Life expectancy associated with different ages at diagnosis of type 2 diabetes in high-income countries: 23 million person-years of observation

BACKGROUND

The prevalence of type 2 diabetes is increasing rapidly, particularly among younger age groups. Estimates suggest that people with diabetes die, on average, 6 years earlier than people without diabetes. We aimed to provide reliable estimates of the associations between age at diagnosis of diabetes and all-cause mortality, cause-specific mortality, and reductions in life expectancy.

METHODS

For this observational study, we conducted a combined analysis of individual-participant data from 19 high-income countries using two large-scale data sources: the Emerging Risk Factors Collaboration (96 cohorts, median baseline years 1961-2007, median latest follow-up years 1980-2013) and the UK Biobank (median baseline year 2006, median latest follow-up year 2020). We calculated age-adjusted and sex-adjusted hazard ratios (HRs) for all-cause mortality according to age at diagnosis of diabetes using data from 1 515 718 participants, in whom deaths were recorded during 23·1 million person-years of follow-up. We estimated cumulative survival by applying age-specific HRs to age-specific death rates from 2015 for the USA and the EU.

FINDINGS

For participants with diabetes, we observed a linear dose-response association between earlier age at diagnosis and higher risk of all-cause mortality compared with participants without diabetes. HRs were 2·69 (95% CI 2·43-2·97) when diagnosed at 30-39 years, 2·26 (2·08-2·45) at 40-49 years, 1·84 (1·72-1·97) at 50-59 years, 1·57 (1·47-1·67) at 60-69 years, and 1·39 (1·29-1·51) at 70 years and older. HRs per decade of earlier diagnosis were similar for men and women. Using death rates from the USA, a 50-year-old individual with diabetes died on average 14 years earlier when diagnosed aged 30 years, 10 years earlier when diagnosed aged 40 years, or 6 years earlier when diagnosed aged 50 years than an individual without diabetes. Using EU death rates, the corresponding estimates were 13, 9, or 5 years earlier.

INTERPRETATION

Every decade of earlier diagnosis of diabetes was associated with about 3-4 years of lower life expectancy, highlighting the need to develop and implement interventions that prevent or delay the onset of diabetes and to intensify the treatment of risk factors among young adults diagnosed with diabetes.

FUNDING

British Heart Foundation, Medical Research Council, National Institute for Health and Care Research, and Health Data Research UK.

Measurement and initial characterization of leukocyte telomere length in 474,074 participants in UK Biobank

Leukocyte telomere length (LTL) is a proposed marker of biological age. Here we report the measurement and initial characterization of LTL in 474,074 participants in UK Biobank. We confirm that older age and male sex associate with shorter LTL, with women on average ~7 years younger in 'biological age' than men. Compared to white Europeans, LTL is markedly longer in African and Chinese ancestries. Older paternal age at birth is associated with longer individual LTL. Higher white cell count is associated with shorter LTL, but proportions of white cell subtypes show weaker associations. Age, ethnicity, sex and white cell count explain ~5.5% of LTL variance. Using paired samples from 1,351 participants taken ~5 years apart, we estimate the within-individual variability in LTL and provide a correction factor for this. This resource provides opportunities to investigate determinants and biomedical consequences of variation in LTL.

Management of Gustilo-Anderson IIIB open tibial fractures in adults-a systematic review

INTRODUCTION

Open tibial fractures are the most common open long bone fracture, despite this, the management of these complex injuries still remains a topic of discussion amongst orthopaedic surgeons.

SOURCES OF DATA

We searched the EMBASE, MEDLINE and Google Scholar and a systematic review of 7500 articles, leaving 23 after exclusion criteria were applied, in order to analyse the management of open tibial fractures.

AREAS OF AGREEMENT AND CONTROVERSY

Infection was noted to be the most significant concern amongst authors, with definitive external fixation having a high rate of superficial pin-site infection and internal fixation having a high deep infection rate.

GROWING POINTS

It is essential to have a combined ortho-plastic approach to the management of these fractures as muscle flaps were the most common form of soft tissue coverage.

