Bedside monitoring to adjust antiplatelet therapy for coronary stenting

BACKGROUND

Patients' responses to oral antiplatelet therapy are subject to variation. Bedside monitoring offers the opportunity to improve outcomes after coronary stenting by individualizing therapy.

METHODS

We randomly assigned 2440 patients scheduled for coronary stenting at 38 centers to a strategy of platelet-function monitoring, with drug adjustment in patients who had a poor response to antiplatelet therapy, or to a conventional strategy without monitoring and drug adjustment. The primary end point was the composite of death, myocardial infarction, stent thrombosis, stroke, or urgent revascularization 1 year after stent implantation. For patients in the monitoring group, the VerifyNow P2Y12 and aspirin point-of-care assays were used in the catheterization laboratory before stent implantation and in the outpatient clinic 2 to 4 weeks later.

RESULTS

In the monitoring group, high platelet reactivity in patients taking clopidogrel (34.5% of patients) or aspirin (7.6%) led to the administration of an additional bolus of clopidogrel, prasugrel, or aspirin along with glycoprotein IIb/IIIa inhibitors during the procedure. The primary end point occurred in 34.6% of the patients in the monitoring group, as compared with 31.1% of those in the conventional-treatment group (hazard ratio, 1.13; 95% confidence interval [CI], 0.98 to 1.29; P=0.10). The main secondary end point, stent thrombosis or any urgent revascularization, occurred in 4.9% of the patients in the monitoring group and 4.6% of those in the conventional-treatment group (hazard ratio, 1.06; 95% CI, 0.74 to 1.52; P=0.77). The rate of major bleeding events did not differ significantly between groups.

CONCLUSIONS

This study showed no significant improvements in clinical outcomes with platelet-function monitoring and treatment adjustment for coronary stenting, as compared with standard antiplatelet therapy without monitoring. (Funded by Allies in Cardiovascular Trials Initiatives and Organized Networks and others; ARCTIC ClinicalTrials.gov number, NCT00827411.).

Sirolimus-eluting versus uncoated stents in acute myocardial infarction

BACKGROUND

Sirolimus-eluting stents reduce rates of restenosis and reintervention, as compared with uncoated stents. Data are limited regarding the safety and efficacy of such stents in primary percutaneous coronary intervention (PCI) for acute myocardial infarction with ST-segment elevation.

METHODS

We performed a single-blind, multicenter, prospectively randomized trial to compare sirolimus-eluting stents with uncoated stents in primary PCI for acute myocardial infarction with ST-segment elevation. The trial included 712 patients at 48 medical centers. The primary end point was target-vessel failure at 1 year after the procedure, defined as target-vessel-related death, recurrent myocardial infarction, or target-vessel revascularization. A follow-up angiographic substudy was performed at 8 months among 174 patients from selected centers.

RESULTS

The rate of the primary end point was significantly lower in the sirolimus-stent group than in the uncoated-stent group (7.3% vs. 14.3%, P=0.004). This reduction was driven by a decrease in the rate of target-vessel revascularization (5.6% and 13.4%, respectively; P<0.001). There was no significant difference between the two groups in the rate of death (2.3% and 2.2%, respectively; P=1.00), reinfarction (1.1% and 1.4%, respectively; P=1.00), or stent thrombosis (3.4% and 3.6%, respectively; P=1.00). The degree of neointimal proliferation, as assessed by the mean (+/-SD) in-stent late luminal loss, was significantly lower in the sirolimus-stent group (0.14+/-0.49 mm, vs. 0.83+/-0.52 mm in the uncoated stent group; P<0.001).

CONCLUSIONS

Among selected patients with acute myocardial infarction, the use of sirolimus-eluting stents significantly reduced the rate of target-vessel revascularization at 1 year. (ClinicalTrials.gov number, NCT00232830 [ClinicalTrials.gov].).

A randomized comparison of high clopidogrel loading doses in patients with non-ST-segment elevation acute coronary syndromes: the ALBION (Assessment of the Best Loading Dose of Clopidogrel to Blunt Platelet Activation, Inflammation and Ongoing Necrosis) trial

OBJECTIVES

We sought to compare the antiplatelet effects of three clopidogrel loading doses (LDs).

BACKGROUND

Administration of a 300-mg clopidogrel LD is beneficial in situations requiring rapid platelet inhibition. Whether higher LDs can provide further benefits remains unknown.

METHODS

Patients (n = 103) with non-ST-segment elevation acute coronary syndromes were randomized to receive a 300-mg, 600-mg, or 900-mg clopidogrel LD, given on top of other standard therapy (including acetylsalicylic acid). The main outcome measure was inhibition of adenosine diphosphate-induced inhibition of platelet aggregation (IPA); inhibition of platelet activation, inflammatory markers, troponin I release, and major adverse cardiac events also were evaluated; all measures were blindly evaluated.

