Left atrial strain predicts heart failure in the general population

Background

Left atrial (LA) function has shown to be a significant predictor of cardiovascular outcomes. We sought to determine the prognostic value of LA strain in relation to incident heart failure (HF) in the general population.

Methods

The present study includes 3,540 participants from the general population without prevalent atrial fibrillation or HF. All participants underwent health examinations and echocardiography including measures of LA function by means of peak atrial longitudinal strain (PALS), peak atrial contraction strain (PACS), and LA strain during the conduit phase (LACS). Cox proportional hazards regressions were utilised to access the association between incident HF and LA strain parameters.

Results

Median age of the study population was 57 years (interquartile range: 40, 69) and 2,015 (57%) were female. During follow-up (median 5.4 years), 66 (2%) participants were diagnosed with HF. Participants who developed HF had lower PALS (26.4% vs. 36.6%, p<0.001), PACS (15.6% vs. 16.5%, p=0.016), and LACS (11.4% vs. 19.3%, p<0.001) at baseline. Lower values of all three LA strain parameters were associated with a higher risk of developing HF in univariable analysis (Figure 1 & 2). After multivariable adjustments for Framingham Risk Score and global longitudinal strain, PALS (HR=1.06, 95% CI [1.03; 1.09], p<0.001, per 1% decrease), PACS (HR=1.07, 95% CI [1.02; 1.12], p=0.003, per 1% decrease), and LACS (HR=1.05, 95% CI [1.01; 1.10], p=0.016, per 1% decrease) remained significantly associated with incident HF. However, in participants with normal-sized LA (LA volume index <34 ml/m2) and no ischemic heart disease (n=3,046), only PALS and PACS remained independent predictors of HF (Figure 2).

Conclusion

LA strain provides independent prognostic value regarding the risk of incident HF in the general population.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): The Danish Heart Foundation and The Metropolitan Region of Denmark

The prognostic value of right ventricular free wall and global longitudinal strain in the general population

Background

Right ventricular free wall (RVFWLS) and global longitudinal strain (RV4CLS) have been shown to be prognostic of adverse events in various patient groups including patients with heart failure (HF).

Purpose

We sought to investigate the prognostic value of RVFWLS and RV4CLS for the development of incident HF in participants from the general population.

Methods

Participants from the echocardiographic substudy of the 5th Copenhagen City Heart Study (2011–2015) without chronic ischemic heart disease or heart failure at baseline were included. RVFWLS and RV4CLS were obtained using two-dimensional speckle-tracking echocardiography from the RV-focused apical 4-chamber view. The primary endpoint was incident HF.

Results

Among 2,804 participants (mean age 55, 42% male), 45 (1.6%) developed HF during a median follow-up of 5.4 years (IQR 4.5–6.3). Both RVFWLS and RV4CLS were associated with increased risk of HF in univariable cox regression analysis (HR 1.07, 95% confidence interval (CI) 1.02–1.12, p=0.003, and HR 1.21, 95% CI 1.11–1.31, p<0.001, respectively). Upon adjustment for age, sex, hypertension, diabetes and body mass index (BMI), both RVFWLS and RV4CLS remained associated with increased risk of incident HF (HR 1.05, 95% CI 1.00–1.11, p=0.038 and HR 1.13, 95% CI 1.04–1.22, p=0.004, respectively).

Conclusion

RVFWLS and RV4CLS were associated with an increased risk of incident HF in participants from the general population independent of age, sex, hypertension, diabetes and BMI.

Funding Acknowledgement

Type of funding sources: None.

The effects of smoking on cardiac structure and function in a general population

Background

Cigarette smoking is the leading preventable cause of death worldwide. Smoking is known to cause coronary artery disease, but studies have also shown that smoking independently is associated with higher risk of heart failure. However, the link between smoking and cardiac structure and function is not yet fully examined.

Purpose

The aim of the study was to investigate the independent effect of cigarette smoking on cardiac structure and function in a general population using echocardiographic measures.

Methods

A prospective cohort of 3,874 participants from a general population free of prevalent heart disease underwent an echocardiographic examination including two-dimensional speckle-tracking analysis. Smoking history was obtained through a self-administered questionnaire, that generated three groups; current smokers (18.6%), former smokers (40.9%) and never smokers (40.5%). Pack-years were estimated from the questionnaire.