AREAS TIMELY FOR DEVELOPING RESEARCH

A national pragmatic trial into the management of open tibial fractures is required looking at fixation methods and soft tissue coverage, with at least a 2-year follow-up in order to ascertain the most appropriate management of these fractures and patient-related outcomes.

Safety of nicotine replacement therapy in critically ill smokers: a retrospective cohort study

Nicotine replacement therapy (NRT) is a common first-line treatment to prevent nicotine withdrawal in smokers. However, available literature reports conflicting results regarding its efficacy and safety in critically ill patients. The objective of this study was to evaluate the relationship between NRT in smokers in the intensive care unit (ICU) and outcomes. This case-control study was conducted in a university-affiliated tertiary hospital ICU. Over a period of five years, 126 active smokers who received transdermal NRT were matched to 126 active smokers who did not receive NRT. The groups were case-matched for sex, age and Acute Physiology and Chronic Health Evaluation II (APACHE II) score. The primary outcome was administration of antipsychotic medication. Secondary outcomes included use of physical restraints, 30-day mortality, and ventilation requirements. Antipsychotic medication was prescribed in 43 (34.1%) patients who received NRT compared to 14 (11.1%) in controls (P <0.01). Physical restraints were used in 37 (29.4%) patients who received NRT, compared to 12 (9.5%) of controls (P <0.01). The 30-day mortality and number of patients intubated was not statistically different between groups. Average length of intubation time was greater in the NRT group (2.56 days; standard deviation 4.16) compared to the control group (1.44 days; standard deviation 2.68) (P=0.012). The use of NRT to prevent nicotine withdrawal in ICU patients is associated with increased use of antipsychotic medication and physical restraint, and with prolonged mechanical ventilation.

Return to sport following stress fractures of the great toe sesamoids: a systematic review

INTRODUCTION

This review aims to provide information on return rates and times to sport following stress fractures of the great toe sesamoids (SFGTSs).

SOURCES OF DATA

A systematic search of CINAHAL, Cochrane, EMBASE, Google Scholar, Medline, PEDro, Scopus, SPORTDiscus and Web of Science was performed using the keywords 'stress', 'fractures', 'great', 'toe', 'sesamoid', 'athletes', 'sports', 'non-operative', 'conservative', 'operative' and 'return to sport'.

AREAS OF AGREEMENT

Fourteen studies were included: three studies reported on the outcome of conservatively-managed SFGTSs; thirteen studies reported on the outcome of surgically-managed SFGTSs. The management principles were to attempt conservative management for 2-6 months using activity modification, analgesia, orthotics and physiotherapy; if symptoms persisted following this, surgical management was to be recommended, either with internal fixation or sesamoidectomy.

AREAS OF CONTROVERSY

The optimal treatment modalities for SFGTSs remain to be defined.

GROWING POINTS

Internal fixation shows the best return to full-level sport rates with low rates of complications.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future prospective studies should aim to establish the optimal treatment modalities for SFGTSs.

CrossFitter’s knee: patellofemoral chondral injury following high-intensity functional training

We present a case series of patients with patellofemoral joint (PFJ) chondral injuries presenting as anterior knee pain secondary to participation in high-intensity functional training programmes. We aim to highlight PFJ chondral injuries as a potential complication of military servicemen engaging in high-intensity functional training programmes. This may allow medical staff to identify the injuries early, and highlight this possible injury mechanism to Physical Training staff to help educate participants and mitigate the risk of injury.

Return to sport following clavicle fractures: a systematic review

INTRODUCTION

This review aims to provide information on the return rates and return times to sport following clavicle fractures.

SOURCES OF DATA

A systematic search of Medline, EMBASE, CINAHAL, Cochrane, Web of Science, PEDro, SPORTDiscus, Scopus and Google Scholar was performed using the keywords 'clavicle', 'clavicular', 'fractures', 'athletes', 'sports', 'non-operative', 'conservative', 'operative', 'return to sport'.

