value of an imaging protocol that combines dynamic contrast-enhanced T1-weighted magnetic resonance (MR) imaging and T2*-weighted first-pass perfusion imaging in patients with breast tumors and to determine if T2*-weighted imaging can provide additional diagnostic information to that obtained with T1-weighted imaging. MATERIALS AND METHODS: One hundred thirty patients with breast tumors underwent MR imaging with dynamic contrast-enhanced T1-weighted imaging of the entire breast, which was followed immediately with single-section, T2*-weighted imaging of the tumor. RESULTS: With T2*-weighted perfusion imaging, 57 of 72 carcinomas but only four of 58 benign lesions had a signal intensity loss of 20% or more during the first pass, for a sensitivity of 79% and a specificity of 93%. With dynamic contrast-enhanced T1-weighted imaging, 64 carcinomas and 19 benign lesions showed a signal intensity increase of 90% or more in the first image obtained after the administration of contrast material, for a sensitivity of 89% and a specificity of 67%. CONCLUSION: T2*-weighted first-pass perfusion imaging can help differentiate between benign and malignant breast lesions with a high level of specificity. The combination of T1-weighted and T2*-weighted imaging is feasible in a single patient examination and may improve breast MR imaging.

Majority of hip fractures occur as a result of a fall and impact on the greater trochanter of the femur: a prospective controlled hip fracture study with 206 consecutive patients.

The objectives of this study were to learn how hip fracture patients fall, and to compare the mechanics of their falls with those falls that did not result in hip fracture. In this way we sought to obtain reliable insight into the etiology and pathogenesis of hip fracture and fracture prevention. A total of 206 consecutive patients with fresh hip fracture and 100 controls were interviewed and examined between October 1994 and May 1996. The only inclusion criterion was that the fracture had occurred within 24 hours of hospital admittance. The control subjects were admitted from the same community after an accidental fall that did not result in hip fracture. The characteristics of the accident were determined by personal interview and examination of the patients within 24 hours of the event. In 98% of the hip fracture patients, the fracture was a result of a fall. The majority of the patients (76%) reported that they had fallen directly to the side. Forty-eight fracture cases had one or more eyewitnesses and their reports supported this observation. In 56% of the hip fracture patients, a fresh subcutaneous hematoma was seen on the greater trochanter of the proximal femur; such a hematoma was rare in the controls (6%) (P < 0. 001), and this gave evidence for the direct impact of the greater trochanter during the fall of the hip fracture subjects. Most of the elderly fallers who fractured a hip did not manage to break the fall, e.g., with an outstretched arm. In conclusion, our results suggest that a typical hip fracture is the result of a fall and a subsequent impact on the greater trochanter of the proximal femur. The clinical implication of this finding is that effective prevention of hip fractures could be achieved by the diminution of the number and severity of falls of the elderly. We suggest that the severity of the falls (impacts on the greater trochanter) could be decreased by an external hip protector.

Ibuprofen in the treatment of postoperative pain in small children. A randomized double-blind-placebo controlled parallel group study.

The efficacy of ibuprofen as a pre-emptive analgesic for postoperative pain was investigated in 81 children in the age between one and four years subjected to elective surgery. The patients were randomized into two groups receiving rectally either ibuprofen 40 mg.kg-1.d-1, divided into four equal doses, or placebo in a double blind manner. Additional pain relief was provided by morphine. In the recovery room ibuprofen provided superior pain relief during the first hour and significantly reduced the need of morphine. Heart rate and arterial blood pressure were lower in children who received ibuprofen, probably reflecting better analgesia. The side effects were mild and similar in both groups. We conclude that rectal ibuprofen is a safe analgesic in children in the age between 1 and 4 years and reduces the need of opioids for postoperative pain relief.

[Pediatric surgery. A comparison of spinal anesthesia and general anesthesia]. / Operationen im Vorschulalter. Vergleich von Spinalanästhesie und Allgemeinanästhesie.

