A hybrid artificial intelligence model leverages multi-centric clinical data to improve fetal heart rate pregnancy prediction across time-lapse systems

STUDY QUESTION

Can artificial intelligence (AI) algorithms developed to assist embryologists in evaluating embryo morphokinetics be enriched with multi-centric clinical data to better predict clinical pregnancy outcome?

SUMMARY ANSWER

Training algorithms on multi-centric clinical data significantly increased AUC compared to algorithms that only analyzed the time-lapse system (TLS) videos.

WHAT IS KNOWN ALREADY

Several AI-based algorithms have been developed to predict pregnancy, most of them based only on analysis of the time-lapse recording of embryo development. It remains unclear, however, whether considering numerous clinical features can improve the predictive performances of time-lapse based embryo evaluation.

STUDY DESIGN, SIZE, DURATION

A dataset of 9986 embryos (95.60% known clinical pregnancy outcome, 32.47% frozen transfers) from 5226 patients from 14 European fertility centers (in two countries) recorded with three different TLS was used to train and validate the algorithms. A total of 31 clinical factors were collected. A separate test set (447 videos) was used to compare performances between embryologists and the algorithm.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Clinical pregnancy (defined as a pregnancy leading to a fetal heartbeat) outcome was first predicted using a 3D convolutional neural network that analyzed videos of the embryonic development up to 2 or 3 days of development (33% of the database) or up to 5 or 6 days of development (67% of the database). The output video score was then fed as input alongside clinical features to a gradient boosting algorithm that generated a second score corresponding to the hybrid model. AUC was computed across 7-fold of the validation dataset for both models. These predictions were compared to those of 13 senior embryologists made on the test dataset.

MAIN RESULTS AND THE ROLE OF CHANCE

The average AUC of the hybrid model across all 7-fold was significantly higher than that of the video model (0.727 versus 0.684, respectively, P = 0.015; Wilcoxon test). A SHapley Additive exPlanations (SHAP) analysis of the hybrid model showed that the six first most important features to predict pregnancy were morphokinetics of the embryo (video score), oocyte age, total gonadotrophin dose intake, number of embryos generated, number of oocytes retrieved, and endometrium thickness. The hybrid model was shown to be superior to embryologists with respect to different metrics, including the balanced accuracy (P ≤ 0.003; Wilcoxon test). The likelihood of pregnancy was linearly linked to the hybrid score, with increasing odds ratio (maximum P-value = 0.001), demonstrating the ranking capacity of the model. Training individual hybrid models did not improve predictive performance. A clinic hold-out experiment was conducted and resulted in AUCs ranging between 0.63 and 0.73. Performance of the hybrid model did not vary between TLS or between subgroups of embryos transferred at different days of embryonic development. The hybrid model did fare better for patients older than 35 years (P < 0.001; Mann-Whitney test), and for fresh transfers (P < 0.001; Mann-Whitney test).

LIMITATIONS, REASONS FOR CAUTION

Participant centers were located in two countries, thus limiting the generalization of our conclusion to wider subpopulations of patients. Not all clinical features were available for all embryos, thus limiting the performances of the hybrid model in some instances.

WIDER IMPLICATIONS OF THE FINDINGS

Our study suggests that considering clinical data improves pregnancy predictive performances and that there is no need to retrain algorithms at the clinic level unless they follow strikingly different practices. This study characterizes a versatile AI algorithm with similar performance on different time-lapse microscopes and on embryos transferred at different development stages. It can also help with patients of different ages and protocols used but with varying performances, presumably because the task of predicting fetal heartbeat becomes more or less hard depending on the clinical context. This AI model can be made widely available and can help embryologists in a wide range of clinical scenarios to standardize their practices.

STUDY FUNDING/COMPETING INTEREST(S)

Funding for the study was provided by ImVitro with grant funding received in part from BPIFrance (Bourse French Tech Emergence (DOS0106572/00), Paris Innovation Amorçage (DOS0132841/00), and Aide au Développement DeepTech (DOS0152872/00)). A.B.-C. is a co-owner of, and holds stocks in, ImVitro SAS. A.B.-C. and F.D.M. hold a patent for 'Devices and processes for machine learning prediction of in vitro fertilization' (EP20305914.2). A.D., N.D., M.M.F., and F.D.M. are or have been employees of ImVitro and have been granted stock options. X.P.-V. has been paid as a consultant to ImVitro and has been granted stocks options of ImVitro. L.C.-D. and C.G.-S. have undertaken paid consultancy for ImVitro SAS. The remaining authors have no conflicts to declare.

TRIAL REGISTRATION NUMBER

N/A.

Incidence and Time-to-Onset of Carbapenemase-Producing Enterobacterales (CPE) Infections in CPE Carriers: a Retrospective Cohort Study

This study aimed to assess the proportion of carbapenemase-producing Enterobacterales (CPE) infections among all infectious episodes in CPE carriers, compare the time-to-onset of CPE infections with that of other infections, assess the mortality of patients with CPE infections, and identify risk factors for CPE infections in CPE carriers. A retrospective cohort study was performed over a 10-year period in our University Hospital, and 274 CPE carriers were identified. All infectious episodes within the first 6 months following the diagnosis of CPE rectal carriage were considered. Risk factor analysis for CPE infections in CPE carriers was performed by univariate and multivariate analyses. This study revealed an incidence of 24.1% (66/274) of CPE infection within 6 months of CPE carriage diagnosis. The 28-day all-cause mortality due to CPE infections was 25.7%. CPE infections represented 52.6% (70/133) of all infectious episodes in CPE carriers in the first 6 months following CPE carriage detection, and these significantly occurred earlier than non-CPE infections, with a median time of 15 versus 51 days, respectively (P < 0.01). Based on the multivariate analysis, prior neurological disease was the only risk factor associated with CPE infections in CPE carriers. CPE infections have an early onset, accounting for a large proportion of infections in CPE carriers, and are associated with high mortality. IMPORTANCE Carbapenemase-producing Enterobacterales (CPE) infections are emerging infections and may represent a therapeutic challenge, while effective antibiotic therapy is likely to be delayed. We aimed to assess the proportion of CPE infections in CPE carriers and to identify risk factors of CPE infections among this population that could guide empirical antibiotic therapy. We showed that CPE infections are frequent in CPE carriers, have an early onset after CPE carriage diagnosis, and represent a significant proportion of all infectious episodes in CPE carriers. No significant risk factors for CPE infections could be identified. Overall, this study suggests that empirical antibiotic treatment covering CPE might be initiated in CPE carriers at least in the first month after its diagnosis and in severe infections due to the high frequency and early occurrence of CPE infections in these patients.

O-124 A new artificial intelligence (AI) system in the block: impact of clinical data on embryo selection using four different time-lapse incubators

Study question

Can AI algorithms assist embryologists in evaluating embryos from any time-lapse system (TLS) along with clinical data to better predict pregnancy outcomes and reduce time-to-pregnancy?

Summary answer

Our algorithm (Embryoly) significantly increases accuracy in predicting clinical pregnancy by 26.9% amongst embryos deemed of fair and good quality when clinical data is included.

What is known already

Embryologists routinely use defined morpho-kinetic criteria to decide which embryo to transfer, and yet, many embryos deemed of good quality fail to lead to a pregnancy. Thus, AI algorithms to assist embryologists in objectively selecting the most promising embryos are in demand. To date, several reports indicate that AI algorithms are capable of predicting pregnancy clinical outcomes but to the best of our knowledge they only consider visual data (or together with a small set of clinical features) from individual TLI systems to generate their predictions. 

Study design, size, duration

A dataset of 6790 embryos (97.82% known clinical pregnancy outcome, 31.47% frozen transfers) from 2519 patients from 11 European fertility centers recorded with 4 different TLS (GERI-Merck, Embryoscope & EmbryoscopePlus-Vitrolife and MIRI-Esco) was used to train and validate Embryoly. Nine out of 93 clinical factors were identified as being the most predictive, including woman age, woman and man BMI and AMH levels. Performances were evaluated on a separate test dataset (393 videos).

