The association of smoking to cardiovascular death differs according to age and sex following myocardial infarction complicated by heart failure or left ventricular dysfunction

Background

Smoking is associated with higher morbidity and mortality following myocardial infarction (MI), but reports of the impact on cardiovascular (CV) death in aged and female patients experiencing MI complicated with left ventricular dysfunction or overt heart failure are limited.

Methods

In an individual patient data meta-analysis of high-risk MI patients, the association of smoking to CV death was investigated. Cox proportional hazard models exploring smoking status and risk according to age and sex were performed to study the relationship of smoking to independently adjudicated CV death endpoints.

Results

28,771 patients from the CAPRICORN, EPHESUS, OPTIMAAL and VALIANT trials were assessed. 18,325 (64%) reported smoking (9185 (32%) current and 9051 (32%) past), 2662 (9%) were above ≥80 years and 8607 (30%) were women. Overall, using non-smokers as referent, the association of smoking to CV mortality was neutral (HR=1.07, 0.98 to 1.16, p=0.12 for active smoking and HR=1.10, 1.02 to 1.18, p=0.01 for past smoking). The associations for active and past smokers with outcome, adjusted for age and sex in the overall study sample and according to different age and sex categories, are presented in figure 1. In analyses that included interaction terms, the association for active smokers depended on age and sex; the risk of CV mortality was weakened in women (interaction HR=0.81, 0.69 to 0.96, p=0.01) and older age (interaction HR per 10 years increase=0.88, 0,82 to 0.95, p=0.001). In contrast, the association to CV death for past smokers was not modified by sex or age (p=0.86 and p=0.17 respectively).

Conclusions

The association of smoking to CV death differed according to age and sex in MI complicated with left ventricular dysfunction or overt heart failure. Significant association of active and/or past smoking with increased risk of CV death was mainly observed in the 60–69 years category. The underlying reasons of the lack of association of smoking with outcome in older patients in this specific context should be explored further in future studies.

Figure 1

Funding Acknowledgement

Type of funding source: None

Complete soft-tissue clubfoot release with and without internal fixation

Two groups of patients who underwent soft-tissue release of clubfoot are compared. In group I, internal fixation (two Kirschner wires) was used for 6 weeks to retain correction of clubfoot. In group II, no internal fixation was used. Patients from the two groups were operated on by one surgeon using the same procedure. Because there was no statistically significant difference in functional result between the two treatment groups (P = .08; Mann-Whitney Test), the authors recommend avoiding internal fixation (with all the associated problems) in cases of uncomplicated clubfoot, and encourage early removal of the cast and frequent manipulations to prevent stiffness of the joints and reduce the recurrence rate.

Effect of magnesium sulphate infusion on ex vivo platelet aggregation in swine

The effect of magnesium sulphate infusion on ex vivo platelet aggregation in 11 female Yorkshire swine was observed using platelet-rich plasma and different agonists (ADP 5 mM; ADP 10 mM and collagen 1 mg/ml). Infusion of 1 g MgSO4 over 1 h produced a significant decrease in platelet aggregability. A dose-dependent effect of different ADP concentrations on platelet aggregation was noticed. Platelet inhibition was most consistent when using ADP 5 mM. We estimate this concentration of agonist as optimal in swine. The swine model is a good choice for investigation of in vivo platelet activation, especially with regard to cardiovascular research. We conclude that there is an inhibitory effect of supplemental magnesium on ex vivo platelet aggregation in swine with initial normomagnesaemia.

Postpoliomyelitis syndrome problems of knee function: a review

Postpoliomyelitis syndrome describes a ¿new¿ weakness, unrelated to any other neurological or medical disorder. It appears 10 to 15 years or more after recovery from the initial paralysis. This new weakness interferes with activities of daily living. The management of postpoliomyelitis syndrome may include orthotics, special exercises, a change in their lifestyle, or a combination of these regimens. This article is especially concerned with knee joint stabilization in various deformities that are weakened by the postpoliomyelitis syndrome.

Hip dislocation caused by infantile myofibromatosis

An unusual case of newborn unilateral dislocated hip is presented. The condition was refractory to conservative treatment. The cause was found during surgery at the age of 1 month: the adductors were replaced by myofibromatosis. The tumor was excised and at follow-up a normal hip was noted.

Ilizarov technique in treatment of congenital hand anomalies. Two case reports

An Ilizarov apparatus was successfully used in the treatment of a six-year-old child with a radially deviated hand caused by congenital pseudoarthrosis of the distal radius after previous traditional surgery failed. The limb length was restored, the pseudoarthrosis healed, and the deviated hand corrected. A second child, five years old, with Poland's syndrome, had a 90 degrees flexion contracture of the wrist that was treated with the Ilizarov apparatus. The flexion contracture was gradually corrected. It seems that the Ilizarov apparatus can be an important tool in the treatment of complex limb deformities.