Forty patients aged 2 to 5 years who were admitted for paediatric operations were randomly assigned to have either spinal or general anaesthesia. Spinal anaesthesia was achieved with isobaric bupivacaine 0.5% at a dose of 0.5 mg/kg. General anaesthesia was induced with thiopentone 2-5 mg/kg and continued with low-dose fentanyl (1-2 micrograms/kg, oxygen/nitrous oxide/isoflurane (30/70/0.1-0.5%), vecuronium normoventilating the patients. The time spent in the operation room was shorter in the spinal anaesthesia group because the children were awake and could immediately be transferred. The haemodynamic pattern and respiratory function were stable during spinal anaesthesia. After general anaesthesia, respiratory function deteriorated as indicated by arterial desaturation (< 90%), which was detected in 11 of the 20 patients after general anaesthesia. Vomiting (2), sore throat (4) and micturition difficulties (2) were the adverse events associated with general anaesthesia. Three patients were restless after spinal anaesthesia. It can be concluded that spinal anaesthesia is a suitable anaesthetic technique for paediatric surgery.

Biodegradable fixation of distal humeral physeal fractures.

Polyglycolic acid (PGA) has been used worldwide as a biodegradable suture material since 1970. Biodegradable polyglycolide implants were introduced in osteofixation of cancellous bone fractures in 1985. From September 1987 to September 1989, 19 consecutive children with physeal fractures of the distal humerus necessitating open reduction and internal fixation were treated by transphyseal biodegradable fixation using 1.5 x 60-mm2 self-reinforced polyglycolide (SR-PGA) pins. Included were nine displaced fractures of the lateral humeral condyle, five severe avulsions of the medial epicondyle of the humerus, four displaced fractures of the humeral capitellum, and one intraarticular fracture of the medial condyle of the humerus. After accurate reduction, two smooth Kirschner pins 1.5 mm in diameter were introduced across the growth plate for temporary fixation. The metallic pins then were removed one by one and subsequently replaced with the cylindrical SR-PGA pins 1.5 mm in diameter. After operation, a padded plaster splint was worn for four weeks. Neither secondary displacement nor signs of growth disturbance were seen during the 26-month follow-up time (mean, 17.2 months). Not only the reduction of the costs but also the psychological aspects should be considered when dealing with biodegradable fixation of physeal fractures in children. Transphyseal biodegradable fixation has established itself as a procedure of choice for handling simple physeal fractures.

Totally absorbable screws in fixation of subtalar extra articular arthrodesis in children with spastic neuromuscular disease: preliminary report of a randomized prospective study of fourteen arthrodeses fixed with absorbable or metallic screws.

Seven patients with spastic neuromuscular disease and severe hindfoot valgus deformity were treated by subtalar arthrodesis. Arthrodesis was performed in both feet at the same operation and fixed on one side with a self-reinforced poly-L-lactide (SR-PLLA) screw, and with a standard AO screw on the other side. The functional status state was improved, and radiographic union of the arthrodesis occurred in all feet. The radiograph showed better solid fusion in five feet treated with PLLA screws, similar fusion in both sides in one patient, and one slower fusion in the side treated initially with a PLLA screw. Totally absorbable SR-PLLA screws appear to be firm enough for fixation of subtalar extraarticular arthrodesis in children.

The effect of an intramedullary self-reinforced poly-L-lactide (SR-PLLA) implant on growing bone with special reference to fixation properties. An experimental study on growing rabbits.

Polylactic acid (PLA) is a synthetic biodegradable material. The self-reinforced implants made of poly-L-lactic acid (SR-PLLA) were manufactured of biodegradable polymeric matrix reinforced with fibres of the same material. The purpose of this study was to find out the effect of an intramedullary SR-PLLA implant on growing bone and its applicability to the fixation of a femoral shaft osteotomy in a growing rabbit. In seven rabbits 6 weeks of age a SR-PLLA implant 2.0 mm in diameter and 50 mm in length was introduced into the intramedullary cavity of the right femur. A proximal femoral shaft osteotomy of the right femur was made in another ten 6-weeks-old rabbits. After accurate reduction, fixation of the osteotomy was achieved with an intramedullary 2.0 mm by 50 mm SR-PLLA-rod. The follow-up times were 6 and 28 weeks. An intramedullary SR-PLLA-rod neither caused any disturbance of the bone growth nor abnormalities of the peripheral blood cell counts. Solid union of the osteotomy was seen in six weeks after fixation with SR-PLLA implant.