AREAS OF AGREEMENT

Twenty-three studies were included: 10 reported on mid-shaft fractures, 14 on lateral fractures. The management principles for athletic patients were to attempt non-operative management for undisplaced fractures to undertake operative intervention for displaced lateral fractures and to recommend operative intervention for displaced mid-shaft fractures.

AREAS OF CONTROVERSY

The optimal surgical modality for mid-shaft and lateral clavicle fractures.

GROWING POINTS

Operative management of displaced mid-shaft fractures offers improved return rates and times to sport compared to non-operative management. Suture fixation and non-acromio-clavicular joint (ACJ)-spanning plate fixation of displaced lateral fractures show promising results.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future prospective studies should aim to establish the optimal treatment modalities for clavicle fractures.

Return to sports after stress fractures of the tibial diaphysis: a systematic review

INTRODUCTION

This review aims to provide information on the time taken to resume sport following tibial diaphyseal stress fractures (TDSFs).

SOURCES OF DATA

A systematic search of Medline, EMBASE, CINHAL, Cochrane, Web of Science, PEDro, Sports Discus, Scopus and Google Scholar was performed using the keywords 'tibial', 'tibia', 'stress', 'fractures', 'athletes', 'sports', 'non-operative', 'conservative', 'operative' and 'return to sport'.

AREAS OF AGREEMENT

Twenty-seven studies were included: 16 reported specifically on anterior TDSFs and 5 on posterior TDSFs. The general principles were to primarily attempt non-operative management for all TDSFs and to consider operative intervention for anterior TDSFs that remained symptomatic after 3-6 months. Anterior TDSFs showed a prolonged return to sport.

AREAS OF CONTROVERSY

The best time to return to sport and the optimal management modalities for TDSFs remain undefined.

GROWING POINTS

Management of TDSFs should include a full assessment of training methods, equipment and diet to modify pre-disposing factors.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future prospective studies should aim to establish the optimal treatment modalities for TDSFs.

Previous caesarean delivery and the risk of unexplained stillbirth: retrospective cohort study and meta-analysis

OBJECTIVE

To determine whether caesarean delivery in the first pregnancy is a risk factor for unexplained antepartum stillbirth in a second pregnancy.

DESIGN

A population-based retrospective cohort study and meta-analysis.

SETTING

All maternity units in Scotland.

PARTICIPANTS

A cohort of 128 585 second births, 1999-2008.

METHODS

Time-to-event analysis and random-effects meta-analysis.

MAIN OUTCOME MEASURE

Risk of unexplained antepartum stillbirth in a second pregnancy.

RESULTS

There were 88 stillbirths among 23 688 women with a previous caesarean delivery (2.34 per 10 000 women per week) and 288 stillbirths in 104 897 women who had previously delivered vaginally (1.67 per 10 000 women per week, P = 0.002). When analysed by cause, women with a previous caesarean delivery had an increased risk of unexplained stillbirth (hazard ratio, HR 1.47; 95% confidence interval, 95% CI 1.12-1.94; P = 0.006) and, as previously observed, the excess risk was apparent from 34 weeks of gestation onwards. The risk did not differ in relation to the indication of the caesarean delivery, and was independent of maternal characteristics and previous obstetric complications. We identified three other comparable studies (two in North America and one in Europe), and meta-analysis of these studies showed a statistically significant association between previous caesarean delivery and the risk of antepartum stillbirth in the second pregnancy (pooled HR 1.40; 95% CI 1.10-1.77; P = 0.006).

CONCLUSIONS

Women who have had a previous caesarean delivery are at increased risk of unexplained stillbirth in the second pregnancy.

TWEETABLE ABSTRACT

Caesarean first delivery is associated with an increased risk of unexplained stillbirth in the next pregnancy.

