Maternal HPV Infection: Effects on Pregnancy Outcome

The human papilloma virus (HPV) infection, caused by a ubiquitous virus typically transmitted through the direct contact of infected organs, either through the skin or mucosa, is the most common sexually transmitted infection, placing young women at a high risk of contracting it. Although the vast majority of cases spontaneously clear within 1-2 years, persistent HPV infection remains a serious concern, as it has repeatedly been linked to the development of multiple malignancies, including cervical, anogenital, and oropharyngeal cancers. Additionally, more recent data suggest a harmful effect of HPV infection on pregnancy. As the maternal hormonal environment and immune system undergo significant changes during pregnancy, the persistence of HPV is arguably favored. Various studies have reported an increased risk of adverse pregnancy outcomes among HPV-positive women, with the clinical impact encompassing a range of conditions, including preterm birth, miscarriage, pregnancy-induced hypertensive disorders (PIHD), intrauterine growth restriction (IUGR), low birth weight, the premature rupture of membranes (PROM), and fetal death. Therefore, understanding the mechanisms employed by HPV that negatively impact pregnancy and assessing potential approaches to counteract them would be of interest in the quest to optimize pregnancy outcomes and improve child survival and health.

[Relationship of acromial morphology and rotator cuff tears]

PURPOSE OF THE STUDY

To evaluate the effect of acromial morphology, as assessed on radiographs, on rotator cuff tears.

MATERIAL

A total of 200 patients surgically treated for shoulder disorders were enrolled. All were older than 40 years and had good quality shoulder radiographs. Two groups were composed: First, a clinical model group of 136 patients to be investigated for three parameters of rotator cuff injury that was divided into two subgroups. One included 68 patients, with an average age of 53.5 years, in whom surgery revealed no injury to the rotator cuff; the other subgroup of 68 patients, with an average age of 58 years, had a ruptured supraspinatus tendon. Subsequently, a control group of 64 patients (32 with rotator cuff injury and 32 without it) was used to verify the results of the model group.

METHODS

Three parameters describing the acromion, i.e., acromion index (AI), lateral acromion angle and acromial slope, were measured on standard radiographs. Tangential antero-posterior and scapular "Y" (supraspinatus outlet) views were taken, the images were digitalised and evaluated using a TomoCon 3.0 Viewer programme, and the results of the two groups were statistically analysed and compared.

RESULTS

The difference between the patients with rotator cuff injury and those without it was best shown, in both groups, by significant differences in the acromion index. This was true for both the men and women. The AI values for the patients with rotator cuff injury were 0.66 and 0.65 in the model and control groups, respectively. The same AI value of 0.76 was found for uninjured rotator cuffs in both groups. The two other parameters investigated did not appear to be of any significant validity for assessment of rotator cuff tears.

DISCUSSION

The aetiology of injury to the rotator cuff has not been fully understood yet but, undoubtedly, the causes will be many. The shape of the acromion is regarded as one of the important factors. We agree with Nyffeler et al. that a lateral extension of the acromion is most often associated with rotator cuff tears and that the acromion index proposed by these authors is a good parameter to assess this morphological change.

CONCLUSIONS

A lateral extension of the acromion plays an important role in the aetiology of degenerative tears of the supraspinatus tendon. The acromion index appears to be the best instrument for assessing this morphological change.

Hematologic toxicities before and during bevacizumab chemotherapy in women with gynecologic malignancy