Results

After multivariable adjustment for age, sex, body mass index, hypertension, hypercholesterolemia, diabetes and lung function, current smokers had significantly alterations in septal thickness (1.1±0.2 cm, P=0.018) and relative wall thickness (0.4±0.1 cm, P=0.016) compared to never smokers. Furthermore, left ventricular mass index (LVMi) was increased in current smokers compared to never smokers (85.8±19.3 g/cm2, P=0.048). Reduced left ventricle systolic function as assessed by global longitudinal strain (GLS) was evident in current smokers compared to never smokers (19.1±2.3%, P<0.001). Additionally, after multivariable adjustment increasing pack-years was associated with decreases in left ventricular ejection fraction (LVEF) (β=−0.04, P=0.031), E/A ratio (β=−0.06, P<0.001) and GLS (β=−0.04, P=0.008). Comparing cardiac structure and function in never smokers, continuous smokers and former smokers after 10 years, showed that continuous smokers developed increased LVMi (Δ=3.97±17.48 g/cm2, P<0.001) and decreased GLS (Δ=−0.77±3.84%, P=0.04) and LVEF (Δ=−4.23±5.7, P<0.001) compared to never and former smokers.

Conclusion

In a large general population study without known heart disease, current smoking and accumulated pack-years were independently associated with alterations in cardiac structure and reduced systolic function. Furthermore, we found that continuous smokers over a 10-year period developed relatively worse systolic function and increased LV structure alterations compared to never smokers and to participants that stopped smoking during that period.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Copenhagen City Heart Study is funded by The Danish Heart Foundation andThe Metropolitan Region of Denmark.

[Current trends in reverse fracture arthroplasty]

The reliable results of reverse arthroplasty have made this the preferred treatment method for non-reconstructable proximal humeral fractures. The individual consideration of the patient and the morphological features of the fractures are essential. Computed tomography (CT) images provide crucial information on the perfusion of the humeral head relevant for the prognosis and treatment. In this context a differentiation must be made between hard and soft criteria against a reconstruction. Tuberosities should be reduced whenever possible, because reverse arthroplasty with healed tuberosities provides a better range of motion and more strength for external rotation and anteversion, less complications and longer survival rates. In recent years the trend has been towards anatomical designs of prostheses with a humeral inclination of 135°. Revision rates for primary fracture prostheses are overall low with instability as the main reason for revision surgery, followed by periprosthetic fractures and infections. Reverse fracture arthroplasty has comparable or better clinical results compared to conservative treatment, osteosynthesis for geriatric patients, hemiarthroplasty and prosthesis implantation by elective surgery. Reverse arthroplasties, which were implanted in conditions of fracture sequelae, did not achieve significantly poorer clinical outcome at mid-term follow-up and can significantly improve shoulder function.

The distribution and relationship between 3D LVEF and 3D strain in a general population

Introduction

Three-dimensional (3D) echocardiography (3DE) is currently extensively used to estimate left ventricle (LV) morphology and heart valves. However, it is underutilized in the assessment of LV function. Most likely, it is due to limited knowledge of the normal reference intervals. In order to fill this knowledge gap, studies which investigates the 3DE reference ranges in a larger cohort of a general population are needed. The objective of the current study was to study the relationship and distribution of 3D LV ejection fraction (EF) and its corresponding strain values in subjects enrolled in Copenhagen City Heart Study (CCHS).

Methods

The echocardiograms were acquired from CCHS subjects from 2011–2014 by using GE Vivid E9 (GE Medical, Copenhagen, Denmark), during four consecutive heart beats. Exclusion critera were missing data or measurements in 3D, poor image quality or frame rate (<12 fps) and, based on visual evaluation of the echocardiograms, inappropriate tracking of three or more myocardial segments in the strain analysis. The echocardiograms were analysed in 2019 on EchoPacTM v. 201 (GE Medical, Copenhagen, Denmark).

Results are presented in means, interquartile ranges (IQR) and as adjusted correlation values (r2). R2 values equal to or above 0.64 (equals to r=0.8) were considered as strong correlation. LV function parameters included were LVEF, global longitudinal strain (GLS), global circumferential strain (GCS) and area strain (AS). LVEF and strain results are presented as percentages (%). The distribution and relationship between 3D LVEF, GLS, GCS and AS are visualized as scatter plots and box-whiskers plots. The statistical analysis and the visualisation of the data was performed in RStudio v. 3.5.1. P-values <0.005 were considered as markers for statistical significance.

Results

There were 2955 subject with available 3DEs in CCHS among which 1202 subjects had sufficient image quality for evaluation. The mean 3D LVEF was 54.6% (IQR: 50–60%), 3D GLS −14.5% (IQR: −13 to −16), 3D GCS −13.4% (IQR: −11 to −15) and AS −24.7% (IQR: −22 to −27).

The adjusted correlation values between LVEF with strain parameters were: 0.04 (GLS), 0.37 (GCS) and 0.26 (AS), which was poor.

Conclusion

This study provides valuable data of the distribution of 3D LVEF and its corresponding 3D strain values in a general population. The 3D strain values are lower than the reference interval described in literature for two-dimensional echocardiography. Moreover, correlation was also found to be poor between LVEF and different strain parameters.