A single strain of Tetratrichomonas gallinarum causes fatal typhlohepatitis in red-legged partridges (Alectoris rufa) to be distinguished from histomonosis

Typhlohepatitis was observed in a flock of 2500 red-legged partridges in Great Britain, characterized by the sudden deaths of 15 birds within 2 days. Necropsy of five dead birds revealed severe lesions in the caeca with thickened caecal walls, a reddened lining and bloody contents. The livers contained multiple miliary lesions and similar pathological changes were found in the spleens of some birds. Microscopic examination of intestinal contents showed the occurrence of coccidial oocysts in two partridges. Different methods for the detection of bacteria from liver and intestine samples were conducted without positive results. Histopathological examination revealed the presence of protozoan parasites in the caecum, liver and spleen of the affected birds. In situ hybridization (ISH) for the detection of trichomonads resulted in positive findings and polymerase chain reaction (PCR) confirmed the presence of Tetratrichomonas gallinarum in the lesions. Additionally, archived tissues of red-legged partridges from different flocks suffering from severe typhlohepatitis in Great Britain in 2008 and 2009 were re-investigated by ISH and PCR. Beside the sporadic occurrence of histomonosis, in most of the cases trichomonads were detected by ISH in the caecum and liver of affected birds. Furthermore, dissemination of the flagellate into the lung and bursa of Fabricius could be demonstrated. Analyses of T. gallinarum DNA obtained from the different cases resulted in homologous nucleotide sequences. Altogether, the results demonstrate the circulation of a virulent strain of T. gallinarum in reared red-legged partridges.

Previous miscarriage and the subsequent risk of preterm birth in Scotland, 1980-2008: a historical cohort study

OBJECTIVE

To determine whether the relationship between previous miscarriage and risk of preterm birth changed over the period 1980-2008, and to determine whether the pattern varied according to the cause of the preterm birth.

DESIGN

Linked birth databases.

SETTING

All Scottish NHS hospitals.

POPULATION

A total of 732 719 nulliparous women with a first live birth between 1980 and 2008.

METHODS

Risk was estimated using logistic regression.

MAIN OUTCOME MEASURES

Preterm birth, subdivided by cause (spontaneous, induced with a diagnosis of pre-eclampsia, or induced without a diagnosis of pre-eclampsia) and severity [extreme (24-28 weeks of gestation), moderate (29-32 weeks of gestation), and mild (33-36 weeks of gestation)].

RESULTS

Consistent with previous studies, previous miscarriage was associated with an increased risk of all-cause preterm birth (adjusted odds ratio, aOR 1.26; 95% confidence interval, 95% CI 1.22-1.29). This arose from associations with all subtypes. The strongest association was found with extreme preterm birth (aOR 1.73; 95% CI 1.57-1.90). Risk increased with the number of miscarriages. Women with three or more miscarriages had the greatest risk of all-cause preterm birth (aOR 2.14; 95% CI 1.93-2.38), and the strongest association was with extreme preterm birth (aOR 3.87; 95% CI 2.85-5.26). The strength of the association between miscarriage and preterm birth decreased from 1980 to 2008. This was because of weakening associations with spontaneous preterm birth and induced preterm birth without a diagnosis of pre-eclampsia.

CONCLUSIONS

The association between a prior history of miscarriage and the risk of preterm birth declined in Scotland over the period 1980-2008. We speculate that changes in the methods of managing incomplete termination of pregnancy might explain the trend, through reduced cervical damage.

Lower limb stress fractures in military training

This article describes stress fractures that are seen in military training, and reviews the relevant literature. The information is vital for medical personnel who work with the United Kingdom (UK) Armed Forces, particularly those working in training establishments. The author suggests areas for further research and discusses some of the issues in current UK Armed Forces training.

Infection control hazards associated with the use of forced-air warming in operating theatres

A review is presented of the published experimental and clinical research into the infection control hazards of using forced air-warming (FAW) in operating theatres to prevent inadvertent hypothermia. This evidence has been reviewed with emphasis on the use of ultra-clean ventilation, any interaction it has with different types of patient warming (and FAW in particular), and any related increased risk of surgical site infection (SSI). We conclude that FAW does contaminate ultra-clean air ventilation; however, there appears to be no definite link to an increased risk of SSI based on current research. Nevertheless, whereas this remains unproven, we recommend that surgeons should at least consider alternative patient-warming systems in areas where contamination of the operative field may be critical. Although this is not a systematic review of acceptable randomized controlled clinical trials, which do not exist, it does identify that there is a need for definitive research in this field.