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Background: Many women undergoing chemotherapy for gynecologic malignancy experience hematologic toxicity that delays therapy or requires supportive intervention. In animal models anti-VEGF antibodies increase erythropoietin levels. We examined the hematologic toxicities experienced by patients prior to (PR) and during bevacizumab (BR) treatment. Methods: Retrospective, single-institution study of women with gynecologic malignancy treated at the University of North Carolina with bevacizumab as part of their therapy from January 2005 to June 2007. Data collected included prior therapies, blood product and growth factor use, and interruptions in therapy. Comparisons were made between individual patients’ hematologic parameters during the PR and BR. Median differences between hematologic nadirs were compared using Wilcoxon Signed Rank Tests. Differences in proportions were compared by Chi-Square or Fisher's Exact tests. Results: 43 patients ware identified, 40 with complete data. Most women were Caucasian (88%) and had ovarian or primary peritoneal carcinoma (77%); median (range) age was 53 (23–73). 32 (74%) received three or more different chemotherapy drugs before starting bevacizumab. The median difference in HCT nadir (31.2 vs. 33, p = 0.01) and ANC nadir (1.2 vs. 1.4, p = 0.04) during the PR and BR were significant in favor of the bevacizumab regimens. The median nadir differences for WBC (2.7 vs. 3.1, p = 0.1) and PLT (129 vs. 150, p = 0.07) were non-significant favoring BR. For HCT toxicity grades, 22 (55%) had the same grade during their PR and BR, 15 (38%) had a lower grade during BR, and 3 (7%) had a higher grade during BR (p = 0.001). Similar trends were seen for WBC (p = 0.27), ANC (p = 0.1), and PLT (p = 0.15). During BR there was a trend toward fewer patients receiving darbepoetin (66% vs. 44%, p = 0.07) and filgastrim (29% vs. 14%, p = 0.1). Conclusions: Patients receiving bevacizumab had no worse hematologic toxicity compared to their prior regimens and may have had less severe anemia. While not statistically significant, there were trends toward less growth factor use with bevacizumab. Patients who have had prior hematologic toxicity should be considered for bevacizumab. The effect of bevacizumab on hematologic toxicity should be evaluated with prospective data.

No significant financial relationships to disclose.

[Arthroscopic capsular release in frozen shoulder syndrome]

PURPOSE OF THE STUDY To evaluate the results of arthroscopic capsular release for the treatment of severe frozen shoulder syndrome. MATERIAL Between 2006 and 2008, 27 patients with severe frozen shoulder syndrome were treated by arthroscopic capsular release. The average age of the patients was 54 years (range, 34 to 75), 15 were men and 12 were women. The right shoulder was operated on more frequently (16 patients). The average pre-operative flexion was 73 degrees (range, 10 degrees to 150 degrees ) and pre-operative abduction was 56 degrees (10 degrees to 140 degrees ). The average Constant score was 35 points. METHODS With the patient in a lateral recumbent position, arthroscopic release of the joint capsule is performed with the Mitek VAPR 3 radiofrequency system, using a hook or an LPS electrode. The rotator interval, coracohumeral ligament, superior and middle glenohumeral ligaments and anterior part of the inferior glenohumeral ligament are gradually released, as well as the anterior glenohumeral joint capsule along its full width at the anterior rim of the labrum.To avoid damage to the axillary nerve, the axillary part of the joint capsule is released along the edge of the glenoid cavity. When internal rotation in abduction still remains restricted, release is extended to the posterior glenohumeral joint capsule.The procedure also involves exploration of the subacromial space and, if necessary, subacromial bursectomy or acromioplasty. Subsequently, the range of motion after release is tested and, when necessary, the remaining fibres of the joint capsule are disintegrated by careful manipulation (redress). The surgery is followed by analgesic and rehabilitation therapy. RESULTS All treated patients reported an improved range of motion. The average post-operative flexion and abduction extended to 160 degrees and 155 degrees, respectively, and 23 patients gained the motion range necessary for normal shoulder function.The average Constant score was 80.3 points and the University of California at Los Angeles (UCLA) score was 28.6 points. When using the school marking system, the average result evaluation was 1.75. All patients were satisfied with the outcome and were willing to undergo surgery on the other side if need be. No complications were recorded. DISCUSSION Therapy for frozen shoulder can be conservative or surgical. Most of the cases can be managed by correct conservative treatment. In accordance with the current literature data, we are using arthroscopic capsular release in resistant cases. This technique allows us to release contracted structures without the risk of iatrogenic injury and offers possibilities for the treatment of co-existing lesions. In the majority of patients this procedure can remedy their complaints, although the affected shoulder joint rarely remains asymptomatic. The aim of this approach is to accelerate the treatment of this disability; the long-term results are similar to those of conservative therapy. CONCLUSIONS Arthroscopic capsular release is the method of choice for the treatment of frozen shoulder syndrome in patients who have failed to respond to conservative therapy. It provides marked improvement in the range of motion and is associated with a minimum of post-operative complications. However, some patients may complain of persisting discomfort in the joint treated. Key words: frozen shoulder, arthroscopy, capsular release.

[Indications for and methods of hallux rigidus treatment]

PURPOSE OF THE STUDY

In a retrospective study, to evaluate the results of surgical treatment of hallux rigidus on the basis of clinical rating, radiographic findings and visual analogue scale (VAS).

MATERIAL

The group included 68 patients, 38 women and 30 men, treated at the orthopaedic ward of the Hospital Ceské Budejovice in the period from April 2004 to June 2007. The average age of the patients was 58.6 years (range, 34 to 79). Right and left feet were affected in 42 and 26 patients, respectively. Follow-up ranged from 3 to 30 months.