Participants/materials, setting, methods

Clinical pregnancy outcome was predicted using a 3D convolutional neural network that analyzed up to 5 days of embryo development. The output score was further analyzed considering the clinical features to generate a second clinical score. Both predictions were compared to those of 10 senior embryologists made on the same test dataset (with and without clinical features). Embryo quality was assessed as: poor, fair, good. Unless specified otherwise, McNemar test was used for statistical tests.

Main results and the role of chance

Overall accuracy of embryologists in predicting clinical pregnancy  based on videos alone was 57.25% (CI 95% : 52.34% - 62.16%) compared to 60.56% (CI 95% : 55.71% - 65.41%) for Embryoly (p = 0.35).

When videos were analyzed together with the clinical factors, overall accuracy of embryologists was significantly lower than Embryoly (60.05% [CI 95% : 55.19% - 64.91%] vs 68.19% [CI 95% : 63.57% - 72.82%], p-value=0.015, respectively). Clinical factors significantly increased our accuracy by 7.63% (p-value=0.030). More specifically, Embryoly algorithms fared better in terms of detecting false positives (31.30% vs 19.34%) compared to embryologists, with a specificity of 74.4% vs. 58.6%, respectively.

If we consider only embryos of fair and good quality (71.50% of our test dataset) Embryoly’s accuracy was 13.52% higher than that of embryologists. This translates into AI having an even better ability to detect false positives for embryos that could be seen as good candidates for transfer (20.28% false positives against 42.70% for the embryologists). Embryoly performs differently across selected TLS when analyzing videos alone, but not when clinical data was also considered (chi2 test, p &lt; 0.001 and 0.5, respectively). Further work will investigate these discrepancies across TLS.

Limitations, reasons for caution

As of today, Embryoly’s accuracy in predicting the outcome of poor-quality embryos is not different to that of embryologists (79.46% vs 84.96%; p-value=0.19). We are improving this by exposing Embryoly to more “poor quality” embryos, so as to also identify poor quality embryos with unexpected potential for implantation.

Wider implications of the findings

Our pioneering findings support the use of AI for a standardized and couple-centered care in clinical embryology, integrating male and female factors with embryo development analyses from multiple TLS. Our approach has the potential to cost-effectively reduce time to pregnancy and is another step toward a personalized embryo transfer strategy.

Trial registration number

Not applicable

P-308 Spontaneous reports of menstrual cycle disorders after mRNA Covid-19 vaccine

Study question

Does the mRNA Covid-19 vaccine have an influence on the ovulatory process and menstrual disorders?

Summary answer

Menstrual disorders were more frequently reported in women aged 25 to 45 years, mainly amenorrhea and increased cycle length, and were often not severe.

What is known already

Menstrual disorders can be due to several factors, including stress, especially during a pandemic or sometimes during a vaccination. However, the SARS-CoV-2 spike protein is able to interact with the human ACE2 receptor, which is widely expressed in the ovaries, uterus, vagina, and hypothalamic pituitary axis. Accumulating evidence now suggests that 2019-nCoV/ACE2 may interfere with the female reproductive functions, leading to menstrual disorder. The role of this spike protein is also to trigger an immune response, used in particular for mRNA vaccines. The aim of this study is to describe the side effects on menstrual cycles after mRNA Covid-19 vaccine.

Study design, size, duration

This is a descriptive analysis of adverse events affecting the menstrual cycle reported to a regional pharmacovigilance center between May 2021 and January 2022. A case-by-case review was performed to collect variables characterizing the patient and the reactions.

Participants/materials, setting, methods

Patients upper 11 years and under 60 years with mRNA Covid-19 vaccine suspected, were enrolled. Medical Dictionary for Drug Regulatory Activities (MedDRA) was used to identify cases of menstrual disorders. Reactions related to the following System Organ Classes from MedDRA were extracted: amenorrhea, disorder of menstrual cycle, dysmenorrhea, long menstrual cycle, menorrhea, menometrorrhagia, metrorrhagia. Seriousness was defined, according to the WHO, as the occurrence of death, lifethreatening, hospitalisation, requirement of consultation.

Main results and the role of chance

Side effects with mRNA Covid-19 vaccine concerned women in 67.8% (N = 1306) of cases, between 12 and 59 years old.5.1% (N = 67) were related to the menstrual cycle. Serious cases 53.7% (N = 36) were no more frequent than in the whole women 50.1% (N = 654). Menstrual disorders were more represented in the 25-45 age group 64.2% (N = 43) vs 12-24 age group 14.9% (N = 10) and over 45 age group 20.9% (N = 14) p = 0.001. Menstrual disorders not recovered at the time of reporting accounted for 38.9% (N = 26). For the all studied population, amenorrhea or increased cycle length were more frequent 53.8% (n = 36) vs increased duration of menstruation or menorrhagia 26.8 % (N = 18) or increased frequency of menstruation metrorrhagia/menometrorrhagia 22.4% (N = 13) p < 0.001. Long cycles or amenorrhea were most represented in the 12-24 age group 90% (N = 9) p < 0.0001 and 25-45 age group 62.7% (N = 27) p < 0.1 vs dysmenorrhea , menorrhea, metrorrhagia, menometrorrhagia. The difference was not significative in women over 45 years old 35.7% (N = 5). Finally amenorrhea and long cycles were less often reported with severity 22.2% (N = 8) than other menstrual side effect (dysmenorrhea , menorrhea, menometrorrhagia, metrorrhagia) 45.2% (N = 14), p < 0.1.

Limitations, reasons for caution

The most important limitation relies on the spontaneous reporting. Underreporting is estimated to about 90%. It was probably not the case for side effect due to the Covid-19 vaccination. Furthermore, serious cases are more likely to be reported than mild or minor cases resulting in a possible reporting bias.

Wider implications of the findings

The cases reported reflect the experience of clinicians who were asked about cycle disturbances after covid-19 vaccination (V. Male BMJ 2021).We observed more frequent changes in cycle length but not in menstrual length, as reported by A. Edelman (Obstet Gynecol 2022). Fertility may be punctually affected by Covid-19 vaccination.

Trial registration number

Analyzing anonymous data, being retrospective and non-interventional, the approval of an Ethics committee was not necessary according to the Good Clinical Practice in pharmacovigilance.

O-078 Predictive factors of autologous Oocyte Post-warming Survival rate

Study question

Are there any clinical or paraclinical predictive factors of Oocyte Post-warming Survival (OPS) rate?

Summary answer

Woman age, Body mass Index, estradiol level on triggering day and estradiol/oocyte ratio are critical predicting factors that should be considered before performing oocyte vitrification.

What is known already

Since the development and the validation of oocyte vitrification, we vitrify oocytes in different medical situations for patients who benefit ICSI. Although the OPS rate in our centre is satisfying, occasionally, it happens to be lower. OPS is dependent on quality of oocyte as demonstrated by the difference of OPS in oocyte donation/autologous cycles. The present study questions the existence of clinical and paraclinical factors predicting in OPS. In order to tackle this issue, we have assessed several parameters related to the woman and to her response to hormonal treatment known to influence oocyte quality in relation to OPS

Study design, size, duration

A retrospective observational study of 786 autologous oocyte vitrification cycles was performed from October 2011 to July 2018 in 5 situations: cycles where only a part of mature collected oocytes were vitrified [1] Partial oocyte vitrification program(n = 605), [2] Patients opposed to embryo cryopreservation(n = 2) and oocyte freeze-all cycles for the following reasons [3] Uncontrolled Ovarian hyperstimulation( = 89), [4] Unfavorable uterine environment/receptivity(n = 71) and [5] Absence of spermatozoa(n = 20). 1175 warming cycles were analyzed to identify predictive factors for OPS.

