How to interpret a cardiorespiratory fitness assessment - Key measures that provide the best picture of health, disease status and prognosis

Graded exercise testing is a widely accepted tool for revealing cardiac ischemia and/or arrhythmias in clinical settings. Cardiopulmonary exercise testing (CPET) measures expired gases during a graded exercise test making it a versatile tool that helps reveal underlying physiologic abnormalities that are in many cases only present with exertion. It also characterizes one's health status and clinical trajectory, informs the therapeutic plan, evaluates the efficacy of therapy, and provides submaximal and maximal information that can be used to tailor an exercise intervention. Practitioners can also modify the mode and protocol to allow individuals of all ages, fitness levels, and most disease states to perform a CPET. When used to its full potential, CPET can be a key tool used to optimize care in primary and secondary prevention settings.

2023 update: The importance of cardiorespiratory fitness in the United States

The American Heart Association issued a Policy Statement in 2013 that characterized the importance of cardiorespiratory fitness (CRF) as an essential marker of health outcomes and specifically the need for increased assessment of CRF. This statement summarized the evidence demonstrating that CRF is "one of the most important correlates of overall health status and a potent predictor of an individual's future risk of cardiovascular disease." Subsequently, this Policy Statement led to the development of a National Registry for CRF (Fitness Registry and the Importance of Exercise: A National Data Base [FRIEND]) which established normative reference values for CRF for adults in the United States (US). This review provides an overview of the progress made in the past decade to further our understanding of the importance of CRF, specifically related to prevention and for clinical populations. Additionally, this review overviews the evolvement and additional uses of FRIEND and summarizes a hierarchy of assessment methods for CRF. In summary, continued efforts are needed to expand the representation of data from across the US, and to include data from pediatric populations, to further develop the CRF Reference Standards for the US as well as further develop Global CRF Reference Standards.

Obesity management for cardiovascular disease prevention

Background

Obesity is a complex disease that leads to higher morbidity and mortality and its rate in the United States is rapidly rising. Targeting obesity management is one of the cornerstones of preventive medicine. Early intervention can significantly reduce the risk of developing cardiovascular disease. While it is well known that lifestyle interventions such as healthful nutrition and routine physical activity are the first and most important step in management, some do not achieve the desired results and require further therapies.

Methods

A literature review was conducted, that included clinical documents, public scientific citations and peer review articles to evaluate anti-obesity medications, endoscopic procedures and bariatric surgeries in the management of obesity. We also included effects of these interventions on weight loss, cardiovascular disease risk reduction and side effects.

Results

This clinical review summarizes recent evidence for the different approaches in obesity management including medications, common endoscopic procedures and bariatric surgeries. For more detailed review on the different management options discussed, we recommend reviewing Obesity Medicine Association Clinical Practice Statement [1].

Conclusion

Management of obesity reduces cardiovascular risk, improves metabolic parameters and other important health outcomes. Different management approaches are available, hence, a high level of awareness of the growing epidemic of obesity is needed to ensure timely referrals to obesity medicine specialists.

Blood Pressure and Cardiovascular Disease Mortality Among US Adults: A Sex-Stratified Analysis, 1999-2019

BACKGROUND

Most research examining the association between blood pressure (BP) and cardiovascular disease (CVD) is sex-agnostic. Our goal was to assess sex-specific associations between BP and CVD mortality.

METHODS

We combined ten cycles of the National Health and Nutrition Examination Survey (1999-2018), N=53 289. Blood pressure was measured 3× and averaged. Data were linked to National Death Index data, and CVD mortality through December 31, 2019, was defined from International Classification of Diseases, Tenth Revision codes. We estimated sex-stratified, multivariable-adjusted incidence rate ratios (IRRs) for CVD mortality.

RESULTS

Over a median follow-up of 9.5 years, there were 2405 CVD deaths. Associations between categories of systolic blood pressure (SBP) and diastolic blood pressure (DBP) with CVD mortality differed by sex (P<0.01). Among men, compared with SBP of 100 to <110 mm Hg, CVD mortality was 76% higher with SBP ≥160 mm Hg (IRR, 1.76 [95% CI, 1.27-2.44]). Among women, compared with SBP 100 to < 110 mm Hg, CVD mortality was 61% higher with SBP 130 to 139 mm Hg (IRR, 1.61 [95% CI, 1.02-2.55]), 75% higher with SBP 140 to 159 mm Hg (IRR, 1.75 [95% CI, 1.09-2.80]), and 113% higher with SBP≥160 mm Hg (IRR, 2.13 [95% CI, 1.35-3.36]). Compared with DBP 70 to <80 mm Hg, CVD mortality was higher with DBP <70 mm Hg and DBP≥80 mm Hg among men, and higher with DBP <50 mm Hg and DBP≥80 mm Hg among women.