The management of the acutely swollen ankle

Patients presenting with an acutely swollen ankle are common in both the military and civilian settings. Accurate diagnosis is vital, as there are various potentially serious causes. This article aims to review the common causes of an acutely swollen ankle, as well as the rarer causes, with their significant consequences.

Ten-year results of the Press Fit Condylar Sigma total knee replacement

We report ten-year clinical and radiological follow-up data for the Sigma Press Fit Condylar total knee replacement system (Sigma PFC TKR). Between October 1998 and October 1999 a total of 235 consecutive PFC Sigma TKRs were carried out in 203 patients. Patients were seen at a specialist nurse-led clinic seven to ten days before admission and at six and 18 months, three, five and eight to ten years after surgery. Data were recorded prospectively at each clinic visit. Radiographs were obtained at the five- and eight- to ten-year follow-up appointments. Of the 203 patients, 147 (171 knees) were alive at ten years and 12 were lost to follow-up. A total of eight knees (3.4%) were revised, five for infection and three to change the polyethylene insert. The survival at ten years with an endpoint of revision for any reason was 95.9%, and with an endpoint of revision for aseptic failure was 98.7%. The mean American Knee Society Score (AKSS) was 79 (10 to 99) at eight to ten years, compared with 31 (2 to 62) pre-operatively. Of 109 knee with radiographs reviewed, 47 knees had radiolucent lines but none showed evidence of loosening.

Injuries and medical issues on the Zambezi "Great River"

We report the injuries and medical issues incurred during a rowing expedition conducted along the Zambezi River in May 2011. All injuries and illnesses requiring medical intervention were recorded during a 30-day expedition. There were 22 rowers and 8 support staff sustaining 32 injuries, an injury incidence of 36 per 1000 days. We discuss the medical issues regarding conducting an expedition along the Zambezi and the medical preparation and education required to successfully support wilderness expeditions.

Femoral acetabular impingement: the sex- and age-linked distribution of alpha angles in 146 patients of service age without pre-existing osteoarthritic or other hip pathology

The use of the alpha angle to help the diagnosis of Femoral Acetabular Impingement (FAI) is common. However, there is currently no standard value available across an asymptomatic pre-arthritic population. We present the first large cohort of Computerised Tomography (CT) based alpha angles in patients with no history of hip pathology, including intra- and interobserver validation. We carried out a retrospective analysis of 73 consecutive individuals (146 hip joints) with ages ranging from 18 to 39 years. The age range 18-39 represents 82.4% of those currently serving in the UK Armed Forces. The cohort was drawn from those patients who had received a CT scan in the Lothian Region between 1 Jan 2011 and 31 Dec 2011 due to abdominal pathology. These patients had their electronic patient record checked to rule out any hip-related problems. The alpha angle of Nötzli was measured on the axial view bilaterally. The mean value for the 18-39 age range was found to be 51.89 degree for the left hip and 52.53 degree for the right. Femoral alpha angle is a reproducible measurement for assessing the femoral neck. However, there is wide variability in the alpha angle for patients, irrespective of the presence of symptoms. Our results would suggest that the alpha angle alone should not be used to diagnose FAI in service personnel, as even large angles may be normal.