Participants/materials, setting, methods

Oocytes were vitrified/warmed using Kitazato media and system. The ratio of OPS survival was measured between the number of intact oocytes and the number of warmed oocytes. The factors assessed as potential predictors of OPS were: woman age, body mass Index (BMI), Estradiol level on triggering day (E2), E2/ number of recovered oocytes (EOR), number of recovered oocytes and maturity ratio (number of mature oocytes/number of recovered oocytes). Statistics were performed using SPSS software.

Main results and the role of chance

A total of 1175 studied warming cycles were performed and 5421 oocytes were warmed with a mean OPS rate of 84,6% (±22,6). OPS rates were comparable in all situations: [1] 3084/3688 (83,6%), [2] 6/6 (100%), [3] 931/1121 (83,1%), [4] 393/458 (85,8%), [5] 125/148 (84,5%). The mean woman age (33,2 years±4,9 vs 33,1 years ±4,3), mean woman BMI (23,1 kg/m2±3,9 vs 22,9 kg/m2±4,2), mean E2 (2587,7pg/ml±1140,5 vs 2513,2pg/ml±1098,7), mean EOR (207,5pg/ml±119,4 vs 196,0pg/ml ±119,4), mean number of total recovered oocytes (15,0±6,8 vs 14,7±6,8), mean maturity ratio (85,4%±13,7 vs 86,0%±14,2) showed no statistical difference in women with reduced OPS (≤85%) as compared to women with standard OPS (&gt;85%). Subgroups analyses revealed significant higher occurrence of reduced OPS in advanced age women (&gt;40years) (OR = 2,4; [95%CI:1,3-4,4] p &lt; 0,05) as compared to women of other age categories: &lt; 30years (OR = 0,5; [95%CI:0,2-0,9]), 30-35years (OR = 0,4; [95%CI:0,2-0,7]), 36-40years (OR = 0,2; [95%CI: 0,3-0,5]). The combination of advanced age with abnormal BMI ( &lt; 18,5 or &gt; 24,9kg/m2: OR = 7,3[95%CI:1,6-34,0] p &lt; 0,01), or elevated E2 (&gt;3000pg/ml: OR = 3,3[95%CI:1,0-11,0] p &lt; 0,05) or atypical EOR ( &lt; 140 or &gt; 250pg/ml: OR = 3,7[1,1-12,2] p &lt; 0,05) amplified the risk of reduced OPS. Women with abnormal BMI combined with elevated E2 (OR = 2,1[95%CI:1,1-3,9] p &lt; 0,05) or atypical EOR (OR = 1,6[95%CI:1,0-2.6] p &lt; 0,05) were also at higher risk of reduced OPS.

Limitations, reasons for caution

Oocyte vitrification is a manual technique that depends on the skill of the operator. Inter-operator variability was not taken into account in our statistical analyses neither were data regarding ovarian stimulation protocols nor were infertility etiologies.

Wider implications of the findings

This work enabled to identify patient or treatment related factors that highly influence the outcome of oocyte vitrification/warming cycles. Our findings will likely help refining criteria for the selection of candidate patients for oocyte vitrification or to cancel bad prognosis cycles.

Trial registration number

NA

Revisional Notes on the Cloud Forest Butterfly Genus Oxeoschistus Butler in Central America (Lepidoptera: Nymphalidae: Satyrinae)

So far, six species of Oxeoschistus Butler, including its junior synonym Dioriste Thieme, were listed from Central America, with five of them from Costa Rica alone, which appears to represent the highest regional diversity of this Neotropical montane butterfly genus. Our research based on field work, morphological studies and barcode analysis proved that one record is a misunderstanding perpetuated in scientific literature for over a century: Oxeoschistus cothonides Grose-Smith is identified here as an individual form of the female of O. cothon Salvin. The presence of Oxeoschistus tauropolis (Westwood) in Costa Rica, subject to some controversy, is confirmed, and a new local subspecies is described from Costa Rica, O. tauropolis mitsuko Pyrcz & Nakamura n. ssp. Specific status of O. euriphyle Butler is reinstated based on morphological and molecular data. A new subspecies O. hilara lempira Pyrcz n. ssp. is described from Honduras. O. puerta submaculatus Butler is reported for the first time from the Darién region on the Panama-Colombia border. Species relationships are preliminarily evaluated based on COI data concluding, among others, that O. hilara and O. euriphyle are less closely related than previously assumed. Altitudinal and distributional data are revised, and ecological and behavioural information of all the species of Central American Oxeoschistus is provided.

Factors associated with treatment failure after advice from infectious disease specialists

OBJECTIVE

Risk factors associated with treatment failure after the infectious disease specialist's (IDS) advice remain unknown. We aimed to identify these risk factors.

METHODS

We included patients hospitalized in our tertiary care center who consulted an infectious disease specialist between January 2013 and April 2015. Treatment failure was defined by a composite criterion: signs of sepsis beyond Day 3, ICU admission, or death. Treatment success was defined by the patient's sustained clinical improvement.

RESULTS

A total of 240 IDS recommendations were made. Diagnosis was changed for 64 patients (26.7%) and 50 patients experienced treatment failure after the IDS advice. In multivariate analysis, compliance with the IDS advice was associated with a higher rate of success (OR=0.09, 95%CI [0.01-0.67]). Variables associated with treatment failure in the multivariate analysis were Charlson comorbidity score at admission (OR=1.24, 95%CI [1.03-1.50]), a history of infection or colonization with multidrug-resistant bacteria (OR=8.27, 95%CI [1.37-49.80]), and deterioration of the patient's status three days after the IDS advice (OR=12.50, 95%CI [3.16-49.46]).

CONCLUSION

Reassessing IDS recommendations could be interesting for specific patients to further adapt and improve them.

Considerations on the Taxonomy of the Genus Arhuaco Adams and Bernard 1977, and its Relationships with the Genus Pronophila Doubleday [1849] (Nymphalidae, Satyrinae)

Arhuaco Adams & Bernard (1977) is one of the least known genera of Neotropical Satyrinae. It comprises two species and presents an unusual disjunct distribution, with A. ica Adams & Bernard (1977), endemic to the isolated Colombian Sierra Nevada de Santa Marta, and A. dryadina (Schaus 1913) found in the mountains of Costa Rica and Panama. Here, the female of A. dryadina is described, and a new generic diagnosis is presented. Affinities with other genera of the subtribe Pronophilina, in particular the potential closest relatives, such as Pronophila Doubleday (1849), are investigated based on morphological, molecular, ecological, and behavioral data. Results from molecular and morphological sources are incongruent. Molecular data indicate that Arhuaco is paraphyletic, with A. dryadina segregating within the Pronophila clade. Morphological data, by contrast, indicate a closer affinity between the two species currently placed in Arhuaco, favoring the monophyly of the genus, and show no consistent synapomorphies for Arhuaco + Pronophila. A vicariance biogeographical scenario is evaluated.

[Satisfaction survey on the use of autologous oocyte vitrification in Assisted Reproductive Technologies]

OBJECTIVES

We organized a survey for in-vitro fertilization couples who beneficiated on self-preservation of part of the oocyte cohort. The main objective was to measure couples' satisfaction. Secondary objectives were; to identify how patients had been informed; to verify that the use of the ART technique met their expectations, and how they felt about oocyte or embryo freezing.

METHODS

The data were collected by a questionnaire sent electronically to couples who had undergone partial vitrification of the oocyte cohort and at least one warming cycle. The questionnaire consisted of 2 components; one for the women and another one for their husband.

RESULTS

Eighty-eight women and 62 men responded to the survey respectively, representing 50.86% and 35.84% of the targeted patients. They were satisfied with a 90% rate, men and women combined. The information we give in the center is heard by couples and is part of the trust in the medical staff. Men are more worried than women about the risks of stimulation or ovarian pick-up and are not displeased to be called upon for sperm recovery for every attempt at oocyte warming. The ambiguity of the answers on the representation of the embryo confirms what is already described, but is independent of the acceptance of freezing whether it is oocyte or embryo.