3D LVEF vs. 3D Strain (GLS, GCS, AS)

Funding Acknowledgement

Type of funding source: None

THU0425 ULTRASOUND DETECTED URATE CRYSTALS DEPOSITIONS ARE ASSOCIATED WITH ELEVATED CALPROTECTIN AND CRP INDICATING SUBCLINICAL INFLAMMATION; BASELINE RESULTS FROM THE NOR-GOUT STUDY

Background:

Ultrasound detects depositions of monosodium urate (MSU) crystals in gout patients. The OMERACT ultrasound group has developed definitions for elementary lesions in gout including the double contour (DC) sign (depositions of crystals on the surface of cartilage) and tophus (larger hypo-echoic aggregation of crystals, usually well delineated). Calprotectin is a major granulocyte protein found to be sensitive to reflect the level of inflammation in several immunological diseases. There may be an association between low grade inflammation and co-morbidity (including cardio-vascular pathology) in gout patients.

Objectives:

To explore whether the extent of depositions (e.g. DC and tophi) was associated with inflammation in gout patients.

Methods:

The baseline data from NOR-GOUT, a prospective observational study of patients with crystal-proven gout with increased serum urate levels (>360 μmol/L), were presently used. All patients had an extensive ultrasound examination(GE E9 machine, grey scale 15MHz) to assess MSU depositions (DC and tophi) with bilateral assessment of radiocarpal joint, MCP 2, insertion of triceps and quadriceps, proximal and distal patellar and the Achilles tendon, cartilage of distal femur (maximal flexed knee), the talar cartilage of tibiotalar joint and MTP 1 joint. The degree of elementary lesions was semi-quantitatively scored 0-3 (0=none, 1=possible, 2=certain, 3=major deposits). Total sum scores of DC and tophi were calculated and the associations with calprotectin (plasma assessed by ELISA (Calpro), normal levels <910 µg/L) as well as C-reactive protein (CRP, assessed as a routine at our laboratory, normal levels <4mg/L) were explored. Correlations were performed by use of Spearman and differences between groups were investigated by Mann-Whitney tests.

Results:

A total of 111 patients who had calprotectin assessed were included in the study (92% men, mean (SD) age 54.5 (14.5) years, disease duration 7.1 (6.6) years) when initiating MSU lowering treatment. The mean (SD) sum sore DC and tophi was 9.1 (7.8), calprotectin 780 (500) µg/L, CRP 7 (15) mg/L, serum urate (SUA) 505 (87) μmol/L, creatinine 96 (18) μmol/l and eGFR 79 (20) ml/min/1.73m2. Table 1 shows significant correlations between sum sore DC/tophi and calprotectin, CRP, SUA, creatinine and eGFR. Increased calprotectin levels (≥910 µg/L) were found in 28% and increased CRP (≥ 4 mg/L) in 39%. Patients with increased vs normal levels of calprotectin had significantly higher levels of DC/tophi depositions (mean (SD) 13.0 (10.4) vs 7.4 (5.8), p=0.01), and similar was found for CRP (11.4 (9.5) vs 7.6 (6.2), p=0.033) (illustrated in table 2).

Conclusion:

In gout patients, higher load of MSU depositions was associated with increased inflammatory markers. This indicates that the amount of depositions is associated with higher inflammatory activity, which could have systemic implications.

Sum score DC and tophiCalprotectinCRPSUACreatinineCalprotectin0.31*CRP0.29*0.65**SUA0.31**0.22*0.19Creatinine0.34**0.25*0.150.36**eGFR-0.38**-0.27*-0.21*-0.18-0.86**

*p≤0.05, **p≤0.001

Disclosure of Interests: :

Hilde Berner Hammer Consultant of: Has received fees as consultant from Roche, AbbVie and Novartis., Speakers bureau: Has received fees for speaking from AbbVie, BMS, Pfizer, UCB, Roche, MSD and Novartis, Gro Jensen: None declared, Lars Karoliussen: None declared, Lene Terslev Speakers bureau: LT declares speakers fees from Roche, MSD, BMS, Pfizer, AbbVie, Novartis, and Janssen., Espen Andre Haavardsholm Grant/research support from: Research funding from Pfizer, UCB, Roche, MSD and AbbVie, Consultant of: Pfizer, Speakers bureau: Pfizer, UCB, Roche, and AbbVie,, Tore K. Kvien Grant/research support from: Received grants from Abbvie, Hospira/Pfizer, MSD and Roche (not relevant for this abstract)., Consultant of: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Paid instructor for: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Speakers bureau: Have received personal fees from Abbvie, Biogen, BMS, Celltrion, Eli Lily, Hospira/Pfizer, MSD, Novartis, Orion Pharma, Roche, Sandoz, UCB, Sanofi and Mylan (not relevant for this abstract)., Till Uhlig Consultant of: Lilly, Pfizer, Speakers bureau: Grünenthal, Novartis

P2441The prognostic value of left atrial dyssynchrony in the general population

Introduction

Parameters derived from left atrial (LA) speckle tracking such as LA peak reservoir strain and LA dyssynchrony are potent predictors of cardiovascular morbidity and mortality in various patient populations. However, whether LA dyssynchrony as evaluated by speckle tracking is associated with long-term outcome in the general population is currently unknown.