CONCLUSIONS

The association between BP and CVD mortality differed by sex, with increased CVD mortality risk present at lower levels of systolic blood pressure among women compared with men.

What has cardiac rehabilitation looked like in the COVID-19 pandemic: Lessons learned for the future

The global coronavirus disease 2019 (COVID-19) pandemic prompted widespread national shutdown, halting or dramatically reducing the delivery of non-essential outpatient services including cardiac rehabilitation (CR). Center-based CR services were closed for as few as two weeks to greater than one year and the uncertainty surrounding the duration of the lockdown phase prompted programs to consider programmatic adaptations that would allow for the safe and effective delivery of CR services. Among the actions taken to accommodate in person CR sessions included increasing the distance between exercise equipment and/or limiting the number of patients per session. Legislative approval of reimbursing telehealth or virtual services presented an opportunity to reach patients that may otherwise have not considered attending CR during or even before the pandemic. Additionally, the considerable range of symptoms and infection severity as well as the risk of developing long lasting, debilitating symptoms has complicated exercise recommendations. Important lessons from publications reporting findings from clinical settings have helped shape the way in which exercise is applied, with much more left to discover. The overarching aim of this paper is to review how programs adapted to the COVID-19 pandemic and identify lessons learned that have positively influenced the future of CR delivery.

Ten things to know about ten cardiovascular disease risk factors - 2022

The American Society for Preventive Cardiology (ASPC) "Ten things to know about ten cardiovascular disease risk factors - 2022" is a summary document regarding cardiovascular disease (CVD) risk factors. This 2022 update provides summary tables of ten things to know about 10 CVD risk factors and builds upon the foundation of prior annual versions of "Ten things to know about ten cardiovascular disease risk factors" published since 2020. This 2022 version provides the perspective of ASPC members and includes updated sentinel references (i.e., applicable guidelines and select reviews) for each CVD risk factor section. The ten CVD risk factors include unhealthful dietary intake, physical inactivity, dyslipidemia, pre-diabetes/diabetes, high blood pressure, obesity, considerations of select populations (older age, race/ethnicity, and sex differences), thrombosis (with smoking as a potential contributor to thrombosis), kidney dysfunction and genetics/familial hypercholesterolemia. Other CVD risk factors may be relevant, beyond the CVD risk factors discussed here. However, it is the intent of the ASPC "Ten things to know about ten cardiovascular disease risk factors - 2022" to provide a tabular overview of things to know about ten of the most common CVD risk factors applicable to preventive cardiology and provide ready access to applicable guidelines and sentinel reviews.

0560 Rest-Activity Rhythms are Associated with Prevalent Cardiovascular Disease, Hypertension, Obesity, and Central Adiposity in a Nationally Representative Sample of US Adults

Introduction

Prior studies have linked rest-activity rhythms (RAR), a measure of circadian rhythmicity in the free-living setting, to morbidity and mortality. However, evidence is limited on the associations of RAR with adiposity, hypertension, and cardiovascular disease (CVD) in a nationally representative sample of US adults.

Methods

Participants were 4,822 adults (age:≥20y) from the 2013-2014 National Health and Nutrition Examination Survey, who participated in the physical activity monitoring examination. Data from a wrist-worn ActiGraph GT3X+ accelerometer were used to estimate non-parametric 24-h RAR variables. Logistic models adjusted for age, sex, race/ethnicity, education, marital status, smoking, and alcohol use were used to evaluate associations of RARs with prevalent CVD (self-reported), hypertension (blood pressure≥130/80mmHg or medication use), obesity (BMI≥30kg/m2), and central adiposity (waist circumference&gt;102cm for men and &gt;88cm for women).