RESULTS

Compared with the 300-mg LD, greater doses were associated with significantly greater platelet inhibition, with dose-effect relationships observed for onset of action, maximal plateau, 24-h areas under the curves of IPA, and rates of low IPA (<10% at 6 h), using 20 micromol/l major adverse cardiac events. A significant dose-response was also observed for the vasodilator-stimulated phosphoprotein index, a measure of P2Y(12) receptor inhibition. Similar but nonsignificant trends were observed for troponin release and major adverse cardiac events. Bleeding rates were similar in each group.

CONCLUSIONS

In low-to-moderate risk patients with non-ST-elevation acute coronary syndromes, clopidogrel LDs >300 mg provide a faster onset of action, a higher IPA plateau, and greater reductions in platelet activation during the first 24 h. A 900-mg LD may induce a greater antiplatelet effect than 600 mg, when compared with the standard 300-mg regimen. These findings require further clinical confirmation.

Circulating microparticles from patients with myocardial infarction cause endothelial dysfunction

BACKGROUND

Shed membrane microparticles circulate in the peripheral blood of nonischemic (NI) patients and patients with myocardial infarction (MI). We investigated whether or not these microparticles would affect endothelium-dependent responses.

METHODS AND RESULTS

Rat aortic rings with endothelium were exposed for 24 hours to circulating microparticles isolated from 7 patients with NI syndromes and 19 patients with acute MI. Endothelium-dependent relaxations to acetylcholine were not affected by high concentrations of microparticles from NI patients (P=0.80). However, significant impairment was observed in preparations exposed to microparticles from patients with MI at low and high concentrations, corresponding to 0.7-fold and 2-fold circulating plasma levels (P=0.05 and 0.001, respectively). Impairment was not affected by diclofenac (P=0.47), nor by the cell-permeable superoxide dismutase mimetic Mn(III)tetra(4-benzoic acid) porphyrin chloride (P=0.33), but it was abolished by endothelium removal or by N(omega)monomethyl-L-arginine. Relaxations to the calcium ionophore ionomycin were decreased in rings exposed to microparticles from MI patients (P=0.05 and 0.009 for low and high concentrations, respectively), but microparticles from NI patients had no effect (P=0.81). Finally, high concentrations of microparticles from MI patients affected neither endothelium-independent relaxation to sodium nitroprusside (P=0.59) nor expression of the endothelial nitric oxide synthase (P=0.43).

CONCLUSIONS

Circulating microparticles from patients with MI selectively impair the endothelial nitric oxide transduction pathway and, therefore, could contribute to the general vasomotor dysfunction observed after MI, even in angiographically normal arteries.

Platelet function monitoring to adjust antiplatelet therapy in elderly patients stented for an acute coronary syndrome (ANTARCTIC): an open-label, blinded-endpoint, randomised controlled superiority trial

BACKGROUND

Elderly patients are at high risk of ischaemic and bleeding events. Platelet function monitoring offers the possibility to individualise antiplatelet therapy to improve the therapeutic risk-benefit ratio. We aimed to assess the effect of platelet function monitoring with treatment adjustment in elderly patients stented for an acute coronary syndrome.

METHODS

We did this multicentre, open-label, blinded-endpoint, randomised controlled superiority study at 35 centres in France. Patients aged 75 years or older who had undergone coronary stenting for acute coronary syndrome were randomly assigned (1:1), via a central interactive voice-response system based on a computer-generated permuted-block randomisation schedule with randomly selected block sizes, to receive oral prasugrel 5 mg daily with dose or drug adjustment in case of inadequate response (monitoring group) or oral prasugrel 5 mg daily with no monitoring or treatment adjustment (conventional group). Randomisation was stratified by centre. Platelet function testing was done 14 days after randomisation and repeated 14 days after treatment adjustment in patients in the monitoring group. Study investigators and patients were not masked to treatment allocation, but allocation was concealed from an independent clinical events committee responsible for endpoint adjudication. The primary endpoint was a composite of cardiovascular death, myocardial infarction, stroke, stent thrombosis, urgent revascularisation, and Bleeding Academic Research Consortium-defined bleeding complications (types 2, 3, or 5) at 12 months' follow-up. We did analysis by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01538446.

FINDINGS

Between March 27, 2012, and May 19, 2015, we randomly assigned 877 patients to the monitoring group (n=442) or the conventional group (n=435). The primary endpoint occurred in 120 (28%) patients in the monitoring group compared with 123 (28%) patients in the conventional group (hazard ratio [HR], 1·003, 95% CI 0·78-1·29; p=0·98). Rates of bleeding events did not differ significantly between groups.

INTERPRETATION

Platelet function monitoring with treatment adjustment did not improve the clinical outcome of elderly patients treated with coronary stenting for an acute coronary syndrome. Platelet function testing is still being used in many centres and international guidelines still recommend platelet function testing in high-risk situations. Our study does not support this practice or these recommendations.

FUNDING

Eli Lilly and Company, Daiichi Sankyo, Stentys, Accriva Diagnostics, Medtronic, and Fondation Coeur et Recherche.