Ten-year survival of cemented total knee replacement in patients aged less than 55 years

We report the ten-year survival of a cemented total knee replacement (TKR) in patients aged < 55 years at the time of surgery, and compare the functional outcome with that of patients aged > 55 years. The data were collected prospectively and analysed using Kaplan-Meier survival statistics, with revision for any reason, or death, as the endpoint. A total of 203 patients aged < 55 years were identified. Four had moved out of the area and were excluded, leaving a total of 221 TKRs in 199 patients for analysis (101 men and 98 women, mean age 50.6 years (28 to 55)); 171 patients had osteoarthritis and 28 had inflammatory arthritis. Four patients required revision and four died. The ten-year survival using revision as the endpoint was 98.2% (95% confidence interval 94.6 to 99.4). Based on the Oxford knee scores at five and ten years, the rate of dissatisfaction was 18% and 21%, respectively. This was no worse in the patients aged < 55 years than in patients aged > 55 years. These results demonstrate that the cemented PFC Sigma knee has an excellent survival rate in patients aged < 55 ten years post-operatively, with clinical outcomes similar to those of an older group. We conclude that TKR should not be withheld from patients on the basis of age.

Delay in diagnosis of neck of femur stress fracture in a female military recruit

We report the delay in diagnosis of a Neck of Femur (NOF) stress fracture in mixed sex basic military training. Stress fractures are common in military training with the incidence reported as ranging between 3.2-31%. NOF stress fractures, whilst only representing around 8% of stress fractures are associated with a high morbidity. It is imperative that medical officers looking after military recruits have a sound knowledge of the potential signs, symptoms and presentation of these injuries. Medical officers should always remains vigilant for stress fractures especially in mixed military training.

Does body mass index affect clinical outcome post-operatively and at five years after primary unilateral total hip replacement performed for osteoarthritis?

Studies describing the effect of body mass index (BMI) on the outcome of total hip replacement have been inconclusive and contradictory. We examined the effect of BMI on medium-term outcome in a cohort of 1617 patients who underwent a primary total hip replacement for osteoarthritis. These patients were followed prospectively for five years with the outcomes of dislocation, revision, duration of surgery and deep and superficial infection studied, as well as collecting Harris hip scores (HHS) and Short-Form 36 (SF-36) questionnaires pre-operatively and at review. A multivariate analysis was performed to see whether BMI is an independent predictor of poor outcome.

We found that patients with a BMI of ? 35 kg/m2 have a 4.42 times higher rate of dislocation than those with a BMI < 25 kg/m2. Increasing BMI is also associated with superficial infection and poorer HHS and SF-36 scores at five years. These trends remain significant even when multivariate analysis adjusts for age, gender, prosthesis, operating consultant, pre-operative HHS and SF-36, and comorbidities including diabetes mellitus, cardiac disease and osteoporosis.

Despite the increased risks, the five-year outcome scores indicate that obese patients have much to gain from total hip replacement. Thus total hip replacement should not be withheld from patients solely on the grounds of an elevated BMI. However, longer-term follow-up of this cohort is required to establish whether adverse outcomes become more evident with time.

ANCA-associated vasculitis is linked to carriage of the Z allele of α₁ antitrypsin and its polymers

BACKGROUND

Small studies have linked α1 antitrypsin (α1AT) deficiency to patients with antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV).

OBJECTIVE

To test the validity and the mechanism of this association between α1AT and AAV.

METHODS

The distribution of α1AT deficiency alleles Z and S was compared between 856 White Europeans with AAV and 1505 geographic and ethnically matched healthy controls. Genotyping was performed by allelic discrimination assay.

RESULTS

were compared between cases and controls using χ(2) tests. The serum and renal biopsies for α1AT polymers were compared using the polymer-specific 2C1 antibody. The role of α1AT polymers in promoting inflammation was investigated by examining their ability to prime neutrophils for ANCA activation as assessed by CD62L shedding, superoxide production and myeloperoxidase degranulation. Results The Z but not the S allele was over-represented in the patients compared with controls (HR=2.25, 95% CI 1.60 to 3.19). Higher concentrations of polymers of α1AT were detected in serum from patients carrying the Z allele than in those not carrying the Z allele (median (IQR) 1.40 (0.91-3.32) mg/dl vs 0.17 (0.06-0.28) mg/dl, p<0.001); polymers of α1AT were also seen in the renal biopsy of a patient with vasculitic glomerulonephritis. Polymers of α1AT primed neutrophils with CD62L shedding and increased superoxide production following ANCA activation. Carriage of the Z allele was not associated with disease severity, survival or relapse.