METHODS

Surgery was undertaken only after all means of conservative treatment had been used. Indications for each type of operation were based on the severity of disorder of the first metatarsophalangeal joint (MTPJ), patient's age, toe's motion restriction and physical stress on the patient's big toe. In patients with moderate degenerative MTPJ disease, in 25 feet, a Moberg dorsal wedge osteotomy of the first proximal phalanx was carried out when plantar flexion was preserved; in 12 feet, a Youngswick sagittal V osteotomy was indicated when both flexion and extension were limited and the first metatarsus was long enough; in 14 cases cheilectomy alone was used. In patients with severe arthritis, the TOEFIT-PLUS modular joint replacement of th first MTPJ was used in seven, the Brandes-Keller resection arthroplasty was carried out in six and arthrodesis of the first MTPJ was performed in four. All patients were examined at 2 and 6 weeks after surgery. Those undergoing osteotomy, arthrodesis or joint replacement were X-rayed after surgery and then at 6 weeks of follow-up.

RESULTS

The outcome of treatment was evaluated at 3 to 30 months after surgery by clinical and X-ray examination and using the VAS. The average range of MTPJ motion improved from 5 degrees to 22 degrees in dorsiflexion and from 17.5 degrees to 27 degrees in plantar flexion. Osteotomy or arthrodesis in all patients healed in correct alignment, without loosening or migration of prosthetic components. Based on the VAS (100-point scale), pain assessment was 34 preoperatively and 78 post-operatively; joint motion increased from 51 before to 82 after surgery; and ability for daily activities from 50 to 84. The overall VAS score was 42 before surgery and improved to 83 after surgery. Five patients were dissatisfied; two of them underwent repeat surgery (arthrodesis) with marked improvement and one achieved improvement by shoe modification. The rest of the group reported good or very good outcomes.

DISCUSSION

Resection arthroplasty, widely used before, is now performed only in patients exerting minimal physical activity and with severe arthritic disease, because it results in loss of the big toe's supporting function. Osteotomies by Moberg or Youngswick procedures involve the use of screws (Barouk). Stable osteosynthesis allows for early post-operative rehabilitation and weight bearing in appropriate modified shoes. Dorsal wedge osteotomy is the method most frequently used in our department to the full satisfaction of our patients.TOEFIT joint replacement is indicated in elderly patients with severe degenerative disease who wish to maintain toe motion and have adequate weight bearing of the treated foot. Emphasis is placed on good post-operative rehabilitation of the joint and on co-operation with the patient.

CONCLUSIONS

The hallux rigidus diagnosis covers several grades of degenerative disease of the first MTPJ and therefore its surgical treatment must necessarily involve more than one operative procedure. Even when an appropriate technique is used, the problems may not resolve completely. When the technique to be used is considered, good communication with the patient is necessary, because they should know the principle of treatment and an anticipated outcome of it. Our results show that the surgical treatment of hallux rigidus has good outcome if it is correctly indicated and technically well performed and completed with good post-operative care.

[Reconstruction of the anterior cruciate ligament: comparison of patellar bone-tendon-bone and hamstring tendon graft methods. Part 1. Evaluation of patients treated by the patellar bone-tendon-bone graft technique]

PURPOSE OF THE STUDY

Reconstruction of the anterior cruciate ligament (ACL) by means of a patellar bone-tendon-bone (B-T-B) graft is currently one of the most frequent arthroscopic procedures. Progress in alternative techniques, particularly the use of hamstring tendon grafts and different methods for graft anchorage, was the reason for evaluation of our group of patients. The results were assessed at 18 months of follow-up.

MATERIAL

We evaluated 137 surgically treated knees in 136 patients, 20 female and 117 male, on the basis of the Lysholm score system completed with a clinical examination of knee joint stability by Lachman's test and the pivot shift test and the ability of assuming a squatting position. We completed the evaluation with the patient's report on their satisfaction with the outcome and willingness to undergo the surgery again in the case of the other knee instability.

METHODS

We carried out surgery under general anesthesia with the extremity in flexion and application of a tourniquet. Arthroscopy is performed from the anterolateral portal and graft is harvested, though a longitudinal incision, from the middle third of the patellar ligament and with the bony blocks from the patella and tibial tubercle. The graft width is 9 to 10 mm. Tibial or femoral tunnels are drilled by means of a tibial of femoral reamer and the inserted graft is fixed with metal interference screws. Cefazolinum with low-molecular heparin is administered during surgery. Rehabilitation of the extremity on a continuous passive motion (CPM) device begins on the first day. Full weight-bearing is allowed from the sixth week.