Quantitation of BDNF mRNA in human parietal cortex by competitive reverse transcription-polymerase chain reaction: decreased levels in Alzheimer's disease

Alzheimer's disease is a progressive neurodegenerative disorder of the central nervous system. One pathological characteristic is excessive neuronal loss in specific regions of the brain. Among the areas most severely affected are the basal forebrain cholinergic neurons and their projection regions, the hippocampus and cortex. Neurotrophic factors, particularly the neurotrophins nerve growth factor and brain-derived neurotrophic factor, play an important role in the development, regulation and survival of basal forebrain cholinergic neurons. Furthermore, brain-derived neurotrophic factor regulates the function of hippocampal and cortical neurons. Neurotrophins are synthesized in hippocampus and cortex and retrogradely transported to the basal forebrain. Decreased levels of neurotrophic factors are suspected to be involved in the neurodegenerative changes observed in Alzheimer's disease. We examined autopsied parietal cortex samples from age- and gender-matched Alzheimer's diseased and neurologically non-impaired individuals using the quantitative technique of competitive RT-PCR. We demonstrate a 3.4-fold decrease in brain-derived neurotrophic factor mRNA levels in the parietal cortex of patients with Alzheimer's disease compared to controls (p<0.004). A decrease in brain-derived neurotrophic factor synthesis could have detrimental effects on hippocampal, cortical and basal forebrain cholinergic neurons and may account for their selective vulnerability in Alzheimer's disease.

Ergotamine in the acute treatment of migraine: a review and European consensus

Ergotamine has been used in clinical practice for the acute treatment of migraine for over 50 years, but there has been little agreement on its place in clinical practice. An expert group from Europe reviewed the pre-clinical and clinical data on ergotamine as it relates to the treatment of migraine. From this review, specific suggestions for the patient groups and appropriate use of ergotamine have been agreed. In essence, ergotamine, from a medical perspective, is the drug of choice in a limited number of migraine sufferers who have infrequent or long duration headaches and are likely to comply with dosing restrictions. For most migraine sufferers requiring a specific anti-migraine treatment, a triptan is generally a better option from both an efficacy and side-effect perspective.

A nationwide survey of migraine in France: prevalence and clinical features in adults. GRIM

In November 1990 a nationwide survey of migraine was conducted in France on a representative sample of residents aged 15 years and older. The diagnosis of migraine was based on the International Headache Society (IHS) classification. In a previous study, we validated a diagnostic algorithm which classifies headache sufferers as IHS migraine, "borderline" migraine, possible migraine and non-migrainous headache. The overall prevalence of migraine patients with the IHS criteria in the present study was 8.1%; another 4% were classified as "borderline" migraine, which we in fact considered as definite migraine. Age, gender and occupation were found to be risk factors for migraine. Neither frequency and duration of attacks nor length of time of disease differed with gender. Expressed intensity of attacks, however, was greater in females.

Immediate vs delayed intervention for acute coronary syndromes: a randomized clinical trial

CONTEXT

International guidelines recommend an early invasive strategy for patients with high-risk acute coronary syndromes without ST-segment elevation, but the optimal timing of intervention is uncertain.

OBJECTIVE

To determine whether immediate intervention on admission can result in a reduction of myocardial infarction compared with a delayed intervention.

DESIGN, SETTING, AND PATIENTS

The Angioplasty to Blunt the Rise of Troponin in Acute Coronary Syndromes Randomized for an Immediate or Delayed Intervention (ABOARD) study, a randomized clinical trial that assigned, from August 2006 through September 2008 at 13 centers in France, 352 patients with acute coronary syndromes without ST-segment elevation and a Thrombolysis in Myocardial Infarction (TIMI) score of 3 or more to receive intervention either immediately or on the next working day (between 8 and 60 hours after enrollment).

MAIN OUTCOME MEASURES

The primary end point was the peak troponin value during hospitalization; the key secondary end point was the composite of death, myocardial infarction, or urgent revascularization at 1-month follow-up.

RESULTS

Time from randomization to sheath insertion was 70 minutes with immediate intervention vs 21 hours with delayed intervention. The primary end point did not differ between the 2 strategies (median [interquartile range] troponin I value, 2.1 [0.3-7.1] ng/mL vs 1.7 [0.3-7.2] ng/mL in the immediate and delayed intervention groups, respectively; P = .70). The key secondary end point was observed in 13.7% (95% confidence interval, 8.6%-18.8%) of the group assigned to receive immediate intervention and 10.2% (95% confidence interval, 5.7%-14.6%) of the group assigned to receive delayed intervention (P = .31). The other end points, as well as major bleeding, did not differ between the 2 strategies.

CONCLUSION

In patients with acute coronary syndromes without ST-segment elevation, a strategy of immediate intervention compared with a strategy of intervention deferred to the next working day (mean, 21 hours) did not result in a difference in myocardial infarction as defined by peak troponin level.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00442949.