Methods

In a cohort study with participants from the general population 385 participants without atrial fibrillation (AF), ischemic heart disease (IHD), heart failure (HF) or previous ischemic stroke (IS) had a health examination and an echocardiogram, including LA speckle tracking, performed. LA dyssynchrony was defined as the standard deviation of the time to peak regional atrial reservoir strain values. The endpoints were all-cause mortality, a combined endpoint of AF and IS, and a combined endpoint of major adverse cardiovascular events (MACE) comprised of acute myocardial infarction (AMI), HF or cardiovascular death (CVD).

Results

Median LA dyssynchrony was 42 ms (IQR: 22–58 ms), 60% percent of included participants were women, mean age was 55 years (SD 16 years), 34% had hypertension and 7% had diabetes mellitus. During a median follow up of 16.1 years (IQR 15.0–16.3 years), 83 (22%) participants died, 60 (15%) reached the composite endpoint of AF and IS, and 38 (10%) reached the composite MACE endpoint.

Increasing LA dyssynchrony was associated with increasing age, lower estimated glomerular filtration rate, lower E/A ratio, lower e' and higher E/e'. In a univariable Cox regression, LA dyssynchrony was a significant predictor of all-cause mortality (HR 1.07, 95% CI 1.02–1.11, p=0.001, per 10 ms increase) but was not significantly associated with the combined endpoint of AF and IS (HR 1.05, 95% CI 1.00–1.10, p=0.064, per 10 ms increase) nor MACE (HR 1.04, 95% CI 0.98–1.12, p=0.22, per 10 ms increase). However, when adjusted for age, LA dyssynchrony did not predict all-cause mortality (HR 1.03, p=0.28), the combined endpoint of AF and IS (HR 1.01, p=0.83), or MACE (HR 0.99, p=0.88,). Similarly, after further adjustment for age, sex, smoking status, systolic blood pressure and cholesterol, LA dyssynchrony did not predict any of the study outcomes (All-cause mortality: HR 1.01, p=0.72) (AF and IS: HR 0.98, p=0.88) (MACE: HR 1.00, p=0.93).

Conclusion

In this general population study, LA dyssynchrony was not an independent predictor of all-cause mortality and did not predict MACE nor a composite outcome consisting of AF and IS.

[Plate osteosynthesis after patellar fracture - the technique and initial results of a prospective study]

BACKGROUND

Tension band wiring after patellar fractures is related to a high number of implant-related complications (22-53 %). Revision surgery is necessary in 10-55 % of patients mostly with unsatisfactory results. The patella plate is an alternative treatment with the advantages of locked plating. The purpose of this study was to evaluate the first clinical prospective results and complications of this new implant.

MATERIALS AND METHODS

Between April 2013 and May 2015 all patients that were treated with locked plating for patella fractures were included in this prospective study. Patients were followed-up clinically after six weeks and six months.

RESULTS

Included in this study were 17 patients, 6 women and 11 men, with a mean age of 58 years (19-87). The knee range of motion was 120° after 6 weeks and improved to 138° after 6 months, corresponding to 84 % and 97 % of the range of motion of the healthy opposite knee. The Tegner activity scale increased from 2,5 to 3,5 (initial value: 4), the Lysholm score increased from 78 to 92 points (initial value: 97) and the Kujala score increased from 72 to 88 points (initial value: 96). Two complications occurred: one patient had a reactive bursitis prepatellaris and one patient sustained a loss of reduction.

CONCLUSION

Locked plating of patella fractures is a reliable alternative treatment with good functional outcomes and low complication rates.

Sex-specific relevance of diabetes to occlusive vascular and other mortality: a collaborative meta-analysis of individual data from 980 793 adults from 68 prospective studies

BACKGROUND

Several studies have shown that diabetes confers a higher relative risk of vascular mortality among women than among men, but whether this increased relative risk in women exists across age groups and within defined levels of other risk factors is uncertain. We aimed to determine whether differences in established risk factors, such as blood pressure, BMI, smoking, and cholesterol, explain the higher relative risks of vascular mortality among women than among men.

METHODS

In our meta-analysis, we obtained individual participant-level data from studies included in the Prospective Studies Collaboration and the Asia Pacific Cohort Studies Collaboration that had obtained baseline information on age, sex, diabetes, total cholesterol, blood pressure, tobacco use, height, and weight. Data on causes of death were obtained from medical death certificates. We used Cox regression models to assess the relevance of diabetes (any type) to occlusive vascular mortality (ischaemic heart disease, ischaemic stroke, or other atherosclerotic deaths) by age, sex, and other major vascular risk factors, and to assess whether the associations of blood pressure, total cholesterol, and body-mass index (BMI) to occlusive vascular mortality are modified by diabetes.

