Clinical and structural outcomes of nonoperative management of massive rotator cuff tears

BACKGROUND

The natural history of massive rotator cuff tears is not well known. The purpose of this study was to determine the clinical and structural mid-term outcomes in a series of nonoperatively managed massive rotator cuff tears.

METHODS

Nineteen consecutive patients (twelve men and seven women; average age, sixty-four years) with a massive rotator cuff tear, documented by magnetic resonance imaging, were identified retrospectively. There were six complete tears of two rotator cuff tendons and thirteen complete tears of three rotator cuff tendons. All patients were managed exclusively with nonoperative means. Nonoperative management was chosen when a patient had low functional demands and relatively few symptoms and/or if he or she refused to have surgery. For the purpose of this study, patients were examined clinically and with standard radiographs and magnetic resonance imaging.

RESULTS

After a mean duration of follow-up of forty-eight months, the mean relative Constant score was 83% and the mean subjective shoulder value was 68%. The score for pain averaged 11.5 points on a 0 to 15-point visual analogue scale in which 15 points represented no pain. The active range of motion did not change over time. Forward flexion and abduction averaged 136 degrees; external rotation, 39 degrees; and internal rotation, 66 degrees. Glenohumeral osteoarthritis progressed (p = 0.014), the acromiohumeral distance decreased (p = 0.005), the size of the tendon tear increased (p = 0.003), and fatty infiltration increased by approximately one stage in all three muscles (p = 0.001). Patients with a three-tendon tear showed more progression of osteoarthritis (p = 0.01) than did patients with a two-tendon tear. Four of the eight rotator cuff tears that were graded as reparable at the time of the diagnosis became irreparable at the time of final follow-up.

CONCLUSIONS

Patients with a nonoperatively managed, moderately symptomatic massive rotator cuff tear can maintain satisfactory shoulder function for at least four years despite significant progression of degenerative structural joint changes. There is a risk of a reparable tear progressing to an irreparable tear within four years.

The Coraliance study: non-compliant behavior. Results after a 6-month follow-up of patients on oral contraceptives

OBJECTIVES

This follow-up study was planned to establish the frequency with which women miss their contraceptive pill, and to observe their behavior when they forget it. In those women who changed from a continuous cycle to an interrupted type of cycle, or vice versa, the study also aimed to evaluate the impact of this change on the pattern of omission of pills.

METHODS

The longitudinal, prospective cohort study included healthy women of child-bearing age for whom a change of pill was being prescribed by their gynecologist. Data were recorded during the 6 months preceding inclusion in the study, and for the 6 months of follow-up; the women were asked to complete a diary in which they recorded the number and exact times of pill omission, and their behavior at each omission.

RESULTS

A total of 617 gynecologists included 3316 women into the study; of these, a group of 2418 (73%) revisited the same gynecologist at follow-up. The groups who either visited the same or a different gynecologist were similar with respect to age, oral contraception type, omission type and frequency. A large non-compliance rate and women's difficulties in maintaining safe contraception after missing a pill were observed in the group with follow-up. Women were never risk-free when they missed a pill; they turned to numerous sources for discordant or conflicting information; 15% of 'not-forgetting' women at the pre-inclusion cycle recorded at least one omission at the last cycle of the 6-month follow-up period. Omission fluctuations during the observational period make it difficult to designate 'forgetful' or 'non-forgetful' classes of women. Administration of the pill in a continuous cycle, and probably 'study' and 'auto-questionnaire' effects, contributed to an improvement in compliance. In the group taking the continuous cycle pill, the omission number slightly decreased, particularly on the first day and week of the cycle, irrespective of the initial cycle type.

CONCLUSIONS

The importance of the phenomenon of non-compliance rate is confirmed as well as women's difficulties in knowing how to maintain contraceptive safety. The continuous cycle regimen is likely to improve women's compliance during the critical period of the cycle.