Fractional lengthening of the flexor tendons in clubfoot surgery

Massive scarring of the Z-lengthened flexor digitorum and flexor hallucis longus is a constant finding in clubfoot surgery. A method of fractional lengthening of the tendons is described. This method has been proven effective in preventing this complication.

[Pelvic lytic lesion, and the need to suspect osteoporosis-related fractures]

Insufficiency fractures of the pelvis may be overlooked as a cause of hip or groin pain. These fractures occur in the elderly, usually those with pronounced osteopenia of the pelvis. Predisposing factors include corticosteroids, local irradiation and postmenopausal osteoporosis. These fractures are difficult to detect clinically and plain radiographs and other studies may be misleading, delaying diagnosis and treatment. A 65-year-old woman had left groin and hip pain for 2 months with no history of trauma. Plain radiographs showed lytic lesions in the left pubic rami. Bone scan revealed increased uptake in that region, suggesting metastatic bone disease. Computed tomography and magnetic resonance imaging demonstrated fractures in the left superior and inferior pubic rami, with callus formation with no involvement of soft tissues. Quantitative computed tomography indicated low calcium concentration, below fracture threshold. The diagnosis of insufficiency fractures of the pelvis was confirmed by the favorable clinical and radiographic outcome. It is therefore important to be familiar with the appearance and location of these fractures.

Cost-Minimization analysis for cardiac revascularization in 12 healthcare systems based on the EuroCMR/SPINS registries

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): EuroCMR registry (Life Sciences GE Healthcare, Medtronic Inc., Minneapolis MN, USA; Novartis International AG, Basel, Switzerland; Siemens Healthcare, Erlangen, Germany), SPINS registry (Siemens Healthineers, Erlangen, Germany; Bayer AG, Leverkusen, Germany)

Background

Coronary artery disease (CAD) is a major contributor to the public health burden. Stress perfusion cardiac magnetic resonance (CMR) has an excellent accuracy to detect CAD, but data on its cost effectiveness are scarce.

Purpose

To compare the costs of a CMR-guided strategy vs 2 invasive strategies based on 2 large international CMR registries.

Methods

In the EuroCMR registry (n = 3’647, 59 centers, 18 countries) and the US-based SPINS registry (n = 2’349, 13 centers, 11 states) costs were calculated for 12 healthcare systems (8 Europe, US, 2 Latin America, 1 Asia). They included diagnostic examinations (CMR, X-ray coronarography (CXA) with/without FFR), revascularizations, and complications during a 1-year follow-up. Endpoints in both registries were all-cause and cardiovascular (CV) death, sudden cardiac death (SCD), aborted SCD, non-fatal myocardial infarction (nf-MI), and stroke. 7 sub-group analyses covered low to high-risk cohorts. Patients with ischemia-positive CMR underwent CXA and revascularization (percuteneous and surgical intervention) at the treating physician’s discretion (=CMR + CXA-strategy). In the hypothetical invasive CXA + FFR-strategy, costs were calculated for an initial CXA and an FFR in vessels with ≥50% stenoses assuming the same proportion of revascularizations/complications as in the CMR + CXA-strategy and FFR positive rates as given in the literature. In the CXA-only strategy, costs included CXA and revascularizations of ≥50% stenoses.

Results

Revascularizations were performed in 8.0% and 6.2% (p < 0.01) of SPINS and EuroCMR patients, respectively. Consistent cost savings were observed for the CMR + CXA strategy vs CXA + FFR in all 12 healthcare systems ranging from 42 ± 20% and 52 ± 15% in the low-risk EuroCMR and SPINS patients with atypical chest pain (CV-death and nf-MI 0.4-0.7%/y), respectively, to 31 ± 16% in the high-risk SPINS patients (CV-death and nf-MI 3.2%/y) with known CAD (p < 0.0001 vs 0 in all groups, Fig 1/2). Cost savings were even higher vs CXA-only with 63 ± 11%, 73 ± 6%, and 52 ± 9%, respectively (p < 0.0001 vs 0 in all groups, Fig 2).

Conclusions

In 12 healthcare systems, a CMR + CXA-strategy yielded consistent moderate to high cost savings compared to a hypothetical CXA + FFR-strategy over the entire spectrum of risk. Cost savings were consistently high vs a CXA-only strategy for all risk groups.

Figure 1: SPINS refers to the subgroup of patients with suspected CAD (n = 1’530), EuroCMR (= suspected CAD; n = 3’647). EuroCMR vs SPINS ns. Countries per region are listed in alphabetical order.