RESULTS

Individual participant-level data were analysed from 980 793 adults. During 9·8 million person-years of follow-up, among participants aged between 35 and 89 years, 19 686 (25·6%) of 76 965 deaths were attributed to occlusive vascular disease. After controlling for major vascular risk factors, diabetes roughly doubled occlusive vascular mortality risk among men (death rate ratio [RR] 2·10, 95% CI 1·97-2·24) and tripled risk among women (3·00, 2·71-3·33; χ2 test for heterogeneity p<0·0001). For both sexes combined, the occlusive vascular death RRs were higher in younger individuals (aged 35-59 years: 2·60, 2·30-2·94) than in older individuals (aged 70-89 years: 2·01, 1·85-2·19; p=0·0001 for trend across age groups), and, across age groups, the death RRs were higher among women than among men. Therefore, women aged 35-59 years had the highest death RR across all age and sex groups (5·55, 4·15-7·44). However, since underlying confounder-adjusted occlusive vascular mortality rates at any age were higher in men than in women, the adjusted absolute excess occlusive vascular mortality associated with diabetes was similar for men and women. At ages 35-59 years, the excess absolute risk was 0·05% (95% CI 0·03-0·07) per year in women compared with 0·08% (0·05-0·10) per year in men; the corresponding excess at ages 70-89 years was 1·08% (0·84-1·32) per year in women and 0·91% (0·77-1·05) per year in men. Total cholesterol, blood pressure, and BMI each showed continuous log-linear associations with occlusive vascular mortality that were similar among individuals with and without diabetes across both sexes.

INTERPRETATION

Independent of other major vascular risk factors, diabetes substantially increased vascular risk in both men and women. Lifestyle changes to reduce smoking and obesity and use of cost-effective drugs that target major vascular risks (eg, statins and antihypertensive drugs) are important in both men and women with diabetes, but might not reduce the relative excess risk of occlusive vascular disease in women with diabetes, which remains unexplained.

FUNDING

UK Medical Research Council, British Heart Foundation, Cancer Research UK, European Union BIOMED programme, and National Institute on Aging (US National Institutes of Health).

[Injuries of the acromioclavicular joint: Hook plate versus arthroscopy]

Acute acromioclavicular (AC) joint injuries are common in clinical practice. The hook plate is a well-established conventional operative treatment option for high grade instability; however, arthroscopically-assisted flexible double button techniques are increasingly being used. Both procedures lead to good or excellent results. The advantages of the hook plate are the simple surgical technique and the possibility of an early functional aftercare. The minimally invasive one-step procedure with the possibility of identification and treatment of frequently concomitant glenohumeral pathologies is advantageous for the arthroscopic technique but mobilization is more restrictive. Available comparative studies have shown no significant clinical differences but a tendency towards better results with a higher degree of acceptance among patients for the arthroscopic and minimally invasive non-rigid double button procedures.

[Suprapectoral mini-open biceps tenodesis - functional and sonographic results]

BACKGROUND

Aim of this study was to evaluate the effectiveness of a suprapectoral mini-open tenodesis of the long head of the biceps (LHB) tendon with ultrasound assessment. Secondary aim was to compare the results of an extraosseous fixation (group I) to those of an intraosseous fixation technique (group II).

PATIENTS AND METHODS

25 patients (10 female, 15 male) aged 54 ± 8 (36 to 68) years were followed-up 21 ± 4.7 (13 to 32) months postoperatively. Tenodesis fixation was extraosseous in 12 (group I) and intraosseous in 13 patients (group II). Preoperative shoulder function and intraoperative findings were recorded. At the time of follow-up the fixation of the biceps tendon was evaluated by ultrasound examination. Furthermore, the shoulder function, the simple shoulder test (SST), the Constant-Murley score (CMS) and the "long head of the biceps (LHB) score" were assessed.

RESULTS

Failure of tenodesis fixation was observed in 3/12 cases (25 %) of group I and 1/13 cases (8 %) of group II. Shoulder flexion (p < 0.001), abduction (p < 0.001), external rotation (p < 0.001) and the pain level (p < 0.001) improved significantly compared to the preoperative status. At time of follow-up the CMS averaged 79.4 ± 13 points, the age and gender related CMS averaged 95.7 ± 16.4 %. Mean SST was 10.6 ± 2.1 points. No significant difference (p = 0.064) could be observed between the LHB of the affected (88.1 ± 9.7) versus the non-affected shoulder (92.7 ± 13.6 points). Age and gender related CMS (p = 0.96), LHB score (p = 0.16) and SST (p = 0.94) of both groups revealed no significant differences.

CONCLUSION

The intraosseous fixation technique seems favourable with less fixation failure compared to the extraosseous suspension technique. The suprapectoral mini-open tenodesis of the LHB is a valuable alternative tenodesis technique with good to excellent clinical results.