Production of type 2 cytokines by CD8+ lung cells is associated with greater decline in pulmonary function in patients with systemic sclerosis

OBJECTIVE

This study addresses the hypothesis that a profibrotic pattern of cytokines is produced in the lungs of patients with systemic sclerosis (SSc) and causes fibrosis.

METHODS

Using a reverse transcriptase-polymerase chain reaction technique, interleukin-4 (IL-4), IL-5, and interferon-gamma (IFNgamma) messenger RNA (mRNA) were measured in unseparated CD8+ and CD4+ bronchoalveolar lavage (BAL) cells from SSc patients and healthy controls. To confirm the results, CD8+ T cells were cloned from BAL fluids, and the pattern of cytokine mRNA made by these cells was determined. Serial pulmonary function tests were done.

RESULTS

BAL cells from healthy controls made IFNgamma mRNA, with no or little IL-4 or IL-5 mRNA. In contrast, BAL cells from the majority of SSc patients made IL-4 and/or IL-5 mRNA, with or without approximately equal amounts of IFNgamma mRNA. This pattern of cytokines was made by CD8+ T cells, which were increased in the lungs of these SSc patients. Patients whose BAL cells made this type 2 pattern of cytokine mRNA had a significant decline in forced vital capacity over time after the BAL, whereas patients whose BAL cells made IFNgamma mRNA alone did not. Both wild-type and an alternative splice variant of IL-4 mRNA were increased in BAL cells from SSc patients. Both forms of IL-4 stimulated alpha2(I) collagen mRNA in human dermal and lung fibroblasts.

CONCLUSION

The type 2 pattern of cytokine mRNA produced by BAL cells from SSc patients differs from unopposed IFNgamma production found in healthy BAL cells. This production of type 2 cytokine mRNA by CD8+ T cells is associated with a significant decline in lung function over time, which suggests a pathologic role for these T cells in interstitial fibrosis in SSc.

Prevalence and clinical characteristics of migraine in France

OBJECTIVE

To determine the prevalence and clinical features of migraine and related headache types in France.

METHODS

The authors recruited a population of subjects with headache representative of the national population using a stratified sampling method. They screened 10,585 subjects aged 15 and older who were representative of the general population. They identified 1,486 of these as having headaches, and these subjects were subsequently interviewed for information on clinical features, natural history, and functional impact of headache. The authors categorized subjects based on the International Headache Society (IHS) classification and assessed disability using the MIDAS questionnaire.

RESULTS

The authors found a standardized prevalence for migraine (IHS categories 1.1 and 1.2) of 7.9% (11.2% for women and 4.0% for men) and 9.1% for migrainous disorder (IHS category 1.7). Migraine attacks were associated with a considerable degree of handicap in activities of daily living, with a MIDAS grade distribution of 74.7% (grade 1), 13.3% (grade 2), 7.7% (grade 3), and 4.3% (grade 4). The prevalence of migraine with MIDAS grade 3 or 4 was 1.6%.

CONCLUSIONS

The prevalence of migraine (IHS categories 1.1 and 1.2) in France is 7.9%, and that of total migraine is 17.0%; this does not seem to have evolved over the past 10 years.

Epidemiology of primary anterior shoulder dislocation requiring closed reduction in Ontario, Canada

BACKGROUND

There is a lack of high-quality population-based literature describing the epidemiology of primary anterior shoulder dislocation.

PURPOSE

To (1) calculate the incidence density rate (IDR) of primary anterior shoulder dislocation requiring closed reduction (CR; "index event") in the general population and demographic subgroups, and (2) determine the rate of and risk factors for repeat shoulder CR.

STUDY DESIGN

Cohort study (prognosis); Level of evidence, 2.

METHODS

All patients who underwent shoulder CR by a physician in Ontario between April 2002 and September 2010 were identified with administrative databases. Exclusion criteria included age <16 and >70 years, posterior dislocation, and prior shoulder dislocation or surgery. Index event IDR was calculated for all populations/subgroups, and IDR comparisons were made. Repeat shoulder CR was sought until September 2012. Risk factors for repeat shoulder CR were identified with a Prentice, Williams, and Peterson proportional hazards model.

RESULTS

There were 20,719 persons (median age, 35 years; 74.3% male) who underwent a shoulder CR after a primary anterior shoulder dislocation (23.1/100,000 person-years). The IDR was highest among young males (98.3/100,000 person-years). A total of 3940 (19%) patients underwent repeat shoulder CR after a median of 0.9 years, of which 41.7% were ≤20 years of age. Less than two-thirds of all first repeat shoulder CR events occurred within 2 years; in fact, 95% occurred within 5 years. The risk of repeat shoulder CR was lowest if the primary reduction had been performed by an orthopaedic surgeon (hazard ratio [HR], 0.76; 95% CI: 0.64, 0.90; P = .002) or was associated with a humeral tuberosity fracture (HR, 0.71; CI, 0.53, 0.95; P = .02). Older age (HR, 0.97; CI, 0.97, 0.98; P < .0001) and higher medical comorbidity score (HR, 0.92; CI, 0.87, 0.98; P = .009) were also protective. Risk was highest among males (HR, 1.26; CI, 1.16, 1.36; P < .0001) and patients from low-income neighborhoods (HR, 1.23; CI, 1.13, 1.34; P < .0001).