CONCLUSIONS

The Z but not the S deficiency allele is associated with AAV. Polymers of α1AT are present in the serum and glomeruli of at least some patients with the Z allele, which may promote inflammation through priming of neutrophils.

The Genetic Counseling Outcome Scale: a new patient-reported outcome measure for clinical genetics services

The aim of this study was to develop a patient-reported outcome measure (PROM) for clinical genetics services. Previous research was used to develop a draft 84-item questionnaire, which was completed by 527 members of patient support groups. Responses were subjected to exploratory factor analysis (EFA). Parallel analysis was used to identify the number of factors to extract using oblique rotation. Twenty-four questions were selected to form the Genetic Counseling Outcome Scale (GCOS-24). Two hundred and forty-one patients completed a questionnaire pack before and after attendance at a genetics clinic that included the GCOS-24, and validated measures of health locus of control, perceived personal control, anxiety, depression, satisfaction with life and authenticity. Concurrent validity of the GCOS-24 was assessed using bivariate correlation. Sensitivity to change of the GCOS-24 was assessed using analysis of variance. EFA identified a single overarching construct consisting of seven dimensions. Internal consistency (α = 0.87) and test-retest reliability (r = 0.86) are good. The GCOS-24 shows convergent and divergent validities, and sensitivity to change over time with a medium-to-large effect size (Cohen's d = 0.70). The GCOS-24 has potential as a clinical genetics-specific PROM.

Recurrent miscarriage is associated with a family history of ischaemic heart disease: a retrospective cohort study

OBJECTIVE

To determine whether women experiencing recurrent miscarriage were more likely to have a family history of cardiovascular disease.

DESIGN

Retrospective cohort study.

SETTING

Women having a first birth in Scotland between 1992 and 2006.

SAMPLE

A total of 74, 730 first births were linked to the hospital admission and death certification data for the women's parents through the women's birth certificates.

METHODS

The incidence of cardiovascular disease in the women's parents was related to the number of miscarriages experienced before their daughters' first births using a Cox proportional hazards model.

MAIN OUTCOME MEASURES

Death or hospital admission of the women's parents for ischaemic heart disease (IHD), cerebrovascular disease (CVD) or venous thromboembolism (VTE).

MAIN RESULTS

There was an increased incidence of IHD in the parents of women who experienced two miscarriages before their first birth (hazard ratio 1.25, 95% CI 1.04-1.49) and parents of women who experienced three or more miscarriages before their first birth (hazard ratio 1.56, 95% CI 1.14-2.15). Adjustment for the characteristics of the women at the time of the first birth was without material effect. There was no significant association between miscarriage and family history of CVD or VTE. There was no significant association between the number of therapeutic terminations of pregnancy before the first birth and the incidence of any type of cardiovascular disease in the women's parents.

CONCLUSIONS

The parents of women who experience recurrent miscarriage are more likely to experience IHD. Recurrent miscarriage and IHD may have common patho-physiological pathways and genetic predispositions.

Primary cardiac angiosarcoma arising from the interatrial septum: magnetic resonance imaging appearances

We present a case of primary cardiac angiosarcoma arising from the interatrial septum that had imaging features overlapping with those of right atrial myxoma. The mass was initially discovered on a thoracic CT study. Further evaluation with echocardiography was limited by poor acoustic windows and cardiac magnetic resonance (CMR) imaging was performed prior to surgical resection. CMR provided a detailed morphological assessment; imaging features included a frond-like surface architecture, a narrow attachment point at the interatrial septum, mild signal hyperintensity compared with that of myocardium on T(1) weighted sequences, patchy foci of delayed gadolinium enhancement and a haemorrhagic pericardial effusion. To the best of our knowledge, this is the first reported case of angiosarcoma arising from the interatrial septum that has undergone evaluation with CMR.