[Corrective osteosynthesis of proximal humeral fractures. Technique and prospective results]

BACKGROUND

Fracture sequelae of proximal humeral fractures arise following nonoperative and operative forms of treatment. Due to a painful restricted range of motion, in most cases shoulder prostheses are implanted. There is a need for joint-preserving alternatives especially for younger patients.

OBJECTIVES

The aim of this study was to evaluate the surgical techniques and prospective results of fracture sequelae of proximal humeral fractures following corrective osteosynthesis.

MATERIAL AND METHODS

A total of 11 patients (4 female) with an average age of 53 years (range 29-71 years) and a mean follow-up of 19.5 months were included prospectively. The preoperative and postoperative ranges of motion of the affected shoulder were compared by statistical means. At the time of follow-up the constant score (CS), the simple shoulder test (SST) and the simple shoulder value (SSV) were assessed.

RESULTS

Fracture sequelae were classified as type II in four patients, as type III in two and as type IV in five patients using the Boileau classification. Shoulder flexion (p = 0.006), abduction (p = 0.003) and external rotation (p = 0.02) improved significantly in the postoperative course. The mean age and gender-adapted CS was 74.8 ± 19.9 % at the time of follow-up, 10.1 out of 12 points were reached in the SST and the mean SSV was 77 %.

CONCLUSION

Corrective osteosynthesis of fracture sequelae (Boileau types II-IV) of proximal humeral fractures appears to be a good alternative to implantation of shoulder prostheses, especially in younger patients (< 60 years of age).

[Shoulder stiffness]

Primary shoulder stiffness is idiopathic. Due to coincidence with other diseases, a systemic genesis with hormonal influence is discussed. The result of chronic inflammation with fibroblastic proliferation is a fibrotic capsule, atrophy of ligaments, and muscular dysbalance. The main symptom is painful restricted passive and active shoulder motion. There is a high rate of unsatisfactory courses. Therapy depends on the phase and duration of shoulder stiffness. Primary treatment of choice is oral steroid therapy, followed by physical and physiotherapy. Steroids can be applied intraarticular, as an alternative. If conservative treatment fails after a period of 6 months, arthroscopic arthrolysis is indicated. Secondary shoulder stiffness often results from traumatization or operation of the shoulder. Primary treatment is also conservative, but operative intervention should be performed early after unsuccessful therapy. Intensive, passive mobilization is necessary after arthrolysis.

[Subscapularis tendon lesions. Anatomy, diagnosis and importance of arthroscopic treatment]

The subscapularis tendon is involved in up to 43% of arthroscopically treated rotator cuff lesions. Due to the close anatomic relationship, participation of the long head of the biceps and supraspinatus tendon is common. Subscapularis tendon lesions are often not primary diagnosed correctly. Using specific clinical tests and modern sectional imaging, the percentage of correct diagnoses can be increased. Convincing clinical results, advantages of minimally invasive surgery, and superior visualization compared to the open approach argue for arthroscopic treatment of subscapularis lesions. Awareness of the footprint allows anatomic reconstruction. In case of planned open treatment, arthroscopy should precede as particularly articular-sided lesions might be missed otherwise.

Validity of clinical symptoms in benign esophageal disease, assessed by questionnaire

A questionnaire designed to test the value of questions identifying benign esophageal disease was sent to patients representing four well-defined entities: angina pectoris (n = 30), benign esophageal disease (n = 25), gastroduodenal ulcer or former gallstones (n = 27) and normal subjects (n = 38). By means of logistic regression, three key-questions were selected. A combination of an affirmative answer to "difficulty in swallowing solid food" and to "pain in the chest" or "heartburn at night" or both did not occur in the group of normal subjects, while occurring in 68% of the patients with esophageal diseases. The combination occurred in only 10% of the patients with angina pectoris and 15% of those suffering from gastroduodenal ulcer or gallstones. The predictive accuracy of the combination of the three questions is estimated for various hypothetic prevalences of esophageal disease. These questions appear to identify approximately two-thirds of individuals with esophageal disease with acceptable false-positive rates and can therefore be used in epidemiological studies.

Acupuncture in severe, stable angina pectoris: a randomized trial

Twenty-six patients with stable angina pectoris, resistant to medical treatment, were randomized to either active or sham acupuncture in a single-blind design. Sham acupuncture was defined as the insertion of needles in a point within the same spinal segments as the active acupuncture, but outside the Chinese meridian system. The effect was evaluated from anginal attack rate, nitroglycerin consumption and exercise tests. Compared to patients receiving sham acupuncture the patients receiving active acupuncture increased cardiac work capacity significantly, expressed as dPRP (difference in pressure-rate-product between rest and maximum exercise) and maximal PRP during exercise (p less than 0.001). None of the other variables showed any significant difference between the two groups. Concerning exercise tolerance the median difference was 138 Wmin (95% confidence limits - 12.5 to 325 Wmin), concerning anginal attack rate the median difference was 29.5% (95% confidence limits 55% to -11%) and with regard to nitroglycerin consumption the median difference was 5% (95% confidence limits +67% to -44%). No significant effect of sham treatment was observed, no adverse effect was observed. We suggest that acupuncture may improve cardiac work capacity in patients with angina pectoris, refractory to medical treatment.