CONCLUSION

Young male patients have the highest incidence of primary anterior shoulder dislocation requiring CR and the greatest risk of repeat shoulder CR. Patient, provider, and injury factors all influence repeat shoulder CR risk. A comprehensive understanding of the epidemiology of primary anterior shoulder dislocation will aid management decisions and injury prevention initiatives.

The effectiveness of combined oral lysine acetylsalicylate and metoclopramide compared with oral sumatriptan for migraine

Aspirin is commonly used to treat migraine attacks, although sumatriptan, a much more expensive treatment, is also effective. We compared a combination of lysine acetylsalicylate (equivalent to 900 mg aspirin) and 10 mg metoclopramide (LAS+MTC) with oral sumatriptan (100 mg) and placebo in 421 patients with migraine. LAS+MTC was as effective as sumatriptan with a decrease of headache from severe or moderate to mild or none of 57% and 53%, respectively, for the first migraine attack treated. Both treatments were better than placebo (success rate 24%, p < 0.0001). LAS+MTC was significantly more effective in the treatment of nausea than sumatriptan (p < 0.0001) and was better tolerated (adverse events in 18% and 28%, respectively, p < 0.05). LAS+MTC is as effective as sumatriptan in the treatment of migraine attacks. It is also much cheaper.

Risk of total knee arthroplasty after operatively treated tibial plateau fracture: a matched-population-based cohort study

BACKGROUND

The aims of operative treatment of displaced tibial plateau fractures are to stabilize the injured knee to restore optimal function and to minimize the risk of posttraumatic arthritis and the eventual need for total knee arthroplasty. The purpose of our study was to define the rate of subsequent total knee arthroplasty after tibial plateau fractures in a large cohort and to compare that rate with the rate in the general population.

METHODS

All patients sixteen years of age or older who had undergone surgical treatment of a tibial plateau fracture from 1996 to 2009 in the province of Ontario, Canada, were identified from administrative health databases with use of surgeon fee codes. Each member of the tibial plateau fracture cohort was matched to four individuals from the general population according to age, sex, income, and urban/rural residence. The rates of total knee arthroplasty at two, five, and ten years were compared by using time-to-event analysis. A separate Cox proportional hazards model was used to explore the influence of patient, provider, and surgical factors on the time to total knee arthroplasty.

RESULTS

We identified 8426 patients (48.5% female; median age, 48.9 years) who had undergone fixation of a tibial plateau fracture and matched them to 33,698 controls. The two, five, and ten-year rates of total knee arthroplasty in the plateau fracture and control cohorts were 0.32% versus 0.29%, 5.3% versus 0.82%, and 7.3% versus 1.8%, respectively (p < 0.0001). After adjustment for comorbidity, plateau fracture surgery was found to significantly increase the likelihood of total knee arthroplasty (hazard ratio [HR], 5.29 [95% confidence interval, 4.58, 6.11]; p < 0.0001). Higher rates of total knee arthroplasty were also associated with increasing age (HR, 1.03 [1.03, 1.04] per year over the age of forty-eight; p < 0.0001), bicondylar fracture (HR, 1.53 [1.26, 1.84]; p < 0.0001), and greater comorbidity (HR, 2.17 [1.70, 2.77]; p < 0.001).

CONCLUSIONS

Ten years after tibial plateau fracture surgery, 7.3% of the patients had had a total knee arthroplasty. This corresponds to a 5.3 times increase in likelihood compared with a matched group from the general population. Older patients and those with more severe fractures are also more likely to need total knee arthroplasty after repair of a tibial plateau fracture.

Psychiatric Comorbidity in the Evolution From Migraine to Medication Overuse Headache

We set out to study the role of psychiatric comorbidity in the evolution of migraine to medication overuse headache (MOH) by a comparative study of 41 migraineurs (MIG) and 41 patients suffering from MOH deriving from migraine. There was an excess risk of suffering from mood disorders [odds ratio (OR) = 4.5, 95% confidence interval (CI) 1.5, 13.5], anxiety (OR = 5, 95% CI 1.2, 10.7) and disorders associated with the use of psychoactive substances other than analgesics (OR = 7.6, 95% CI 2.2, 26.0) in MOH compared with MIG. Retrospective study of the order of occurrence of disorders showed that in the MOH group, psychiatric disorders occurred significantly more often before the transformation from migraine into MOH than after. There was no crossed-family transmission between MOH and psychiatric disorders, except for substance-related disorders. MOH patients have a greater risk of suffering from anxiety and depression, and these disorders may be a risk factor for the evolution of migraine into MOH. Moreover, MOH patients have a greater risk of suffering from substance-related disorders than MIG sufferers. This could be due to the fact that MOH is part of the spectrum of addictive disorders.

