The prediction of postoperative stroke or death in patients with preoperative atrial fibrillation undergoing non-cardiac surgery: a VISION sub-study

BACKGROUND

The optimal means of pre-operative risk stratification in patients with atrial fibrillation (AF) is uncertain.

OBJECTIVE

To examine the accuracy of AF thromboembolic risk models (the CHADS2, CHA2DS2-VASc, and R2CHADS2 scores) for predicting 30-day stroke and/or all-cause mortality after non-cardiac surgery in patients with preoperative AF, and to compare these risk scores with the Revised Cardiac Risk Index (RCRI).

PATIENTS/METHODS

A multicentre (8 countries, 2007-2011) prospective cohort study of patients ≥ 45 years of age undergoing inpatient non-cardiac surgery, who were followed until 30 days after surgery. We calculated c-statistics for each risk prediction model and net reclassification improvements (NRIs) compared with the RCRI.

RESULTS

The 961 patients with preoperative AF were at higher risk of any cardiovascular event in the 30 days postoperatively compared with the 13 001 patients without AF: 26.6% vs. 9.0%; adjusted odds ratio, 1.58; 95% confidence interval [CI], 1.33-1.88. All thromboembolic risk scores predicted postoperative death just as well as the RCRI (with c-indices between 0.67 and 0.72). Compared with the RCRI (which had a c-index of 0.64 for 30-day stroke/death), the CHADS2 (c-index, 0.67; NRI, 0.31; 95% CI, 0.02-0.61) significantly improved postoperative stroke/mortality risk prediction, largely due to improved discrimination of patients who did not subsequently have an event.

CONCLUSIONS

In AF patients, the three thromboembolic risk scores performed similarly to the RCRI in predicting death within 30 days and the CHADS2 score was the best predictor of postoperative stroke/death regardless of type of surgery.

Influence of a scheduled-waiting task on EMG reactivity and oral habits among facial pain patients and no-pain controls

Recent research has strongly implicated the role of psychological stress in the development of temporomandibular disorders (TMD). It is widely reported that oral habits (e.g., teeth grinding) probably provide a behavioral link between stress and the development of TMD symptomatology. Extrapolation of research in the field of adjunctive behavior to the TMD disorders suggests that oral behaviors may develop conjointly with fixed-time (FT) stimulus presentation. The current experiment extended previous research examining this possibility by assessing the influence of experimental stress on masseter EMG and oral habits among persons who met broadband criteria for TMD and no-pain controls. Oral habit activity was assessed via self-report questionnaire whereas masseter muscle activity was measured continuously via electromyography across four phases (Adaptation, Free-Play, Scheduled-Play, Recovery). The Scheduled-Play phase was designed as a stress-reactivity task that included an FT schedule. Results indicated that, consistent with the stress-reactivity model, the Scheduled-Play phase resulted in a significant increase in masseter EMG levels relative to Free-Play and Adaptation, and that this effect was significantly larger for the TMD group relative to controls. The results suggest an adjunctive behavior effect although the effect was not specific to those with facial pain. Oral habit data showed a significant phase effect with oral habits that was significantly higher during the Scheduled-Play phase relative to Adaptation. The findings are the impetus for further study regarding the mechanisms whereby oral habits are developed and maintained despite their painful consequences.

Intramedullary nailing of femoral shaft fractures in children via the trochanter tip

Closed rigid intramedullary nailing of femoral shaft fractures in children has been associated with avascular necrosis of the femoral head. Avascular necrosis of the femoral head is thought to result from damage to the medial femoral circumflex artery by placing the nail through the piriformis fossa. The authors describe the early results of a technique in which the nail is placed through the tip of the greater trochanter, thus avoiding the piriformis fossa and possible damage to the medial circumflex artery. Between 1988 and 1995, the authors performed this procedure on 34 patients, who ranged in age from 10 years 2 months to 17 years 6 months. Followup time ranged from 1 month to 120 months. There were no infections, nonunions, rotational deformities, or implant failures. Twenty patients with open physes had a followup of 2 years or more. To date, no patient had avascular necrosis of the femoral head develop. The trochanteric tip entry point is recommended for closed rigid intramedullary nailing of femoral shaft fractures in children and adolescents.

Early versus delayed reduction and pinning of type III displaced supracondylar fractures of the humerus in children: a comparative study

OBJECTIVES

To determine whether children with Type III displaced supracondylar fractures of the humerus that were pinned in a delayed fashion, defined as more than eight hours after fracture, had a greater need for open reduction than patients with similar fractures pinned more urgently, within eight hours after the trauma. Also, to determine whether those patients treated later fared any worse than patients treated earlier.

DESIGN

Retrospective review of consecutive patients.

SETTING

Level I pediatric trauma center at a tertiary children's hospital.

PATIENTS

Fifty-eight consecutive patients, twenty-three with early pinning and thirty-five with delayed pinning. A subgroup of sixteen patients was followed for detailed clinical outcome.

INTERVENTION

Closed or open reduction and percutaneous pinning

MAIN OUTCOME MEASUREMENTS

Need for open reduction in either group. A separate subgroup was examined for carrying angle and evidence of low-grade compartment syndrome (such as grip strength and range of motion).

RESULTS

There was no difference in the need for open reduction in the group that was delayed and pinned more than eight hours following fracture. Follow-up examination showed no clinical difference between the two groups in any parameter measured.

CONCLUSIONS

These results indicate that many supracondylar fractures of the humerus can be treated safely in a delayed manner with an excellent clinical result and without unduly prolonging the hospital stay (such as with traction). This allows the patient to be NPO and the surgeon to operate in daylight hours, saving time, hospital resources, and fatigue.

Demography of genotypes: failure of the limited life-span paradigm in Drosophila melanogaster

Experimental systems that are amenable to genetic manipulation can be used to address fundamental questions about genetic and nongenetic determinants of longevity. Analysis of large cohorts of ten genotypes of Drosophila melanogaster raised under conditions that favored extended survival has revealed variation between genotypes in both the slope and location of age-specific mortality curves. More detailed examination of a single genotype showed that the mortality trajectory was best fit by a two-stage Gompertz model, with no age-specific increase in mortality rates beyond 30 days after emergence. These results are contrary to the limited life-span paradigm, which postulates well-defined, genotype-specific limits on life-span and brief periods of intense and rapidly accelerating mortality rates at the oldest age.