CONCLUSION

In the same way as evaluating the results, the evaluation of patient satisfaction is useful for the implementation of therapeutic strategies and care pathways.

[Between "pragmatic" interpretation and "disturbing" understanding: Embryonic cryopreservation for IVF patients]

OBJECTIVES

The aim of this article is to question the feeling of IVF patients towards embryonic cryopreservation, in order to understand their potential reluctance to freeze embryos and their difficulties to consider the fate of their frozen embryos once their parental project completed.

METHODS

Twenty-seven semi-directive interviews with homologous IVF patients were conducted. These persons were followed in two fertility centres in Marseille.

RESULTS

If all the patients interviewed have accepted embryonic cryopreservation or have accepted on principle, a majority have an ambivalent attitude towards this technique. If some share the "pragmatic" vision of professionals (embryologists, technicians and gynaecologists), they are numerous to worry about a possible deterioration of embryonic quality, or again about a disrupted order of generation. Finally, it appears that patients do not anticipate the possible fate of their frozen embryos if they are uninscribed from their parental project.

CONCLUSIONS

Patients are mainly ambivalent towards embryonic cryopreservation. They prioritize different rationality depending on the situations and issues they are dealing with.

Uncovered Diversity of a Predominantly Andean Butterfly Clade in the Brazilian Atlantic Forest: a Revision of the Genus Praepedaliodes Forster (Lepidoptera: Nymphalidae, Satyrinae, Satyrini)

The genus Praepedaliodes Forster, 1964, the only representative of the mega-diverse mostly Andean Pedaliodes complex lineage in the Brazilian Atlantic Forest, is revised. Prior to this study, four species were known, P. phanias (Hewitson, 1862), P. granulata (Butler, 1868), P. amussis (Thieme, 1905) and P. exul (Thieme, 1905). Here, a further six are described, all from SE Brazil, expanding to 10 the number of species in this genus. Lectotypes are designated for P. phanias, P. granulata and P. amussis. The genus is most diverse in the Serra da Mantiqueira (São Paulo, Rio de Janeiro, Minas Gerais) and in the Serra Geral (Paraná, Santa Catarina) with seven species occurring in both ranges. Praepedaliodes phanias is the most widespread species and the only one found in the western part of the Atlantic Forest; only this species and P. duartei Dias, Dolibaina & Pyrcz n. sp. occurring to near sea level. Other species, P. zaccae Dolibaina, Dias & Pyrcz n. sp., P. francinii Freitas & Pyrcz n. sp., P. sequeirae Pyrcz, Dias & Dolbaina n. sp., P. landryi Pyrcz & Freitas n. sp. and P. pawlaki Pyrcz & Boyer n. sp. are strictly montane and the highest species richness is reached at 1400-1800 m. One species, P. sequeirae n. sp., is a narrow endemic found only at timberline in the Agulhas Negras massif above 2300 m. Immature stages are described for two species, P. phanias and P. landryi n. sp. Molecular data (barcode region of cytochrome oxidase, subunit I) and adult morphology, including male and female genitalia, support the genus as monophyletic, belonging to a predominantly Andean clade of the Pedaliodes Butler, 1867 complex. Morphological evidences, in particular female genitalia comparative analysis, indicate the genera Physcopedaliodes Forster, 1964 and Panyapedaliodes Forster, 1964 as possibly the closest relatives to Praepedaliodes. Molecular data are inconclusive in this respect.

Arthroscopically assisted reduction of acute acromioclavicular joint dislocation using a single double-button device: Medium-term clinical and radiological outcomes

INTRODUCTION

Double-button devices for endoscopic management of acute acromioclavicular joint dislocation (ACJD) provide satisfactory short-term functional and radiological results. However, little exists in the literature regarding the long- and medium-term results of these implants, especially regarding the evolution of the acromioclavicular joint (ACJ).

HYPOTHESIS

Satisfactory and steady long- and medium-term outcomes can be achieved in patients with acute ACJD undergoing endoscopically assisted ACJ repair using a single double-button device.

MATERIAL AND METHOD

A retrospective single-center study was conducted in patients with acute Rockwood III and IV ACJD treated endoscopically with a single double-button device from October 2008 to October 2010, allowing a minimum 5-year follow-up. Functional evaluation used Constant and Quick-DASH scores. Clinical evidence of dislocation recurrence was combined with bilateral Zanca views to assess coracoclavicular distance. Acromioclavicular osteoarthritis was evaluated on the Paxinos test and Zanca views.

RESULTS

Nineteen of the 25 operated patients were seen at a mean 76.9±8.5 months' follow-up. Mean age was 34.4±8.3 years. Mean Constant and Quick-DASH scores were 96.2±5.1 and 0.9±1.6 points, respectively. Four patients had a recurrence of their initial dislocation, 3 of whom had positive Paxinos test, whereas the 15 patients without recurrence had a negative test (p=0.004). Five patients had radiological evidence of ACJ osteoarthritis: all 4 patients with recurrence and 1 without (p=0.001).

CONCLUSION

Long- and medium-term radioclinical outcome of endoscopically assisted management of acute ACJD using a single double-button device seems to be satisfactory and steady over time. Recurrence of the initial dislocation appears to be related to onset of degenerative ACJ arthropathy.

LEVEL OF EVIDENCE

Therapeutic type IV-Retrospective case series.

Tunnel positioning assessment after anterior cruciate ligament reconstruction at 12months: Comparison between 3D CT and 3D MRI. A pilot study

BACKGROUND

Tunnel positioning assessment is a major issue after anterior cruciate ligament (ACL) reconstruction surgery. Historically, it used plain X-ray and, more recently, CT with 3D reconstruction. MRI is a reliable method of assessing ACL graft integrity and postoperative complications. To our knowledge, there have been no studies of efficacy in tunnel positioning assessment. The aim of this study was to assess the efficacy of 3D MRI in assessing femoral and tibial tunnel positioning after ACL reconstruction. The hypothesis was that 3D MRI sequences with reconstruction are as accurate as 3D CT for tunnel positioning assessment in ACL reconstruction.

METHODS

Twenty-two patients who underwent an arthroscopic ACL reconstruction using hamstring graft were included in a prospective study. All patients were examined on 3D CT and 3D MRI at 12months post-surgery. Tunnel positioning was assessed on both imaging systems by a musculoskeletal radiologist and an orthopedic surgeon specialized in knee arthroscopy, both blind to all clinical data.

RESULTS

No statistically significant difference was found between 3D CT and 3D MRI on coronal and sagittal reconstructions. For coronal assessment of tibial tunnel orifice, sagittal assessment of tibial tunnel orifice and sagittal assessment of femoral tunnel orifice, P-values ranged from 0.37 to 0.99, 0.051 to 0.64 and 0.19 to 0.59, respectively. For tibial and femoral tunnel angulation, P-values were respectively 0.52 and 0.29.

CONCLUSION

3D MRI is a reliable method to assess femoral and tibia tunnel positioning in ACL reconstruction, compared to 3D CT as gold standard. Indeed, in our opinion 3D MRI could in the future replace CT for ACL reconstruction assessment, concerning not only the meniscus and ligaments but also tunnel position.

LEVEL OF EVIDENCE

Level 3; comparative prospective study.

Single-server queues with impatient customers

We consider a single-server queueing system in which a customer gives up whenever his waiting time is larger than a random threshold, his patience time. In the case of aGI/GI/1 queue with i.i.d. patience times, we establish the extensions of the classicalGI/GI/1 formulae concerning the stability condition and the relation between actual and virtual waiting-time distribution functions. We also prove that these last two distribution functions coincide in the case of a Poisson input process and determine their common law.

[Female age - related fertility decline: Far from the myth of the "selfish working-girl" and the "right to have a child"]

OBJECTIVES

To study the social dimension of age-related female infertility through an analysis of three key themes: the personal life histories of infertile women over 40 years of age; representations of age and the desire to become pregnant after age 40; opinions of French legislations framing Assisted Reproductive Technologies, age limits, egg donation, and egg freezing for non-medical reasons.