Prevalence and description of chronic daily headache in the general population in France

The objective of this study was to describe the epidemiology, clinical presentation and consequences of chronic daily headache (CDH) in France. A representative nation-wide sample of the general population was identified using a stratified sampling method. Ten thousand five hundred and eight-five subjects were screened in face-to-face interviews, and data collected using a standard questionnaire. An overall point prevalence of CDH in the general population of 2.98% was observed. Two-thirds of these subjects presented migraine-like features. Severity, functional impact and healthcare consumption were higher than in subjects reporting episodic migraine in the same sample. Of the subjects, 28.2% reported the most severe migraine disability assessment scores (Grades 3 and 4), compared to 12% of episodic migraineurs. A qualité de vie et migraine score of 68.4 was observed, indicating severely attenuated quality of life. Only 6.6% of subjects were taking prophylactic treatment, whilst 88% were using non-specific acute headache treatments. The frequency of physician consultations and laboratory examinations was significantly higher than in individuals with episodic headache. CDH is thus a relatively prevalent condition in the general French population, associated with an important burden of suffering and with considerable expenditure in the health service. Management of this condition is generally inappropriate.

Immediate and Delayed Implant Placement Into Extraction Sockets: A 5-Year Report

BACKGROUND

As a complement to the earlier reported 3-year results from a prospective multicenter study of immediate and delayed placement of implants into fresh extraction sockets, the 5-year results are reported.

PURPOSE

The purpose of this 5-year report was to evaluate the immediate and long-term success of implants placed into fresh extraction sockets, with respect to implant size and type, bone quality and quantity, implant position, initial socket depth, and reason for tooth extraction.

MATERIALS AND METHODS

This paper presents the 5-year results of the original 12 centers that participated with 143 consecutively included patients. A total of 264 implants were placed either immediately after tooth extraction or after a short soft-tissue healing time (3-5 weeks). The patients were divided into five subgroups, depending on the type of insertion method used.

RESULTS

The outcome demonstrated that the cumulative implant survival rate after 5 years of loading has not changed and remains 92.4% in the maxilla and 94.7% in the mandible. No difference in failure rates can be seen between the groups when relating the failures to insertion method.

CONCLUSION

This prospective study demonstrated that placing Brånemark implants into fresh extraction sites can be successful over a period of 5 years of loading. One of the outcomes of the study shows that there is a clinical correlation between implant failure and periodontitis as a reason for tooth extraction, even if it is difficult to give it a casual association. It can be hypothesized that periodontitis affected tissues might have a negative local influence because of the presence of infrabony defects that could possibly increase the gap between bone and implant or jeopardize achievement of primary stability.

Arthroscopic Repair for Chronic Massive Rotator Cuff Tears: A Systematic Review

PURPOSE

To systematically review the available evidence for arthroscopic repair of chronic massive rotator cuff tears and identify patient demographics, pre- and post-operative functional limitations, reparability and repair techniques, and retear rates.

METHODS

Medline, Embase, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched to identify all clinical papers describing arthroscopic repair of chronic massive rotator cuff tears. Papers were excluded if a definition of "massive" was not provided, if the definition of "massive" was considered inappropriate by agreement between the 2 reviewers, or if patients with smaller tears were also included in the study population. Study quality and clinical outcome data were pooled and summarized.

RESULTS

There were 18 papers that met the eligibility criteria; they involved 954 patients with a mean age of 63 (range, 37 to 87), 48% of whom were female. There were 5 prospective and 13 retrospective study designs. The overall study quality was poor according to the Modified Coleman Methodology Score. Of the 954 repairs, 81% were complete repairs and 19% were partial repairs. The follow-up range was between 33 and 52 months, and the mean duration between symptom onset and surgery was 24 months. Single-row repairs were performed in 56% or patients, and double-row repairs were performed in 44%. A pooled analysis demonstrated an improvement in visual analog scale from 5.9 to 1.7, active range of motion from 125° to 169°, and the Constant-Murley score from 49 to 74. The pooled retear rate was 79%.

CONCLUSIONS

Arthroscopic repair of chronic massive rotator cuff tears is associated with complete repair in the majority of cases and consistently improves pain, range of motion, and functional outcome scores; however, the retear rate is high. Existing research on massive rotator cuff repair is limited to poor- to fair-quality studies.

LEVEL OF EVIDENCE

Level IV, systematic review including Level IV studies.