Oral contraception: patterns of non-compliance. The Coraliance study

OBJECTIVES

To determine the number of times women failed to take their oral contraceptive medication and their behavior in response to a missed pill. Another objective was to determine the potential benefit provided by a continuously administered oral contraceptive compared with an oral contraceptive involving a pill-free interval during a 6-month period.

METHODS

Healthy women were enrolled in a cohort study; their contraceptive practices were followed by their gynecologists. Data were collected at inclusion using cross-sectional method with retrospective data collection for the previous 6 months and, more specifically, on their previous or their current menstrual cycle. Women on the pill were asked to specify the number of times and precise time at which they missed one or more pills and what they did in response to missing a pill.

RESULTS

A total of 617 gynecologists enrolled and followed 3316 patients from six geographic areas throughout France. The mean age of patients was 30 years. Duration of oral contraceptive use was 8 years. During their previous cycle, 23% of women (n = 737) missed a pill at least once. Among women on the pill involving a treatment-free interval, 42% of instances of missing a pill occurred during the first week following the treatment-free interval. In response to missing a pill, patients read the product information leaflet (39%) or asked someone's advice (28%), mainly their gynecologist (63%) or their family physician (18%). Almost one-third of women did not take any specific measures.

CONCLUSIONS

Patients on a discontinuous oral contraceptive regimen tended to miss a pill during the first week of treatment. Prescription of a continuous regimen without a treatment-free interval may improve compliance.

[The experience of menstruation and its disorders in 603 women using contraception in 1999]

AIM

An epidemiological survey completed during the first quarter of 1999 assesses the frequency of menstrual disorders as well as their effects on the lives of women using contraception.

MATERIALS AND METHODS

The results presented involve a sample of 603 women, with 405 using the pill and 198 fitted with an IUD. The average age of onset of menstruation in the sampled population was 12.8 years. Although most women declared that they felt no anxiety at the time, over one-third of the women surveyed explained that they felt a certain hesitancy in discussing the topic. Even today, certain feelings, such as shame or pride, are still evoked in the interviews. Although over half believe that it is normal to menstruate, the process is nevertheless considered "somewhat bothersome" by certain women who also refer to "purification." Traditional cultural perspectives remain a strong influence. Menstrual disorders predating the initial use of contraception were reported in 150 women (occasional intermenstrual bleeding, 130 cases; other anomalies excluding metrorrhagia, 27 cases). Even if most of the women believe these problems to be inevitable, they also claim to be relatively troubled by these disorders, which often involve a considerable degree of discomfort. Such disorders are significantly more frequent in the "IUD" group, as well as in women who claim a very early onset of menstruation and those who consider explanations provided by the physician as "insufficient."

CONCLUSION

The difference creates a certain fear with respect to any social or individual norm that may have been internalized. Thus the information presented in this study may provide ways and means to better understand women in general and our women patients in particular.

A visually impaired savant artist: interacting perceptual and memory representations

In this single case study, paintings by a visually impaired and cognitively handicapped savant artist are evaluated. He paints his pictures exclusively from memory, either after having looked at a natural scene through binoculars, or after studying landscape photographs in brochures, catalogues, and books. The paintings are compared with the models from which they were derived, and the resulting generative changes are accounted for by an interaction between impaired visual input and memory transformations.

[In defense of intra-uterine inseminations]

Intrauterine insemination (IUI) has been used for treatment of infertility for many years with discouraging results (8.3% in the analysis of Dorangeon and Quereux). A new approach of IUI, using ovarian stimulation, ovulation monitoring and sperm preparation has significantly improved the results. The obtained pregnancy rate (15 to 25%) are now comparable to those reported with IVF or GIFT. Therefore IUI should be offered to patients with patent tubes prior to their referral for the more invasive procedure FIV or GIFT.

HLA-DR antigens in multiple sclerosis: two-dimensional gel electrophoresis

Fifty to eighty percent of white patients with clinically definite MS express the DR2 antigen. In patients and normal controls who possess the DR2 antigens, analysis of the polymorphic light chain by two-dimensional polyacrylamide gel electrophoresis revealed no structural differences.