Results

Participants (mean age: 48y, 53% female, 33% racial/ethnic minority) in the highest vs. lowest tertile of relative amplitude, indicative of more robust RAR, had lower odds of prevalent CVD (OR(95%CI):0.47(0.25-0.87)), hypertension (OR(95%CI):0.63(0.40-0.99)), obesity (OR(95%CI):0.50(0.36-0.69)), and central adiposity (OR(95%CI):0.50(0.36-0.69)). Those in the highest vs. lowest tertile of M10 counts, indicating a more active wake period, had 66%, 54%, and 39% lower odds of CVD, obesity, and central adiposity, respectively. In contrast, participants in the highest vs. lowest tertile of intradaily variability, indicative of more fragmented RARs, had &gt;2-fold (OR(95%CI):2.40(1.23-4.70)) and 40% (OR(95%CI):1.40(95%CI:1.04-1.88)) higher CVD and obesity odds, respectively. Further, those in the highest vs. lowest tertile of L5 midpoint, indicative of a later sleep period, had 68% and 41% higher odds for CVD and hypertension, while those with higher L5 counts, indicative of less efficient sleep, had 72%, 57%, and 79% higher hypertension, obesity, and central adiposity odds, respectively. A statistically significant linear trend was observed across RAR tertiles for all associations (p-trend&lt;0.05).

Conclusion

Robust RAR, an active wake period, and an earlier and more efficient sleep period are associated with lower odds for CVD, hypertension, obesity, and central adiposity, with evidence of a dose-response relationship. The timing, regularity, and periodicity of sleep-wake and rest-activity patterns may represent an important target for reducing cardiovascular risk in adults.

Support (If Any)

NHLBI R00-HL148511; AHA grant #855050

The importance of healthy lifestyle behaviors in the prevention of cardiovascular disease

Cardiovascular disease (CVD) is the leading cause of death globally. Advancements in the treatment of CVD have reduced mortality rates, yet the global burden of CVD remains high. Considering that CVD is still largely a preventable disease, prioritizing preventative measures through healthy lifestyle (HL) behaviors is necessary to lessen the burden of CVD. HL behaviors, such as regular exercise, healthy eating habits, adequate sleep, and smoking cessation, can influence a number of traditional CVD risk factors as well as a less commonly measured risk factor, cardiorespiratory fitness (CRF). It is important to note that cardiac rehabilitation programs, which traditionally have focused on secondary prevention, also emphasize the importance of making comprehensive HL behavior changes. This review discusses preventative measures to reduce the burden of CVD through an increased uptake and assessment of HL behaviors. An overview of the importance of CRF as a risk factor is discussed along with how to improve CRF and other risk factors through HL behavior interventions. The role of the clinician for promoting HL behaviors to prevent CVD is also reviewed.

Pro-fibrotic phenotype of bone marrow stromal cells in Modic type 1 changes

Modic type 1 changes (MC1) are painful vertebral bone marrow lesions frequently found in patients suffering from chronic low-back pain. Marrow fibrosis is a hallmark of MC1. Bone marrow stromal cells (BMSCs) are key players in other fibrotic bone marrow pathologies, yet their role in MC1 is unknown. The present study aimed to characterise MC1 BMSCs and hypothesised a pro-fibrotic role of BMSCs in MC1. BMSCs were isolated from patients undergoing lumbar spinal fusion from MC1 and adjacent control vertebrae. Frequency of colony-forming unit fibroblast (CFU-F), expression of stem cell surface markers, differentiation capacity, transcriptome, matrix adhesion, cell contractility as well as expression of pro-collagen type I alpha 1, α-smooth muscle actin, integrins and focal adhesion kinase (FAK) were compared. More CFU-F and increased expression of C-X-C-motif-chemokine 12 were found in MC1 BMSCs, possibly indicating overrepresentation of a perisinusoidal BMSC population. RNA sequencing analysis showed enrichment in extracellular matrix proteins and fibrosis-related signalling genes. Increases in pro-collagen type I alpha 1 expression, cell adhesion, cell contractility and phosphorylation of FAK provided further evidence for their pro-fibrotic phenotype. Moreover, a leptin receptor high expressing (LEPRhigh) BMSC population was identified that differentiated under transforming growth factor beta 1 stimulation into myofibroblasts in MC1 but not in control BMSCs. In conclusion, pro-fibrotic changes in MC1 BMSCs and a LEPRhigh MC1 BMSC subpopulation susceptible to myofibroblast differentiation were found. Fibrosis is a hallmark of MC1 and a potential therapeutic target. A causal link between the pro-fibrotic phenotype and clinical characteristics needs to be demonstrated.