Prasugrel compared with high-dose clopidogrel in acute coronary syndrome. The randomised, double-blind ACAPULCO study

Compared with the approved dose regimen of clopidogrel (300-mg loading dose [LD], 75-mg maintenance dose [MD]), prasugrel has been demonstrated to reduce ischaemic events in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). In ACS, antiplatelet effects of a prasugrel MD regimen have not been previously compared with either a higher clopidogrel MD or after switching from a higher clopidogrel LD. The objective of this study was to evaluate the antiplatelet effect of a prasugrel 10-mg MD versus a clopidogrel 150-mg MD in patients with ACS who had received a clopidogrel 900-mg LD. Patients with non-ST elevation ACS, treated with aspirin and a clopidogrel 900-mg LD, were randomised within 24 hours post-LD to receive a prasugrel 10-mg or clopidogrel 150-mg MD. After 14 days of the initial MD, subjects switched to the alternative treatment for 14 days. The primary endpoint compared maximum platelet aggregation (MPA, 20 microM adenosine diphosphate [ADP]) between prasugrel and clopidogrel MDs for both periods. Responder analyses between treatments were performed using several platelet-function methods. Of 56 randomised subjects, 37 underwent PCI. MPA was 26.2% for prasugrel 10 mg and 39.1% for clopidogrel 150 mg (p<0.001). The prasugrel MD regimen reduced MPA from the post-900-mg LD level (41.2% to 29.1%, p=0.003). Poor response ranged from 0% to 6% for prasugrel 10 mg and 4% to 34% for clopidogrel 150 mg. Thus, in ACS patients a prasugrel 10-mg MD regimen resulted in significantly greater platelet inhibition than clopidogrel at twice its approved MD or a 900-mg LD.

Precipitating factors of headache. A prospective study in a national control-matched survey in migraineurs and nonmigraineurs

Prospective studies of precipitating factors in migraine are rare. Mig Access is a national control-matched survey conducted to evaluate the access of migraineurs to health care in France. This study allowed us to screen prospectively some precipitating factors of headache in migraineurs and in nonmigraineurs. Three hundred eighty-five migraineurs (group 1) and 313 nonmigraineurs (group 2) kept a diary for a 3-month period (a total of 35,805 day in group 1 and 29,109 days in group 2). Precipitating factors were reported for each headache period. Headache intensity was self-assessed during each headache period using a visual analog scale of 0 to 100. Headache was reported on 4274 days (12%) in group 1 and on 602 days (2%) in group 2. Headache intensity was greater in group 1 (39 +/- 20 versus 32 +/- 19, P < .05). The most frequent precipitating factors (reported at least once by more than 10% of subjects [range 18% to 80%] in both groups) were fatigue and/or sleep, stress, food and/or drinks, menstruation, heat/cold/weather, and infections in both groups. All these factors except infections were reported to cause headache more frequently in migraineurs than in nonmigraineurs. Mean intensity of headache related to fatigue and/or sleep, stress, food and/or drinks, hot/cold weather, and menstruation varied from 37 to 43 in migraineurs and from 29 to 35 in nonmigraineurs. Headache with the highest mean intensity was due to infections in the two groups (47 +/- 20 in group 1, 45 +/- 23 in group 2). Our results support that endogenous factors are the most frequent triggers of headache in migraineurs. The most frequent precipitating factors of headache appear identical in migraineurs and in nonmigraineurs. Our results suggest that similar triggers could precipitate headache of different type in these two populations.

Increased plasma concentrations of interleukin-18 in acute coronary syndromes

OBJECTIVE

To examine the relation between plasma concentrations of interleukin-18 (IL-18), the interferon gamma inducing factor, and clinical instability of coronary artery disease.

DESIGN AND SETTING

Observational study in a university hospital.

PATIENTS

11 patients with unstable angina and negative troponin I, 21 patients with acute non-Q wave myocardial infarction (MI), 21 patients with acute Q wave MI, 9 patients with stable angina, and 11 controls.

MAIN OUTCOME MEASURES

Plasma IL-18 concentrations and their relation to clinical instability and myocardial dysfunction.

RESULTS

Plasma concentrations of IL-18 were significantly increased in the unstable angina and MI groups in comparison with the stable angina and control groups (p < 0.01). No difference in IL-18 concentrations were found between patients with unstable angina, patients with non-Q wave MI, and patients with Q wave MI. Plasma IL-18 concentrations significantly correlated with decreased left ventricular ejection fraction (p = 0.01).

CONCLUSIONS

Plasma IL-18 concentrations are increased in patients with acute coronary syndromes and correlate with the severity of myocardial dysfunction.

24-hour time-dependent aspirin efficacy in patients with stable coronary artery disease

Aspirin-induced cyclooxygenase (COX)-1 acetylation is irreversible and it is assumed that the platelet thromboxane-A2 aggregation pathway is inhibited for at least 24 hours (h) after aspirin ingestion. However, time course of biological efficacy of daily low-dose aspirin has rarely been assessed in patients with coronary artery disease (CAD). We aimed to assess the 24-h biological efficacy of daily low-dose aspirin in CAD patients. The peak and trough (2 h –24 h) effect of a chronic treatment with once daily dose aspirin were studied in 150 consecutive stable CAD patients. The main outcome measure was light transmission aggregometry (LTA) triggered with 0.5 mg/ml arachidonic acid (AA). In the last 47 consecutive patients, additional tests were conducted at 6, 12, 16, 20 h after last aspirin administration. 4.7% of the patients had significant aggregation (>20% maximal intensity LTA-AA) 2 h after aspirin ingestion and 24.7% at 24 h (p<0.0001). The more precise assessments in the last 47 patients showed that significant platelet aggregation progressively reappeared with time after aspirin intake (2 h – 4% of patients, 6 h – 4%, 12 h – 11%, 16 h – 16%, 20 h – 19% and 24 h – 28%). Concordant results were observed using production of thromboxane-B2 and other techniques evaluating AA-induced platelet aggregation/activation. No significant differences were found between lower (75–100 mg/day) and higher (>100 mg/day) dose aspirin. Such aspirin «resistance» at 24 h after ingestion was related to biological inflammatory markers, current smoking and diabetes. In conclusion, once daily aspirin does not provide stable 24-h antiplatelet protection in a significant proportion of CAD patients. Any biological assessment of aspirin efficacy should take time since last aspirin intake into consideration.