METHODS

This qualitative sociological study was based on semi-structured interviews with infertile women over age 40 going through fertility treatments. The interviews contained three parts: personal and relationship histories; experiences related to age; opinions related to French legislation.

RESULTS

Twenty-three interviews were conducted; each lasting between 90 to 120minutes. Far from having similar life histories, the women interviewed had very different backgrounds leading to their desire for a pregnancy after 40 years of age. From the beginning of their fertility treatments, they perceived a "race against the clock". This feeling of urgency accompanied their experiences and was related to the desire to not be too old for their future child. The women interviewed were mainly in favor of loosening French bioethical laws in order to avoid the need to travel abroad to pursue fertility treatments.

CONCLUSION

The profiles studied attest to a growing gap between biological and biographical temporalities, as well as an inability of women to reduce their desire for a child. Faced with this disparity, egg donation and egg freezing were seen as practical solutions.

Complication rates and types of failure after arthroscopic acute acromioclavicular dislocation fixation. Prospective multicenter study of 116 cases

AIMS

To report and analyze both the surgical and radiographic complications associated with anatomic coracoclavicular (CC) ligament procedures and to evaluate the effect of these complications on patient outcomes.

PATIENTS AND METHODS

From July 2012 to July 2013, 116 primary anatomic CC ligament procedures (all arthroscopic endobutton fixations) were performed in 14 different centers. Demographic, surgical, subjective, and radiographic data were prospectively analyzed in 14 centers with a minimum follow-up of 12 months.

RESULTS

This series included 96 men and 20 women, mean age 37 years old, with a mean delay to surgery of 10 days. No intraoperative complications were reported. There were 11 complications due to hardware failure resulting in a loss of reduction, 1 coracoid fracture, 7 cases of adhesive capsulitis, 2 local infections, 5 cases of hardware pain. There were significant differences in outcomes between patients who did and did not develop complications: mean CS=71 vs. 93, (P<0.0001). All the parameters of the CS were statistically affected (P<0.0001). Forty-eight patients had persistent dislocation>150% on an AP X-ray which affected the pain and activity CS (P=0.023 and P=0.044). No preoperative predictive factors were identified. These patients could not return to the same level of sports activities due to persistent pain.

DISCUSSION

Anatomic procedures to treat AC joint dislocation using CC ligament reconstruction resulted in an overall complication rate of 22.4% and influenced the return to sports. Good to excellent outcomes were reported in patients without complications.

CLINICAL SERIES

Level of evidence 4.

Prognostic factors to succeed in surgical treatment of chronic acromioclavicular dislocations

INTRODUCTION

Treatment of chronic acromioclavicular joint dislocation (ACJD) remains a poorly known and controversial subject. Given the many surgical options, it is not always easy to determine which steps are indispensable.

METHODS

This article reports a multicenter prospective study. The clinical and radiological follow-up involved a comparative analysis of the preoperative and postoperative data at 1 year, including pain (visual analogue scale), subjective functional incapacity (QuickDASH), and the objective Constant score, as well as a comparative analysis of vertical and horizontal movements measured on simple x-rays.

RESULTS

Based on a series of 140 operated ACJDs, we included 24 chronic ACJDs. The mean time to surgery was 46 weeks (range, 1 month to 4 years). The patients' mean age was 41 years, with a majority of males (75%), 72% of whom participated in recreational sports. Professionally, 40% of the subjects had jobs involving manual labor. We noted 40% grade III, 24% grade IV, and 36% grade V injury according to the Rockwood classification. In 92% of cases, coracoclavicular stabilization was provided by a double button implant, reinforced with a biological graft in 88% of the cases. In 29%, millimeters to centimeters of the distal clavicle were resected and acromioclavicular stabilization was associated in 54%. We observed complications in 33% of the cases. At 1 year postoperative, 21 patients underwent clinical and radiological follow-up (87.5%). Only 35% of the patients were satisfied or very satisfied, whereas 100% of them would recommend the operation. Full-time work was resumed in 91% of the cases and all sports could be resumed in 86%. The pre- and postoperative values at 1 year changed as follows: the mean Constant score improved from 61 to 87 (p=0.00002); the subjective QuickDASH score decreased from 41 to 9 (p=0.00002); and radiologically significant reduction of the initial displacement was observed in the vertical plane (p<10(-3)) and the horizontal plane (p=0.022).

CONCLUSION

In this study, the favorable prognostic factors found were: time to surgery less than 3 months (p=0.02), associated acromioclavicular stabilization, and postoperative immobilization with a sling extended to 6 weeks. However, resection of the distal clavicle did not influence the final result.

LEVEL OF PROOF

Level II prospective non-randomized comparative study.

Is coracoclavicular stabilisation alone sufficient for the endoscopic treatment of severe acromioclavicular joint dislocation (Rockwood types III, IV, and V)?

BACKGROUND

The primary objective was to evaluate correlations linking anatomical to functional outcomes after endoscopically assisted repair of acute acromioclavicular joint dislocation (ACJD).

HYPOTHESIS

Combined acromioclavicular and coracoclavicular stabilisation improves radiological outcomes compared to coracoclavicular stabilisation alone.

MATERIAL AND METHODS

A prospective multicentre study was performed. Clinical outcome measures were pain intensity on a visual analogue scale (VAS), subjective functional impairment (QuickDASH score), and Constant's score. Anatomical outcomes were assessed on standard radiographs (anteroposterior view of the acromioclavicular girdle and bilateral axillary views) obtained preoperatively and postoperatively and on postoperative dynamic radiographs taken as described by Tauber et al.

RESULTS

Of 116 patients with acute ACJD included in the study, 48% had type III, 30% type IV, and 22% type V ACJD according to the Rockwood classification. Coracoclavicular stabilisation was achieved using a double endobutton in 93% of patients, and concomitant acromioclavicular stabilisation was performed in 50% of patients. The objective functional outcome was good, with an unweighted Constant's score ≥ 85/100 and a subjective QuickDASH functional disability score ≤ 10 in 75% of patients. The radiographic analysis showed significant improvements from the preoperative to the 1-year postoperative values in the vertical plane (decrease in the coracoclavicular ratio from 214 to 128%, p=10(-6)) and in the horizontal plane (decrease in posterior displacement from 4 to 0mm, p=5×10(-5)). The anatomical outcome correlated significantly with the functional outcome (absolute R value=0.19 and p=0.045). We found no statistically significant differences across the various types of constructs used. Intra-operative control of the acromioclavicular joint did not improve the result. Implantation of a biological graft significantly improved both the anatomical outcome in the vertical plane (p=0.04) and acromioclavicular stabilisation in the horizontal plane (p=0.02). The coracoclavicular ratio on the anteroposterior radiograph was adversely affected by a longer time from injury to surgery (p=0.02) and by a higher body mass index (BMI) (p=0.006). High BMI also had a negative effect on the difference in the distance separating the anterior edge of the acromion from the anterior edge of the clavicle between the injured and uninjured sides, as assessed on the axillary views (p=0.009).

CONCLUSION

This study demonstrates that acute ACJD requires stabilisation in both planes, i.e., at the coracoclavicular junction and at the acromioclavicular joint. Coracoclavicular stabilisation alone is not sufficient, regardless of the type of implant used. Implantation of a biological graft should be considered when the time from injury to surgery is longer than 10days. The weight of the upper limb should be taken into account, with 6weeks of immobilisation to unload the construct in patients who have high BMI values.

LEVEL OF EVIDENCE

II, prospective non-randomised comparative study.

Arthroscopic treatment of acute acromioclavicular dislocations using a double button device: Clinical and MRI results

INTRODUCTION

Arthroscopic treatment of acute grade 3 and 4 acromioclavicular dislocation is controversial, due to the risk of recurrence and of postoperative reduction defect. The purpose of the present study was to investigate whether the healing of the acromioclavicular (AC) and coracoclavicular (CC) ligaments and the accurate 3D positioning parameters of the AC joint using MRI were correlated with satisfactory functional outcome.