Sleep, Sedentary Behavior, Physical Activity, and Cardiovascular Health: MESA

INTRODUCTION

Sleep, sedentary behavior, and physical activity are each independently associated with cardiovascular health (CVH). It is unknown how substituting time in sedentary behavior with sleep or physical activity affects overall CVH.

METHODS

Data for this analysis were taken from the Multi-Ethnic Study on Atherosclerosis Sleep Ancillary Study. Eligible participants (N = 1718) wore Actiwatch accelerometers for 24 h and had at least 3 d of valid accelerometry. The American Heart Association's Life's Simple 7 was used to represent the CVH score after excluding the physical activity component, with higher scores indicating more favorable CVH. Isotemporal substitution modeling was conducted to examine the effect of substituting 30 min of sedentary time for an equivalent amount of sleep, light-intensity physical activity (LIPA), or moderate to vigorous physical activity (MVPA).

RESULTS

Substituting 30 min of sedentary time to sleep, LIPA, and MVPA was associated with a significantly higher CVH score [β (95% confidence interval) = 0.077 (0.056), 0.039 (0.033), and 0.485 (0.127), respectively]. Substituting 30 min of sedentary time to sleep was associated with lower body mass index (BMI). Substituting 30 min of sedentary time to LIPA was associated with higher diastolic blood pressure and total cholesterol, and lower BMI. Substituting 30 min of sedentary time to MVPA was associated with lower systolic and diastolic blood pressure, and lower BMI.

CONCLUSIONS

Sleep, LIPA, and MVPA are all associated with more favorable overall CVH and several key risk factors for cardiovascular disease. These findings underscore the importance of lifestyle modifications in improving CVH.

Relations Between Physical Activity, Subclinical Myocardial Injury, and Cardiovascular Mortality in the General Population

We examined the association between poor physical activity (PA) and subclinical myocardial injury (SC-MI), and how concomitant exposure to poor PA and SC-MI modifies their association with cardiovascular disease (CVD) mortality. This analysis included 6,044 participants free of CVD from the NHANES-III survey. Leisure time PA was defined as: ideal (3 to 5.99 METs and ≥5 times/week or any PA with ≥6METs and ≥3times/week), intermediate (any activity other than ideal), or poor (no activity at all). SC-MI was defined as an electrocardiographic cardiac infarction/injury score ≥10 units. CVD mortality was ascertained from the National Death Index. In multivariable logistic regression analysis, poor PA (odds ratio [OR] [95% confidence interval, CI]: 1.30 [1.10 to 1.54]) and intermediate PA (OR [95%CI]: 1.19 [1.02 to 1.38]), compared with ideal PA, were associated with an increased odds of SC-MI. During a median follow-up of 14 years, 589 CVD deaths occurred. In multivariable Cox-proportional hazard analysis, the presence (vs absence) of SC-MI was associated with a 33% increased risk of CVD mortality whereas poor (vs ideal) PA was associated with a 67% increased risk of CVD mortality (HR [95%CI]: 1.33 [1.11 to 1.58] and 1.67 [1.37 to 2.05], respectively). Additionally, the concomitant presence of both poor PA and SC-MI were associated with a higher risk of CVD mortality (HR [95%CI]: 2.25[1.68 to 3.00]) compared with ideal PA and the absence of SC-MI. In conclusion, poor PA is associated with an increased risk of SC-MI and their concomitant presence is associated with a marked increase in CVD mortality, underscoring the potential role of PA in preventing clinical and subclinical CVD outcomes.

Incremental risk of cardiovascular disease and/or chronic kidney disease for future ASCVD and mortality in patients with type 2 diabetes mellitus: ACCORD trial

BACKGROUND

Cardiovascular disease (CVD) and chronic kidney disease (CKD) are complications of type 2 diabetes mellitus (DM). Current cholesterol guidelines recommend the same prevention strategy for patients with DM alone as patients with DM + CKD. However, the incremental risk of these common complications for incident cardiovascular disease and mortality has not been well studied.

METHODS

We compared the incremental risk of having DM + CKD, DM + CVD and DM + CVD + CKD in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial participants for incident CVD as the primary outcome and all-cause mortality.