Incorporation of growth factor containing Matrigel promotes vascularization of porous PLGA scaffolds

In tissue engineering, rapid ingrowth of blood vessels into scaffolds is a major prerequisite for the survival of three-dimensional tissue constructs. In the present study, we investigated whether the vascularization of implanted poly-D,L-lactic-co-glycolic acid (PLGA) scaffolds may be accelerated by incorporation of Matrigel. For this purpose, we investigated in the aortic ring assay the proangiogenic properties of growth factor reduced Matrigel (GFRM) and growth factor containing Matrigel (GFCM), which were then incorporated into the pores of PLGA scaffolds. Subsequently, we analyzed vascularization, biocompatibility, and incorporation of these scaffolds during 14 days after implantation into dorsal skinfold chambers of balb/c mice by means of intravital microscopy, histology, and immunohistochemistry. Matrigel-free scaffolds served as controls. In the aortic ring assay, GFCM stimulated the development of a network of tubular vessel structures with a significantly increased sprout area and density when compared with GFRM. Accordingly, GFCM accelerated and improved in vivo the ingrowth of new blood vessels into scaffolds, resulting in the formation of a pericyte-coated vascular network with an increased functional capillary density in comparison to the GFRM and control group. Besides, analysis of leukocyte-endothelial cell interaction in host tissue venules located in close vicinity to the scaffolds showed no marked differences in numbers of rolling and adherent leukocytes between the observation groups, indicating that incorporation of Matrigel did not affect biocompatibility of PLGA scaffolds. These findings demonstrate that the combination of proangiogenic extracellular matrices with solid scaffold biomaterials may represent a novel approach to accelerate adequate vascularization of tissue engineering constructs.

Has endovascular aneurysm repair improved outcome for patients with asymptomatic abdominal aortic aneurysm?

AIM

The aim of this study was to compare risk factors, complications, operative mortality and relative survival of patients treated with endovascular aneurysm repair (EVAR) for asymptomatic abdominal aortic aneurysm (AAA) to that of those subjected to open operation.

METHODS

SETTING

University Hospital. A total of 118 EVAR patients were compared with 386 with open repair during the period from 1995 through 2005, in a single center retrospective study.

RESULTS

The two groups had similar risk profiles. EVAR patients were older and had shorter hospital stays than those with open operation. Throughout follow-up, 45.8% of EVAR patients had complications, as compared to only 26% of open repairs. Operative mortality, long-term survival and relative survival did not differ significantly between the two groups.

CONCLUSION

EVAR appears initially safe in selected patients. The complication rate after EVAR is high, but declines throughout the study period. Focus must still be on patient selection and device improvement to reduce complications. The question whether EVAR has improved AAA treatment remains to be answered.

BNP and N-terminal proBNP are both extracted in the normal kidney

BACKGROUND

Increased plasma concentrations of cardiac-derived B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (proBNP) are both associated with left ventricular dysfunction. Information on the regional elimination of the peptides is, however, still scarce. We therefore examined the renal and peripheral extraction of N-terminal proBNP and BNP.

MATERIALS AND METHODS

The study comprised 18 patients with essential arterial hypertension, 51 with cirrhosis, and 18 control patients without kidney or liver disease. All patients underwent a haemodynamic investigation with catheterization of the femoral artery and femoral and renal veins. Blood sampling from the catheters allowed determination of the arteriovenous extraction ratio of N-terminal proBNP and BNP.

RESULTS

Neither the peripheral N-terminal proBNP (13, 11, 19 pmol L(-1), NS) nor the BNP plasma concentrations (4, 12, 9 pmol L(-1), NS) differed between the patient groups. In addition, similar renal extractions were observed in the groups. The renal extraction of N-terminal proBNP (0.16) was not different from that of BNP (0.16). In contrast, the N-terminal proBNP extraction in the lower extremity was markedly lower compared with BNP (0.00 vs. 0.125, P = 0.007).

CONCLUSIONS

A comparable renal elimination of N-terminal proBNP and BNP is contrasted by a selective extraction of BNP in the lower extremity. Our results suggest a different elimination mechanism in the renal and peripheral circulation, which partly may explain the higher N-terminal proBNP compared with BNP concentrations in normal plasma.

Is the relationship between type of alcohol and mortality influenced by socio-economic status?

OBJECTIVES

To assess the impact of socio-economic status on the relationship between type of alcohol and all-cause mortality.