Figure 2: Top: CMR + CXA vs CXA + FFR: ANOVA: overall p = 0.0017, * vs EuroCMR typ angina: p < 0.005 (Scheffe post-hoc testing). Bottom: CMR + CXA vs CXA-only: ANOVA overall p < 0.0001, * vs SPINS with CAD and vs EuroCMR typ A: p < 0.0001; † vs SPINS with CAD: p < 0.03; ‡ vs EuroCMR typ A: p < 0.0001; § vs SPINS with CAD: p < 0.002; ║ vs EuroCMR typ: p < 0.002 (Scheffe post-hoc tesing)

Pediatric update #12. A simplified method for percutaneous epiphysiodesis

Nine patients have undergone percutaneous epiphysiodesis using a 4.5-mm drill and image intensification fluoroscopy. The minimal surgical exposure resulted in minimal postoperative discomfort, excellent cosmesis, and complete closure of the physis in all patients in three to five months. No complications were encountered. The procedure is easy to perform and reliable.

Re-do clubfoot: surgical approach and long-term results

Images

Neck metaphyseal angle guidance in proximal femoral varus osteotomy

An angle within the femoral arch is defined, and its line is described in selecting the osteotomy site and the position of the fixation device in performing a femoral varus osteotomy. This neck metaphyseal angle was measured with varying degrees of rotation on seven pediatric femurs; it was also studied on 283 randomly selected hip radiographs. The angle varied 25-40 degrees in 90% of the patients and was not age related. The angle is stable within 5 degrees as long as the landmarks, base of the great trochanter, and medial metaphysis of the femoral neck are definable (0-30 degrees of rotation).

Efficacy and safety of dronedarone vs placebo in patients with atrial fibrillation or atrial flutter across a spectrum of renal function: post hoc analyses of the EURIDIS-ADONIS trials

Background/Introduction

The use of antiarrhythmic drugs in patients with chronic kidney disease (CKD) is complex because impaired renal clearance can cause increased drug levels, and risk of intolerance or adverse events. Since CKD commonly co-occurs with atrial fibrillation/atrial flutter (AF/AFL), it is important to establish efficacy and safety for such drugs when used in AF/AFL patients with CKD.

Purpose

To evaluate the efficacy and safety of dronedarone in patients with AF or AFL across different levels of renal function.

Methods

This post hoc analysis evaluated pooled data from two multicentre, double-blind, randomised (2:1) trials of rhythm control with dronedarone 400 mg twice daily vs placebo. Primary endpoint was time to first recurrence of AF or AFL. Renal function (estimated glomerular filtration rate [eGFR]) was assessed with the CKD-Epidemiology Collaboration equation. Patients were grouped by eGFR strata. Log-rank testing and Cox regression were used to compare time to events between treatment groups.

Results

Most (85%) patients had mild or mild-to-moderate decrease in eGFR (Table 1). Median time to first AF recurrence was significantly longer in the dronedarone vs placebo group for all eGFR subgroups except the 30–44 mL/min group (Figure 1), where the trend was consistent; however, the small population size may have precluded meaningful analyses in this subgroup. Serious adverse events, deaths, and treatment discontinuations did not differ notably between each group irrespective of eGFR strata.

Conclusions

This analysis confirms the efficacy and safety of dronedarone in patients with AF across a wide spectrum of renal function.

Figure 1

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Sanofi

Combined hip surgery in cerebral palsy patients

Seventeen cases of dislocated/subluxated hips in 14 cerebral palsy patients that were relocated by the combined hip procedure were reviewed. The combined hip procedure includes varus derotation osteotomy, open reduction, innominate bone osteotomy, adductor releases, and iliopsoas recession, all done at one stage. Eleven patients were spastic quadriplegic, 1 was spastic diplegic; and 2 were spastic hemiplegic. Average age at operation was 10 years. Average follow-up was 3 years. A total of 16 hips (94%) remained stable at follow-up with almost no change in center edge angle and the migration percentage, although the neck shaft angle remodeled over time. We conclude that the combined hip procedure is effective in maintaining hip reduction in cerebral palsy patients.