RESULTS

The average Lysholm score of the group was 86.9. Excellent, good and satisfactory outcomes were achieved in 46.38%, 23.91% and 14.49% of the knees, respectively; 14.49% showed poor outcomes. Satisfaction with the outcome of surgery was reported by 90.5% of the patients, 75.18% complained of problems with knee-bend and pain at the donor site and scar. DISCUSSION The results of our evaluation are similar to those reported in the relevant literature. There are no differences in Lysholm scores from literature data or from the results recorded in a group of patients operated on with the use of the Rigidfix system and hamstring tendon grafts, in whom the average score was 84.3. The patients treated by the B-T-B technique, however, experience more problems at the graft harvest site, with subsequent femoropatellar complaints.

CONCLUSIONS

ACL reconstruction with a patellar B-T-B graft is a surgical technique which resolves the patient's existing complaints due to knee instability, but may also have a preventive effect. This technique is suitable for sportsmen and sportswomen. Because of frequent postoperative complaints of pain at the donor site, it is not indicated for persons with femoropatellar problems, elderly persons and those who have kneeling jobs.

[Reconstruction of the anterior cruciate ligament: comparison of patellar bone-tendon-bone and hamstring tendon graft methods. Part 2. Short-term evaluation of the hamstring tendon graft technique with use of the Rigidfix system]

PURPOSE OF THE STUDY

The high number of patients with femoropatellar complaints following ACL reconstruction with bone-tendon-bone (B-T-B) autograft led us to use and subsequently evaluate hamstring tendon grafts fixed with the Rigidfix system. In this study we present the evaluation of short-term results.

MATERIAL

We evaluated 85 patients (51 male and 34 female) at an average follow-up of 14 months. The average age of the group was 29.7 years (range, 16 to 59 years). In 46 patients we treated the right knee and in 39 patients the left knee. Fifty-five patients in this group also had an associated injury to the soft knee tissues. For reconstruction, a semitendinosus tendon graft was used in 56 knees and a semitendinosus-gracilis tendon graft in 29 patients.

METHODS

The operation was carried out with tourniquet application to the extremity in a flexed position. The tendon of the semitendinosus muscle was harvested through an oblique incision and, in some cases, when its width and length was not sufficient for graft construction, the gracilis muscle tendon was harvested too. The graft, at least 75 mm by 8 mm in size, was prepared on a graft board. After having drilled the both tunnels, the femoral Rigidfix reamer was inserted in a routine manner and protective sleeves for Rigidfix cross pins were introduced. With the extremity in semiflexion, the inserted graft was fixed to the cortical bone by absorbable cross pins on the femur and absorbable interference screws on the tibia. The postoperative treatment involved procedures as in the B-T-B technique.

RESULTS

The group was evaluated by the Lysholm score system, with an average of 84.3 scores achieved. The men showed better outcomes than women, i. e., 85.7 and 81.4, respectively. The scores in the patients with a single tendon did not differ significantly from the patients with a combined tendon (semitendinosus, 83.2 vs. semitendinosus-gracilis, 84.2), nor did they greatly differ between the patients with injury to ACL alone and those with ACL and associated soft tissue injuries (ACL, 83.9 vs. ACL+ associated injury, 85.5). Most of the patients (94 %) were satisfied with the outcome of treatment. The complications involved thrombosis of the operated lower extremity in three patients and repeat surgery for hematoma in two patients. Knee instability was found in five patients. One graft failed to restructure and incorporate, in two knee tunnels were incorrectly centered and two grafts ruptured due to trauma. Three of these patients underwent repeat surgery.

DISCUSSION

Our results, as evaluated by the Lysholm score system, were in agreement with those of other authors. We did not find any difference in knee stability between the patients treated by the hamstring tendon technique and those undergoing reconstruction with a patellar B-T-B autograft. However, the patients with hamstring tendon reconstruction reported a considerably lower number of femoropatellar problems.

CONCLUSIONS

ACL reconstruction with a hamstring tendon autograft fixed with the Rigidfix system is a suitable alternative technique to ACL reconstruction carried out with a patellar B-T-B graft. It provides equal knee stability but has significantly lower donor site morbidity. It is suitable for patients who have contraindications for the B-T-B technique and in persons practicing little or no sports.