MATERIAL

Thirty-nine patients were enrolled from 2009 to 2011 and managed arthroscopically by CC lacing using a double-button device.

METHODS

Clinical assessment included the Shoulder and Hand (QuickDash) score, Constant-Murley score and visual analog scale (VAS) for residual pain. Time and rate to return to work and return to sport were assessed according to type of sport and work. Postoperative complications were recorded. Radiological examination consisted of anteroposterior clavicle and lateral axillary radiographs. AC ligament healing and 3D joint congruency were assessed on MRI and correlated to the clinical results.

RESULTS

Mean patient age was 35.7 years (range, 20-55). Mean follow-up was 42.3±10.6 months (range, 24-60). At final follow-up, mean QuickDash score, Constant score and VAS were respectively 1.7±4 (range, 0-11), 94.7±7.3 (range, 82-100) and 0.5±1.4 (range, 0-2). Thirty-five (90%) patients were able to resume work, including heavy manual labor, and sport. Radiology found accurate 3D joint congruency in 34 patients (87%) and CC and AC ligament healing in 36 (93%). Complications included reduction loss at 6 weeks in 3 patients, requiring surgical stabilization. Satisfactory functional results were associated with accurate AC joint congruency in the coronal and axial planes (P<0.05) and good AC and CC ligament healing (P<0.04). An initial 25% reduction defect in the coronal plane was not associated with poor functional results (P=0.07).

CONCLUSION

Arthroscopic treatment by CC lacing satisfactorily restored ligament and joint anatomy in the present series. These satisfactory anatomic results correlated with good clinical outcome encourage continuing with this technique.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Initial disc structural preservation in type A1 and A3 thoracolumbar fractures

PURPOSE

Despite a sizable amount of literature, the optimal management of thoracolumbar fractures remains controversial and many authors assume the existence of disc lesions in Magerl type A fractures. The purpose of the study was to assess the intervertebral discs in these fractures at the time of trauma. The hypothesis was that there was no change in shape and signal intensity of the discs initially.

METHODS

Fifty-one patients diagnosed with 87 types A1 and A3 thoracolumbar fractures were enrolled in a prospective study. MRI analysis involved evaluation of disc signal, height and morphological modifications according to Oner's classification.

RESULTS

No signal intensity modification was identified on MRI. Disc morphology was either normal or altered with creeping of discal tissue in the vertebral endplate depression. Overall, 98% of the discs were either type 1 or type 3. Mean disc height on MRI was 1.03 ± 0.36 initially.

CONCLUSIONS

In this study, MRI showed that no loss of height occurred in discs adjacent to fractured vertebra and that there was no major alteration of the disc in terms of signal intensity and morphology. Therefore, the intervertebral disc should not be removed in Magerl type A fractures.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Morphokinetics analysis of embryos derived from vitrified/warmed oocytes

PURPOSE

Oocyte vitrification is a worldwide used technique that has proved its worth. Although it was shown not to alter oocyte integrity, a recent study concluded that it may affect oocyte embryo development. As the morphology and kinetics of embryos derived from sibling fresh and vitrified oocytes have not been described previously, the present study evaluates cleavage rate, blastomeres size, fragmentation rate, and blastocyst formation in vitrified/warmed oocyte derived embryos (VODE) as compared with sibling fresh oocytes derived embryos (FODE).

METHODS

This investigation included 90 infertility cases displaying large cohort of mature oocytes at pick up, divided into 2 groups after denudation. A part of oocytes underwent ICSI while others were vitrified. Oocyte warming cycles were performed when no pregnancy was achieved using fresh eggs. Zygote to blastocyst development was recorded prospectively in an image database up to day 5.

RESULTS

VODE did not show major difference as compared with FODE in terms of cleavage rate, number of blastomeres, fragmentation rate, and blastomeres size. Furthermore, percentage of morulae at day 4 and blastocysts at day 5 are not affected by oocyte vitrification.

CONCLUSION

Although our results show that embryo development is not altered by oocyte vitrification, offspring follow-up is essential to exclude any adverse developmental effect of the technique.

Sperm global DNA methylation level: association with semen parameters and genome integrity

Sperm DNA methylation abnormalities have been detected in oligozoospermic men. However, the association between sperm DNA methylation defects, sperm parameters and sperm DNA, and chromatin integrity remains poorly understood. This study was designed to clarify this issue. We recruited a cohort of 92 men (62 normozoospermic and 30 oligoasthenozoospermic) presenting for infertility evaluation during a 1-year period. Sperm global DNA methylation was evaluated by an ELISA-like method, DNA fragmentation was evaluated by flow cytometry-based terminal transferase dUTP nick end-labeling (TUNEL) assay (reported as DNA fragmentation index or DFI), and sperm denaturation was evaluated by aniline blue staining (reported as sperm denaturation index or SDI, a marker of chromatin compaction). We found a significant positive association between sperm global DNA methylation level and conventional sperm parameters (sperm concentration and motility), supported by the results of methylation analysis on H19-DMR. We also identified significant inverse relationships between sperm global DNA methylation, and, both DFI and SDI. However, sperm global DNA methylation level was not related to sperm vitality or morphology. Our findings suggest that global sperm DNA methylation levels are related to conventional sperm parameters, as well as, sperm chromatin and DNA integrity.

Arthroscopic double-row cuff repair with suture-bridging: a structural and functional comparison of two techniques

PURPOSE

The aim of this study was to compare the functional and structural outcomes of 2 techniques for double-row, suture-bridging cuff repair.

METHODS

A consecutive series of 73 patients who underwent arthroscopic, double-row, suture-bridge primary rotator cuff repair of full-thickness supraspinatus tear were evaluated. Thirty-eight shoulders were repaired by the arthroscopic, tied, suture-bridging technique (group A), and 35 shoulders by knot-less bridging with suture tape material (group B). Constant scores, pain, range of motion, strength, and complications were measured after a minimum follow-up period of 12 months post-operatively. Structural integrity of the repairs was evaluated systematically by either magnetic resonance imaging or computed tomography arthrography.

RESULTS

Median follow-up after surgery was 29 (23-32) months in group A, and 21 (12-23) months in group B. Mean pain relief, range of motion, strength, and constant score improved significantly in both groups. No statistical differences were found between groups in the post-operative period. According to control imaging, the re-tear rate trended to be higher in group A (23.4 %) than in group B (17.1 %), although not significantly.

CONCLUSION

Both bridging repair techniques achieved successful functional outcomes. In terms of structural outcome, the knot-less tape-bridging construct showed a lower but not significant re-tear rate. Longer follow-up is needed to confirm these results and to evaluate potential differences between the two techniques.

LEVEL OF EVIDENCE

A prospective, non-randomized, comparative study, Level III.

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.

Evaluating variability and uncertainty in radiological impact assessment using SYMBIOSE

SYMBIOSE is a modelling platform that accounts for variability and uncertainty in radiological impact assessments, when simulating the environmental fate of radionuclides and assessing doses to human populations. The default database of SYMBIOSE is partly based on parameter values that are summarized within International Atomic Energy Agency (IAEA) documents. To characterize uncertainty on the transfer parameters, 331 Probability Distribution Functions (PDFs) were defined from the summary statistics provided within the IAEA documents (i.e. sample size, minimal and maximum values, arithmetic and geometric means, standard and geometric standard deviations) and are made available as spreadsheet files. The methods used to derive the PDFs without complete data sets, but merely the summary statistics, are presented. Then, a simple case-study illustrates the use of the database in a second-order Monte Carlo calculation, separating parametric uncertainty and inter-individual variability.

Current state of anterior cruciate ligament registers

PURPOSE

The purpose of this work was to report the main characteristics and results of all active anterior cruciate ligament (ACL) reconstruction registers along with the differences between them.