The effect of an intramedullary biodegradable self-reinforced polyglycolic acid implant on tubular bone. An experimental study on growing dogs.

The purpose of this study was to examine the effects of intramedullary self-reinforced polyglycolic acid (SR-PGA) implant to the femoral bone growth in a growing dog by using radiographic, microradiographic, oxytetracycline-fluorescence, histological, polariscopical and histomorphometric studies. Intramedullary reaming and SR-PGA implant did not cause any longitudinal overgrowth phenomenon, but resulted in a slight increase in femoral neck-angle. The bone histology showed normal features and blood cell counts were within normal limits.

Results of 500 general surgery patients operated on in the ambulatory surgery unit.

This study examined the outcome of 597 general surgery operations performed on 500 patients in the ambulatory surgery unit of the University Hospital of Kuopio between November 1989 and May 1990. Endoscopies were excluded from the study. Spinal (41.0%) and local infiltration (31.2%) were the most often used forms of anaesthesia. During anaesthesia 15.8% of patients required treatment for hypotension, and 13.6% for bradycardia. Of the 351 (70.2%) patients, who returned the one month follow-up questionnaire, 41 (11.7%) had visited a doctor postoperatively. The main reasons for this visit were pain in 41 (100%), minor bleeding in 24 (58.5%) and inflammation in 16 (39.0%) patients. No deaths or other major complications were observed. 92% of the patients were satisfied with the treatment and anaesthesia.

Fixation of diaphyseal femoral osteotomy with self-reinforced biodegradable intramedullary implants: an experimental study on growing dogs.

Polyglycolic acid (PGA) was investigated for use as a biodegradable suture and fixation material for the repair of soft and osseous tissue. Self-reinforced (SR-) PGA has been used successfully since 1984 as an internal fixation material for fixation of cancellous bone fractures. The purpose of this study was to examine the possible usefulness of an intramedullary SR-PGA rod in the fixation of femoral shaft osteotomy in the growing dog. Osteotomy of the right femur was made in 14 Beagle dogs at 12 weeks of age. After accurate reduction, the osteotomy was fixed with an intramedullary 45 x 60 mm SR-PGA rod. The intramedullary SR-PGA rod provided sufficient stability for healing of a femoral shaft osteotomy in the growing dog and did not cause any significant growth disturbance.

Dupuytren's contracture: the long-term results after day surgery.

220 operations in 211 hands in 160 consecutive patients suffering from Dupuytren's contracture were performed from 1976 through 1984 at the Kuopio University Central Hospital in Finland. 179 operations were carried out as day cases. The mean follow-up was 3.2 years. Sub-total fasciectomy resulted in good immediate and long-term improvement in 86% of patients. The recurrence rate was 27%. Surgical treatment of Dupuytren's contracture was well-suited to day surgery. A properly planned follow-up programme is suggested because of the relatively high rate of recurrence, which usually appeared within two years after operation.

Mesenchymoma of the chest wall in children.

Benign chest wall mesenchymoma in children is an extremely rare disease. Only 20 patients have been reported in the world literature. We report a chest wall mesenchymoma in a 2-year-old boy who was admitted to the hospital after a routine chest roentgenogram showed a mass in the right upper chest wall. The patient was asymptomatic. Clinical examination was negative, but chest roentgenograms and computed tomography showed a mass in the right upper chest wall involving the third rib. A 2 x 2 x 1.5-cm tumor was excised totally with partial resection of the third rib. The histology of the lesion corresponded to a mesenchymoma (hamartoma) of the chest wall. Our patient has been followed up for 8 years without recurrence.

The incidence and causative factors responsible for femoral shaft fractures in children.

From 1976 through 1985, a total of 1096 children, 0-15 years of age, was treated for fractures in Kuopio University Central Hospital. 131 patients had a femoral shaft fracture and 114 of them, including 82 boys and 32 girls, were studied. The incidence of femoral shaft fracture was 2.16 per 10,000 inhabitants 0-15 years of age. Environmental factors and the ability to move in traffic appeared to be the most important risk factors for femoral shaft fracture.