RESULTS

After a mean (SD) follow up of 4.7(1.4) years, 1,046(10%) participants developed CVD. DM +vCKD, DM + CVD, and DM + CKD + CVD had a significantly increased risk of the primary outcome compared to DM alone [adjusted hazard ratio(95%CI): 1.41 (1.06-1.89), p = 0.02; 2.20 (1.92-2.53), p < 0.001); 2.35 (1.81-3.04), p < 0.001), respectively]. All-cause mortality had a graded increased risk compared to the reference group [adjusted hazard ratio(95%CI): 1.39 (1.01-1.90), p = 0.04; 1.29 (1.51-2.12), p < 0.0001; 2.36 (1.75-3.13), p < 0.0001), respectively].

CONCLUSION

Our post hoc analysis shows an incremental graded risk for CVD outcomes and all-cause mortality with the development of CKD and/or CVD in individuals with DM.

Abstract P106: Effects of Aldosterone Excess and Sodium on Dipping Patterns in Resistant Hypertensive Patients

Background: High dietary sodium intake and aldosterone excess have been independently linked to increased cardiovascular morbidity and mortality. In addition, a large body of literature indicates that aldosterone excess contributes importantly to antihypertensive treatment resistance and is associated with higher 24- hour ambulatory blood pressure (BP) levels.

Objective: This study was designed to determine if high dietary sodium intake, and hyperaldosteronism combine to mediate the development of abnormal diurnal BP patterns including nocturnal hypertension and dipping BP patterns.

Methods: A single-center cohort of 326 African American (AA) and Caucasian resistant hypertensive patients were prospectively evaluated by assessing 24-hr urinary aldosterone (UAldo), plasma renin activity (PRA), sodium (UNa + ) levels, and 24-hr ambulatory blood pressure monitoring (ABPM). Daytime, night-time, and 24-hr BP and dipping patterns were determined. High sodium excretion was defined as UNa + = 200 mEq/24hr and hyperaldosteronism was defined as UAldo = 12 μg/24hr and PRA ≤ 1 ng/ml/hr.

Results: There was no difference in ABPM and dipping patterns when comparing the normal versus high sodium group. However, patients without high sodium excretion had better nocturnal (p=0.024) and 24- hour BP control (p=0.036). Furthermore, there was no difference in ABPM patterns when comparing patients with high versus normal sodium excretion with hyper versus non- hyperaldosteronism. Interestingly, in the group with hyperaldosteronism, patients with normal sodium excretion had improved dipping patterns, but only in the dipper group (p=0.016).

Conclusions: High dietary sodium intake contributes to increased nocturnal hypertension and poor 24-h BP control, but there does not seem to be a significant relationship between hyperaldosteronism and high dietary sodium intake. This data suggests that improvements in dietary sodium intake will lead to better control of nighttime BP and 24-h BP control and therefore reduces the risk of cardiovascular disease. Further studies are underway comparing these relationships in males versus females, and AAs versus Caucasians.

Simulation-based training in echocardiography

The knowledge gained from echocardiography is paramount for the clinician in diagnosing, interpreting, and treating various forms of disease. While cardiologists traditionally have undergone training in this imaging modality during their fellowship, many other specialties are beginning to show interest as well, including intensive care, anesthesia, and primary care trainees, in both transesophageal and transthoracic echocardiography. Advances in technology have led to the development of simulation programs accessible to trainees to help gain proficiency in the nuances of obtaining quality images, in a low stress, pressure free environment, often with a functioning ultrasound probe and mannequin that can mimic many of the pathologies seen in living patients. Although there are various training simulation programs each with their own benefits and drawbacks, it is clear that these programs are a powerful tool in educating the trainee and likely will lead to improved patient outcomes.

Three-dimensional echocardiographic assessment of atrial septal defects

Echocardiography provides a useful tool in the diagnosis of many congenital heart diseases, including atrial septal defects, and aids in further delineating treatment options. Although two-dimensional echocardiography has been the standard of care in this regard, technological advancements have made three-dimensional echocardiography possible, and the images obtained in this new imaging modality are able to accurately portray the morphology, location, dimensions, and dynamic changes of defects and many other heart structures during the cardiac cycle.