Site-specific antibodies distinguish single amino acid substitutions in position 57 in HLA-DQ beta-chain alleles associated with insulin-dependent diabetes

The HLA-DQ beta-chain gene shows a close association with susceptibility or resistance to autoimmune insulin-dependent diabetes mellitus (IDDM) and it has been suggested that the amino acid in position 57 may be of pathogenetic importance. To study the expression of the IDDM associated HLA-DQ beta-chain alleles, we immunized rabbits with 12 to 13 amino acid long peptides representing HLA-DQw7 and -DQw8 allelic sequences, differing only by one amino acid in position 57 being aspartic acid (Asp) and alanine (Ala), respectively. Immunoblot analysis of lymphoblastoid cells showed that several antisera recognized a 29-kDa protein, equivalent to the expected molecular size of the HLA-DQ beta-chain to yield two antisera specific for HLA-DQw7 (pos. 57Asp) and three antisera for HLA-DQw8 (pos. 57Ala) positive cells. Analysis of HLA-DR 3/4 positive IDDM patients (n = 24) and controls (n = 19) showed that all (100%) patients were positive for pos. 57Ala antiserum compared to 13 of 19 (68%) of the controls. The remaining six controls reacted with the pos. 57Asp antisera, whereas none of the patients did. We have therefore successfully been able to generate site-specific antibodies that distinguish single amino acid substitutions in predetermined positions of allelic HLA-DQ beta-chain gene products. Such sera should become useful to detect and investigate HLA associated susceptibility to autoimmune diseases in man.

Rhythm versus rate control in patients with newly diagnosed atrial fibrillation: observations from the GARFIELD-AF registry

Background

Atrial fibrillation is associated with considerable morbidity and mortality. Real-world reports on the effect of early rhythm control on patient outcomes in patient with recent onset atrial fibrillation are limited.

Purpose

To assess the effect of early rhythm versus rate control on clinical outcomes in patients with newly diagnosed non-valvular atrial fibrillation.

Method

The Global Anticoagulant Registry in the FIELD-AF (GARFIELD-AF) is a non-interventional registry of adult (≥18 years) patients with newly diagnosed atrial fibrillation (≤ six weeks' duration) and at least one investigator determined risk factor for stroke. Patients were enrolled in 1317 participating sites in 35 countries between March 2010 and August 2016. Patients with permanent atrial fibrillation were excluded. Stratification to rhythm or rate control was based on treatment strategy initiated at baseline (≤48 days post enrolment). Rhythm control was defined as investigator reported initiation of rhythm control (antiarrhythmic drug(s), cardioversion, or ablation – alone or in combination with rate modifiers). Rate control was defined as investigator reported initiation of rate control and absence of rhythm control therapy. Overlap propensity weighting and Cox proportional-hazards models were used to evaluate effect on outcomes.

Results

Of 45,382 included patients, 23,858 (52.6%) received rhythm control and 21,524 (47.4%) rate control. Rates of rhythm control were similar throughout the study time period (52.7% in 2010/2011, 54.2% in 2015/2016). Patients in the rhythm control group were younger (median age (Q1; Q3) 68.0 (60.0; 76.0) versus 73.0 (65.0; 79.0)), had lower rates of prior stroke/transitory ischemic attack/systemic embolism (9.4% vs 13.0%), and a lower median GARFIELD death score (4.0 (2.3; 7.5) versus 5.1 (2.8; 9.2)). Median CHA2DS2-VASc Scores were 3.0 (2.0; 4.0) in both groups. Rate of anticoagulation treatment was similar in the rhythm and rate control group (66.0% versus 65.5%). After propensity score overlap weighting, patients of the two groups were well balanced on all observed characteristics.

Event rates per 100 person-years (95% confidence interval [CI]) over two years follow-up in the rhythm and rate control group were 2.94 (2.78–3.10) versus 4.43 (4.22–4.64) for mortality, 0.84 (0.75–0.92) versus 1.16 (1.05–1.27) for non-haemorrhagic stroke/systemic embolism and 0.84 (0.76–0.93) versus 1.16 (1.06–1.27) for major bleeding. Adjusted hazard ratios (95% CI) for the same time period were 0.85 (0.79–0.92), 0.84 (0.72–0.97) and 0.9 (0.78–1.04).

Conclusion

In this large, internation registry, a rhythm control strategy was initiated at baseline in about half of the patients with newly diagnosed non-valvular atrial fibrillation. After adjustment for confounding factors, a significantly lower risk of all-cause mortality and non-haemorrhagic stroke/systemic embolism were observed for patients that received an early rhythm control strategy.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): This work was supported by the Thrombosis Research Institute (London, UK).

Pavlik harness pathology

Several complications following Pavlik harness splintage for congenital dislocated hips have been described. Two cases are reported where prolonged Pavlik splintage without concentric hip reduction caused posterior acetabular deficiency. Open reductions were required in both cases to correct deformity.

Complications in clubfoot surgery

Thirty percent to 50% of clubfeet will not respond to conservative treatment and will require surgery. The average failure rate in clubfoot surgery is 25% (range, 13% to 50%). Many complications can occur during surgery and postoperatively. Preoperative planning of the appropriate skin incision and special attention to wound closure may prevent some of these complications. Awareness of the multiple complications that can occur such as cavus, persistent adductus, overcorrection of the hindfoot, and recurrent deformity allows the surgeon to prepare and plan for these often unavoidable problems.