METHODS

We systematically searched on Google and Medline via PubMed to identify ACL registers. National or regional registers were included if they were active and took into account ACL reconstructions. The main results and characteristics, namely the number of inclusions, exhaustivity, data collection methods and results dissemination methods were determined. The collected information was then submitted to each register for validation.

RESULTS

Four registers (3 national, 1 regional) were identified that routinely included every ACL reconstruction procedure. Register data were collected either through dedicated websites or on paper forms. All the registers used the same two outcome measures, namely the revision rate and a subjective patient score (KOOS score). Register results were made available through scientific publications or annual reports. The main differences between registers were in the graft choice and presence of associated meniscus and cartilage injuries.

CONCLUSIONS

Although there are only a few ACL reconstruction-specific registers, their scientific contribution is undeniable thanks to the quality of the collected data and the organization and collaboration between registers. Their impact on health care and science should grow in the future.

Results of angular-stable locked intramedullary nails in the treatment of distal tibia fractures

INTRODUCTION

Intramedullary nailing in distal tibial fracture is controversial because of a lack of stability. The present study sought to assess radiological and clinical results for a new "angular-stable" locking system in difficult indications for intramedullary nailing.

MATERIAL AND METHOD

A prospective study recruited 41 patients (41 tibias) with distal tibial fracture consecutively managed using angular-stable locked intramedullary nails. Radiologic assessment comprised AP and lateral lower-limb views, taken postoperatively and through to last follow-up. The mean distance was measured between fracture and joint line. Fusion, with or without malunion, primary reduction defect, non-union and secondary displacement were recorded, as were all complications.

RESULTS

Mean follow-up was 18 ± 5 months; 3 patients were lost to follow-up. Mean fracture distance from the joint line was 63 ± 25 mm. Fusion was achieved within 3 months in 29 cases (76%); delayed fusion in 7 patients (18%) required secondary dynamization at a mean 3 months, with favorable evolution. Revision surgery was required in 2 cases: 1 for secondary displacement exceeding 10°, and 1 for non-union at 7 months. Other complications mainly comprised 4 malunions of less than 10° due to primary reduction defect.

CONCLUSION

Angular-stable locked lower-limb intramedullary nailing provided a very satisfactory fusion rate, with few complications. It is, however, a demanding procedure, especially as regards fracture reduction and nail positioning in the distal fragment.

PROSPECTIVE COHORT STUDY

level IV.

Normal live birth after vitrified/warmed oocytes intracytoplasmic sperm injection with immotile spermatozoa in a patient with Kartagener's syndrome

The present article is a report on two cases of male Kartagener's syndrome enrolled in intraconjugal IVF programme due to akinetospermia. Viable spermatozoa were selected using a hypo-osmotic swelling test (HOST) and pentoxifylline activation and subsequently microinjected into vitrified/warmed oocytes. The treatment enabled one of these two couples to achieve a pregnancy and to give birth to a healthy baby girl.

Satisfactory long-term MRI after autologous chondrocyte implantation at the knee

PURPOSE

Autologous chondrocyte implantation (ACI) to address isolated condylar lesions is supposed to limit degenerative deterioration in neutrally aligned knees. Here, we report long-term results of the first-generation ACI technique with periosteal flap.

METHODS

Twelve patients, 29 years old on average, were included on the basis of pre-operative MRI selection of lesions >2 cm2. Cartilage carrots were harvested arthroscopically, then cultured and finally re-implanted within a mean time interval of 12 weeks. Ten-year MRI results were analysed according to a semi-quantitative scale, along with functional assessment based on International Knee Documentation Committee score, Lysholm et al. score and the Tegner et al. activity scale.

RESULTS

One patient secondarily required valgus tibial osteotomy with mosaic plasty. Another incurred graft hypertrophy that necessitated arthroscopic peeling. MRI showed that cartilage repair filled more than 50% of the initial defect in 9 patients. Standard radiographs revealed slight narrowing of the joint line. Overall, functional scores improved durably by 50%, although activity level decreased substantially.

CONCLUSION

ACI contained degenerative changes within moderate stages while maintaining durable functional improvement. However, in the absence of controls, it was difficult to differentiate between these findings and the spontaneous evolution of non-treated lesions.

LEVEL OF EVIDENCE

Case series, Level IV.

Acute isolated volar dislocation of the distal radio-ulnar joint: case report and literature review

The acute isolated distal radio-ulnar (DRU) dislocation is a rare traumatic pathology and no consensus concerning its management has been established. This case report describes an acute isolated volar DRU dislocation in a 26-year-old patient. The authors propose, based on this case and after an exhaustive review of the literature, a non-operative management for these isolated and non-complicated dislocations.

Description of a New Species of the Andean Butterfly Genus Forsterinaria Gray (Lepidoptera: Nymphalidae) with Considerations on an Apparently New Structure in Male Genitalia

The butterfly genus Forsterinaria Gray is the only strictly montane representative of the diverse Neotropical subtribe Euptychiina (Nymphalidae, Satyrinae), with 24 described species. Recent research in some of the most isolated and highly diverse Andean regions, such as central Peru, show that its total species richness is still underestimated. An example is the new species described here, Forsterinaria emo n. sp., which is particularly interesting because of an unusual structure discovered in its male genitalia which consists of a bunch of bristle-like processes, composing a fringe-like formation on the dorsum of the tegumen. No similar, homologous structure was found in any congener, nor indeed, in any species of diurnal Lepidoptera. Scanning electron microscope studies revealed that the microstructure of the processes resembles a membrane lining the tegumen. Its function is unknown but two hypotheses are discussed based on a comparative study with other genital structures of butterflies. We argue that it may help stabilizing the partners in the process of mating or it may serve as a 'mating plug', preventing the female from multiple copulations.

Efficacy of second intra-tendinous platelet-rich-plasma injection in case of incomplete response of the first injection: three-year follow up experience

PURPOSE

Tendinopathy is a frequent and ubiquitous disease developing early disorganized collagen fibers with neo-angiogenesis on histology. Peritendinous injection of corticosteroid is the commonly accepted strategy despite the absence of inflammation in tendinopathy. Platelet-rich plasma (PRP) might be a useful strategy to rapidly accelerate healing of the tendinopathy but there is a lack ok knowledge about the amount of PRP to be injected and the opportunity of a second injection in case of partial pain relief. The aim of our study was to assess the potential therapeutic effect of early second PRP intra-tendinous to treat persistent painful tendon tear and tendinosis in a long-term follow-up by ultrasonography (US) and clinical data in case of incomplete efficiency of first PRP treatment injection.

MATERIALS AND METHODS

Twenty-four consecutive patients referred for US treatment of tendon tear or tendinosis (T+) were included retrospectively. All had previously received a single intra-tendinous injection of PRP under US guidance (PRPT+) and benefited of a second PRP injection (PRPT2+) under US guidance in order to treat persistent painful. US and clinical data were collected for each anatomic compartment for upper and lower limbs before treatment (D0), 6 weeks (W6) after first treatment, 6 weeks (W12) after second treatment and until 32-month follow-up. We used Mac Nemar test and regression model to compare US and clinical data.

RESULTS

The residual US size of lesions was not significantly lower at W12 after PRPT2+ as compared to W6 (P=0.86 in upper and P=NS in lower member) independently of age (P=0.22), gender (P=0.97) and kind of tendinopathy (P=NS). Quick dash test values and WOMAC values were not significantly lower in PRPT+ at W12 (average: 21.5 months) as compared to W6 (P>0.66) and long-term follow-up (P>0.75) independently of age (P=0.39), gender (P=0.63) and kind of tendinopathy (P=NS). Nevertheless, comparison between D0 and long-term follow-up (LTF) functionnal score was statistically significant (p<0.001 in upper and lower member).

CONCLUSION

Our study suggests that second early intra-tendinous PRP injection under US guidance does not permit rapid decrease of tendinopathy area in US, nor does it quickly improve clinical pain and functional data in case of incomplete efficiency of first PRP injection. However, in long-term follow-up, patients improved their ability to mobilize pathologic tendons.