Brain asymmetry and facial attractiveness: facial beauty is not simply in the eye of the beholder

We recently reported finding asymmetry in the appearance of beauty on the face [Zaidel et al., Neuropsychologia, Vol. 33, pp. 649-655, 1995]. Here, we investigated whether facial beauty is a stable characteristic (on the owner's very face) or is in the perceptual space of the observer. We call the question 'the owner vs observer hypothesis'. We compared identity judgements and attractiveness ratings of observers. Subjects viewed left-left and right-right composites of faces and decided which most resembled the normal face (Experiment 1). Identity judgements (resemblance) are known to be associated with perceptual factors in the observer. Another group viewed the same normal faces and rated them on attractiveness (Experiment 2). In each experiment, there were two separate viewing conditions, original and reversed (mirror-image). Lateral reversal did affect the results of Experiment 1 (confirming previous findings [Bennett et al., Neuropsychologia, Vol. 25, pp. 681-687, 1987; Gilbert and Bakan, Journal of Anatomy, Vol. 183, pp. 593-600, 1993]) but did not affect the results of Experiment 2. The fact that lateral reversal did not affect the results of Experiment 2 suggests that facial attractiveness is more dependent on physiognomy (of the owner) and less dependent on an asymmetrical perceptual process (in the observer) than is facial identity. The results are discussed in the context of beauty's biological significance and facial processing in the brain.

She is not a beauty even when she smiles: possible evolutionary basis for a relationship between facial attractiveness and hemispheric specialization

The asymmetrical status of facial beauty has rarely been investigated. We studied positive facial characteristics, attractiveness and smiling, through the use of left-left and right-right composites of unfamiliar faces of women and men with natural expressions. Results showed that women's right-right composites were judged significantly more attractive than left-left composites while there was no left-right difference in men's composites (Experiment 1). On the other hand, left-left composites were judged to have more pronounced smiling expressions than right-right composites in both women's and men's faces (Experiment 2). The results confirm previous findings for leftward facial expressiveness and show for the first time asymmetry in facial attractiveness and a difference in its manifestation in women's and men's faces. The findings have biological implications for the relationship between the appearance of the sides of the face and hemispheric specialization. The organization of beauty in the human face may have been shaped by evolutionary pressures on facial asymmetries, especially as they pertain to mate selection.

Cardiac sympathetic and parasympathetic activity during self-regulation of heart period

Fourteen subjects attempted to increase and 15 attempted to decrease cardiac interbeat interval (IBI) while being provided with biofeedback of IBI, T-wave vector magnitude (TWVM), or respiratory sinus arrhythmia (RSA). Subjects in both groups showed directional change in IBI relative to a tracking control task, but the three types of feedback did not differentially affect performance. Voluntary IBI increases were associated with significant increases in TWVM and RSA, and voluntary IBI decreases were associated with significant reductions in RSA and nonsignificant reductions in TWVM. This pattern of results suggests that alterations in cardiac vagal tone are involved in voluntary IBI increase and decrease tasks. The results also suggest a role for cardiac sympathetic nervous activity in voluntary IBI increase. The role of changing respiration cycle period was also investigated.

Revised Craig Lipreading Inventory

The two purposes of this study were to shorten the Craig Lipreading Inventory without affecting its reliability and validity and to establish normative data on the revised version. The full inventory was administered to 75 children. By item analysis, half of the items were selected to comprise the brief version; both versions were administered to another group of 75 children. Scores on the two versions correlated (.91 and .92, respectively, for Word Forms A and B and .97 and .95, respectively, for Sentence Forms A and B), thereby substantiating the construct validity of the briefer version. There was significantly high intertest reliability for the Word Forms (.80) and Sentence Forms (.82) of the briefer inventory. Normative data were computed for each age group. This briefer version is a temporally efficient tool for evaluating lipreading ability of children.

Hemophilus influenzae cellulitis of the hand

Hemophilus influenzae type b cellulitis of the hand is a rare infection presenting mainly in the 2-month to 3-year age group. Three proven cases and one clinical case are reported, and the bacteriology and management are discussed. Most of these infections respond to ampicillin and/or chloramphenicol. One must include H. influenzae type b in the differential diagnosis of cellulitis of the hand in this age group and specify this possibility on all cultures so that appropriate identification of the organism can be made.

Arteriovenous fistula and paralysis of mandibular branch of facial nerve following direct wiring of a jaw fracture: case report

We present a case in which interosseous wiring of the mandible resulted in an A-V fistula and an injury to the mandibular ramus of the facial nerve. These two complications can serve as a reminder to all who desire to use interosseous wiring in the treatment of mandibular fractures.