Rate of and Risk Factors for Reoperations After Open Reduction and Internal Fixation of Midshaft Clavicle Fractures: A Population-Based Study in Ontario, Canada

BACKGROUND

Reoperation rates following open reduction and internal fixation (ORIF) of midshaft clavicle fractures have been described, but reported rates of nonunion, malunion, infection, and implant removal have varied. We sought to establish baseline rates of, and risk factors for, reoperations following clavicle ORIF in a large population cohort.

METHODS

Administrative databases were used to identify patients sixteen to sixty years of age who had undergone an ORIF of a closed, midshaft clavicle fracture from April 2002 to April 2010. The primary outcome was a reoperation within two years (isolated implant removal, irrigation and debridement [deep infection], pseudarthrosis reconstruction [nonunion], or clavicle osteotomy [malunion]). The secondary outcome was rare perioperative complications, including pneumothorax, subclavian vasculature injury, and brachial plexus injury. A multivariable logistic regression analysis was performed to determine the influence of patient and provider factors on these outcomes.

RESULTS

We identified 1350 patients who underwent midshaft clavicle ORIF (median age, thirty-two years [interquartile range, twenty-one to forty-four years]; 81.3% male). One in four patients (24.6%) underwent at least one clavicle reoperation. The most common procedure was isolated implant removal (18.8%), and females were at highest risk (odds ratio [OR], 1.7; p = 0.002). The median time to implant removal was twelve months. A reoperation secondary to nonunion, deep infection, and malunion occurred in 2.6%, 2.6%, and 1.1% of the patients after a median of six, five, and fourteen months, respectively. Risk factors for clavicle nonunion included female sex (OR, 2.2; p = 0.04) and a high comorbidity score (OR, 2.8; p = 0.009). For surgeons, fewer years in practice was associated with a small risk of the patient developing an infection (OR, 1.1; p < 0.001). Sixteen pneumothoraces (1.2%) were identified; however, brachial plexus and subclavian vessel injuries were each found in five or fewer patients.

CONCLUSIONS

Following clavicle ORIF, one in four patients underwent a reoperation. The most common procedure was implant removal, and although the rates of reoperations secondary to nonunion, malunion, and infection were low they were higher than previously reported. Pneumothoraces and neurovascular injuries were infrequent and should continue to be considered rare complications of clavicle ORIF.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Extracorporeal cardiopulmonary resuscitation in out-of-hospital cardiac arrest: a registry study

Aims

Out-of-hospital cardiac arrest (OHCA) without return of spontaneous circulation (ROSC) despite conventional resuscitation is common and has poor outcomes. Adding extracorporeal membrane oxygenation (ECMO) to cardiopulmonary resuscitation (extracorporeal-CPR) is increasingly used in an attempt to improve outcomes.

Methods and results

We analysed a prospective registry of 13 191 OHCAs in the Paris region from May 2011 to January 2018. We compared survival at hospital discharge with and without extracorporeal-CPR and identified factors associated with survival in patients given extracorporeal-CPR. Survival was 8% in 525 patients given extracorporeal-CPR and 9% in 12 666 patients given conventional-CPR (P = 0.91). By adjusted multivariate analysis, extracorporeal-CPR was not associated with hospital survival [odds ratio (OR), 1.3; 95% confidence interval (95% CI), 0.8–2.1; P = 0.24]. By conditional logistic regression with matching on a propensity score (including age, sex, occurrence at home, bystander CPR, initial rhythm, collapse-to-CPR time, duration of resuscitation, and ROSC), similar results were found (OR, 0.8; 95% CI, 0.5–1.3; P = 0.41). In the extracorporeal-CPR group, factors associated with hospital survival were initial shockable rhythm (OR, 3.9; 95% CI, 1.5–10.3; P = 0.005), transient ROSC before ECMO (OR, 2.3; 95% CI, 1.1–4.7; P = 0.03), and prehospital ECMO implantation (OR, 2.9; 95% CI, 1.5–5.9; P = 0.002).

Conclusions

In a population-based registry, 4% of OHCAs were treated with extracorporeal-CPR, which was not associated with increased hospital survival. Early ECMO implantation may improve outcomes. The initial rhythm and ROSC may help select patients for extracorporeal-CPR.