Removal of infected cemented hinge knee prostheses using extended femoral and tibial osteotomies: six cases

Extended femoral and tibial osteotomies were performed to remove infected cemented hinged knee prostheses in five patients (six knees) with a mean age of 72 years (44-85) and a history of multiple knee surgeries. A tibial osteotomy was used to mobilise the distal quadriceps insertion and to release the tibial extension. The femoral component was extracted by downward traction and its cement mantle was cleared through an anterior osteotomy (n=4) or via the distal approach (n=2). The bone flaps were re-approximated by wire cerclage over articulating acrylic spacers. Mean time to re-implantation of a new knee prosthesis was 11 months (6-24). Revision prostheses with cement fixation restricted to the epiphyseal-metaphyseal region were used. Infection recurred in two cases at 16 and 4 months after the prosthetic re-implantation, and was managed by joint fusion for one and irrigation/lavage for the other, respectively. At last follow-up after a mean of 53 months, the mean Parker score was 4 ± 2, the mean IKS knee score was 66 ± 25 (28-93), and the mean IKS function score was 7 ± 16 (0-40). This technique facilitates the removal of infected cemented components of hinge prostheses and of the cement mantle, most notably in the absence of loosening, without compromising re-implantation of a new knee prosthesis.

Efficacy of zolpidem in insomnia

The efficacy of zolpidem, a non benzodiazepine hypnotic agent with a short elimination half life, was reviewed, analysing more than 50 international clinical trials published since 1986. The hypnotic activity of zolpidem has been explored in different patient populations including normal volunteers, general practice outpatients and psychiatric out- or in-patients with varying sleep disorders; both transient and chronic. Assessment methods used have included objective and subjective measures of hypnotic efficacy for different treatment durations, with results confirming that 10 mg is superior to placebo. Zolpidem was shown to be superior in most trials on sleep parameters such as total sleep time, sleep onset latency and nocturnal awakenings, but total REM sleep and REM latency were usually unmodified. Zolpidem maintained normal sleep physiology as demonstrated by the preservation of slow wave stages and no, or minimal, effects on sleep architecture after abrupt discontinuation. Consequently, 10 mg is the recommended dose for the short-term treatment of insomnia in the non-elderly; in elderly patients 5 mg has been shown to be effective at inducing sleep whilst giving an optimum safety profile.

Does fibrin sealant use in total knee replacement reduce transfusion rates? A non-randomised comparative study

BACKGROUND

Studies assessing fibrin sealants use during total knee replacement (TKR) have produced inconsistent results. We evaluated fibrin sealant therapy in TKR procedures performed without tourniquet and without postoperative drains.

HYPOTHESIS

Use of a fibrin sealant during TKR decreases calculated total blood loss, thereby diminishing blood transfusion requirements and costs.

PATIENTS AND METHODS

We studied 62 patients with primary knee osteoarthritis who underwent TKR by the same surgeon between September 2009 and December 2010. Fibrin sealant was used only in the last 31 patients, who were compared to the first 31 patients regarding calculated total blood loss, blood transfusion rate, and mean number of red-blood-cell units used per patient. Costs were compared in the two groups.

RESULTS

In the control group, mean total blood loss calculated using the method of Gross was 1.3±0.6 L, 48% of patients required blood transfusions, and the mean number of units per patient was 0.9±1. In the fibrin-sealant group, 29% of patients required blood transfusions and the mean number of units was 0.6±0.9. The between-group differences in favour of the fibrin-sealant group were not statistically significant. In each group, compared with patients not requiring blood transfusions, patients needing transfusions had significantly lower starting preoperative haemoglobin values and a significantly greater positive difference between the calculated total blood loss and the maximum allowable blood loss. In the test group, the cost of the 31 units of fibrin sealant was 9743€ and the cost reduction due to using 11 fewer red-blood-cell units was only 3484€. Hospital stay was not significantly shorter in any of the two groups.

DISCUSSION

Blood transfusion minimisation during TKR should rely chiefly on correcting preoperative anaemia and optimizing transfusion decisions based on the difference between the total blood loss and the maximum allowable blood loss. Fibrin sealant did not significantly diminish transfusion requirements in our study. Randomised studies in larger patient populations are needed. The cost of fibrin sealant may exceed the expected cost savings in relation with decreased blood transfusion requirements.

LEVEL OF EVIDENCE

Level III (before-after therapeutic study).

Treatment of complex fractures of the distal radius: a prospective randomised comparison of external fixation 'versus' locked volar plating

The traditional treatment of severely impacted fractures of the distal radius involves bridging external fixation and maintaining reduction by applying continuous traction. The recent technique using fixed-angle screws within volar plates is reported restore the radial length and the articular profile whilst avoiding joint distraction. It is also believed to produce better and quicker clinical results. To test these claims, we carried out a randomised controlled comparison of the efficiency of external fixation (EF) 'versus' open reduction and internal fixation (ORIF) in treating severely impacted fractures of the distal radius. A total of 39 patients were treated with EF, eventually associated with percutaneous pinning, whereas 36 underwent ORIF with a locked volar plate. There was no significant difference in the two groups with regard to changes in the ulnar variance. Articular reduction was poor in two patients in the EF group with residual step-offs exceeding 2mm; another patient of the EF group suffered a secondary loss of reduction, healing with a severe articular malunion (>2mm). By contrast, articular reduction was satisfactory in all the patients of the ORIF group. The clinical results on the Green and O'Brien rating were significantly better in the ORIF group than in the EF group (p<0.01 at 6 weeks, p<0.05 at 6 months). Nevertheless, open reduction and volar plating did not yield better subjective results than EF. However, although not statistically significant, patients treated by ORIF seemed to resume their usual activities quicker than those treated with EF, suggesting that this technique may be adapted to a greater extent in the case of active, young individuals.

Total knee replacement following intra-articular malunion

INTRODUCTION

There is a lack of data on the management of osteoarthritis of the knee associated with intra-articular malunion. The present study sought to analyze and report results of total knee replacement (TKR) in this indication, including complications and technical specificities.

HYPOTHESIS

TKR for osteoarthritis of the knee associated with intra-articular malunion entails an elevated risk of complication, with impaired functional results.

OBJECTIVES

To test this hypothesis in a retrospective series of 74 cases of osteoarthritis of the knee associated with intra-articular malunion.

PATIENTS AND METHODS

A multicenter retrospective series collated the records of 74 patients (mean age, 63 ± 14 years) who underwent TKR for post-traumatic osteoarthritis of the knee associated with intra-articular malunion between 2000 and 2008. Mean trauma-to-TKR interval was 21.8 ± 19 years (range 1 to 56 years). Patients were assessed clinically and radiologically at last follow-up, using the Knee Society score as modified by the Western France Orthopedic Society (Société orthopédique de l'Ouest).

RESULTS

At a mean overall follow-up of 4 ± 3 years (range 1 to 9 years), mean knee score improved from 25 ± 12 to 85 ± 7 (P<0.001) and mean functional score from 52 ± 13 to 66 ± 10 (P=0.004). Mean flexion gain was 6°: mean preoperative flexion, 104° ± 28° (10° to 150°), vs. 110° ± 19° (20° to 130°) at follow-up. Nineteen patients (26%) had complications, 13 of which were severe and liable to affect the functional result: three extensor system avulsions, four infections, five cases of stiffness and one of instability.

DISCUSSION AND CONCLUSIONS

The present results highlight an elevated rate of complications, with poorer clinical results than those found with osteoarthritis of the knee secondary to constitutional deformity. The initial trauma, with associated hemarthrosis, and sometimes iterative surgery to reduce and fix the initial fracture, induce fibrosis and synovial attachments, leading to stiffness and hindering exposure. The patient should be informed, and warned that postoperative flexion amplitude may be improved but is bound to remain limited, especially in case of initial stiffness.

LEVEL OF EVIDENCE

Level IV: non-comparative retrospective study.