Carcinoma of the breast in children.

Carcinoma of the breast in children is an extremely rare disease, only 44 patients have been reported in the world literature. We report on a case of breast cancer in a 9-year-old girl, who was admitted to the hospital because of a four-month history of a painless mass in the right breast. Clinical examination and mammography resulted in a strong suspicion of malignancy. The histology corresponded to juvenile secretory carcinoma, the histological type without the characteristics of prepubertal cancer cases. Electron microscopy demonstrated intracellular large vacuoles and acini filled with secretory material. The mitotic index was low, the highest measured value was 4 mitotic figures per 10 high power fields corresponding to 2.78 mitotic figures per mm2 of epithelium in the microscope field. Flow cytometry showed that the neoplastic cells were diploid and had a low S-phase fraction. A simple mastectomy including axillary evacuation was performed. No lymph node or distant metastases were found. Postoperative radiation treatment or chemotherapy were not administered. Our patient has been in follow-up for six years without recurrence. In this case simple mastectomy with axillary evacuation seems to have given a cancer-free development into adulthood. Earlier reports have also shown a favourable outcome in these tumours.

[Intramedullary nailing of tubular bones with resorbable implants. An animal experiment study with growing dogs]. / Marknagelung der Röhrenknochen mit resorbierbaren Implantaten. Eine tierexperimentelle Untersuchung bei heranwachsenden Hunden.

Subtrochanteric osteotomy of the right femur was made in 8 Beagle-dogs 12 weeks of age. After accurate reduction the fixation of the osteotomy was achieved with an intramedullary self-reinforced polyglycolic acid rod. At the follow-up interval of 12 weeks an uncomplicated healing of osteotomy was seen without any growth disturbance. The SR-biodegradable PGA rods provided sufficient stability for rapid healing of subtrochanteric femoral osteotomy in growing dogs.

Reduction of radiation dose and imaging costs in scoliosis radiography. Application of large-screen image intensifier photofluorography.

Photofluorography using a large-field image intensifier (Siemens Optilux 57) was applied to scoliosis radiography and compared with a full-size rare-earth screen/film technique. When scoliosis radiography (PA-projection) was performed on 25 adolescent patients, the photofluorographs were found to be of comparable diagnostic quality with full-size films. A close correspondence between the imaging techniques was found in the Cobb angle measurements as well as in the grading of rotation with the pedicle method. The use of photofluorography results in a radiation dose reduction of about one-half and considerable savings in direct imaging costs and archive space. In our opinion the method is particularly well-suited for follow-up and screening evaluation of scoliosis, but in tall patients the image field size of 40 x 40 cm restricts its usefulness as initial examination.

Experimental fixation of bone cement and composite resins to bone.

The aim of this study was to ascertain whether the use of liquid acrylic resin or NeoCryl XK-53 acrylic emulsion or etching of the bone surface with phosphoric acid or the application of both these methods would improve the bonding of CMW bone cement or Concise and Silar composite resin to bone. The test materials were applied to fresh cortical bovine bone. Their bonding capacity was measured by the Instron Universal Testing Machine. The surfaces of the test materials and the bone surfaces were examined by means of optic microscope or scanning electron microscope. The bonding strength of the bone cement and composite resins as such were found to be of the same magnitude. A three- to five-fold improvement was obtained with liquid acrylic intermediary material. Acid etching impaired the bonding.

Experimental osteotomy fixed with a composite resin.

Some composite resins used in dentistry are claimed to have qualities superior to those of the commercial bone cements. A bis-GMA composite resin was used for the fixation of experimental tibial osteotomies in rats. The osteotomies were fixed with bis-GMA in 84 rats, while intramedullary nailing was used in 28 rats. In 28 rats used as controls the osteotomy was left unfixed. Radiologic, histologic, microradiographic and oxytetracycline (OTC) fluorescence studies were performed after 1,2,3,6, 12, 18 and 24 weeks. The most favorable results as regards the healing of osteotomy were obtained in the intramedullary nailing group, but the results with bis-GMA fixation were more favorable than those obtained in the untreated group. It is concluded that the material employed is suited for the fixation of osteotomies and that the bone tolerated the tested material well.