DESIGN

A prospective population study.

SETTING

The Copenhagen City Heart Study, Denmark.

SUBJECTS

A total of 14,223 men and women participated in the first examination of The Copenhagen City Heart Study in 1976-1978. The participants were followed up until 18th of September 2001 during which 7208 persons died. The effect of beer, wine and spirits on mortality was stratified according to levels of education, income and cohabitation, and the association was examined after controlling for intake of the other types of alcohol, and for sex, smoking, physical activity and body mass index.

MAIN OUTCOME MEASURES

Number and time of death from all causes.

RESULTS

Consumers of wine were better educated and wealthier compared with beer and spirits drinkers. The association between type of beverage and mortality was noticed to differ according to socio-economic level, especially where the apparent protective effect of wine consumption tended to be strongest in the lower income and educational groups.

CONCLUSIONS

This study finds the specific effects of beer, wine or spirits to moderately diverge in the socio-economic groups. Future studies addressing the association between the type of beverage and mortality may need to more thoroughly take socio-economic factors into account.

Copenhagen City Heart Study: longitudinal analysis of ventilatory capacity in diabetic and nondiabetic adults

The natural history of lung function in diabetes is unknown due to the lack of longitudinal observations. The decline of forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) was studied over 15 yrs in the 17,506 adult participants of The Copenhagen City Heart Study, which included 266 individuals with diabetes. Multiple linear regression and a mixed-effects model were used, taking into account correlation between repeated measurements and adjusting for relevant confounders. In both sexes, FEV1 and FVC were consistently lower in diabetic individuals, compared with healthy individuals, with an average reduction of approximately 8% of the predicted value. Longitudinal analyses showed that the decline of FEV1 and FVC in diabetic individuals was similar to that observed in nondiabetic subjects. It was concluded that although diabetic subjects have, on average, a lower forced expiratory volume in one second and forced vital capacity than individuals without diabetes, this deficit seems not to be progressive in the long term. These observations may be of importance with regard to diabetes treatment with inhaled pulmonary insulin, which is likely to become available within a few years.

Clinical reasoning of an experienced physiotherapist: insight into clinician decision-making regarding low back pain

BACKGROUND AND PURPOSE

Investigation of the clinical reasoning skills of experienced clinicians provides insight into decision-making in the practice of physiotherapy. The purpose of the present study was to analyse the clinical reasoning skills of an experienced physiotherapist during her assessment and treatment of clients with low back pain.

METHOD

Deconstruction of the physiotherapist's reasoning process was accomplished through observation of encounters between her and each of six patient subjects. Reconstruction and analysis of the physiotherapist's decision-making process was performed through retrospective interviews and reflective analysis of her clinical reasoning during each encounter.

RESULTS

A working model of the physiotherapist's clinical reasoning was created from an integration of theoretical elements in the literature and the data. Through analysis of this framework, two core dimensions of her clinical reasoning were revealed: the influence of clinical experience and the influence of advanced training in a specific philosophy of treating the spine.

CONCLUSIONS

The construction of these themes has contributed to the growing understanding of clinical reasoning strategies and skills used in orthopaedic physical therapy practice. Detailed description of the physiotherapist's reasoning process provides more meaningful understanding of physiotherapy treatments. In this case the physiotherapist employed a pattern recognition strategy and forward reasoning process in making a diagnosis. Further research is necessary to expand knowledge on the development of clinical reasoning skills.

A new method for CHD prediction and prevention based on regional risk scores and randomized clinical trials; PRECARD and the Copenhagen Risk Score

BACKGROUND

There is a considerable gap between the recommended prevention of coronary heart disease (CHD) in the guidelines from the European Society of Cardiology and the actually conducted clinical practice in preventive cardiology. A new method for implementing the recommended clinical practice in preventive cardiology is described.

AIM

To develop a comprehensive and flexible health educational computer program (the PRECARD program) for individual coronary risk prediction and multifactorial prevention.

MATERIAL AND METHODS

The PRECARD program contains a new coronary risk score (the Copenhagen Risk Score) for myocardial infarction and a model for calculating the effect of intervention. Two Danish population studies (n = 11,765) with 10 years of follow up were used to establish the risk score. The included risk factors were: age, sex, cholesterol (incl. HDL), systolic blood pressure, smoking, body mass index, diabetes, familial predisposition and previous heart disease. Nine randomized clinical trials were used to estimate the effect of intervention.

RESULTS

The findings in the Copenhagen Risk Score and the estimated effect of intervention deducted from the clinical trials were comparable to other similar studies. The PRECARD program gives a graphical or numerical presentation of absolute coronary risk, the potential benefit of intervention, the relative impact of modifiable risk factors and numbers needed to treat. The program compiles individually tailored health messages in print for the patient. The program can easily be adjusted to different regional risk scores, other end-points and languages.

CONCLUSION

The PRECARD program may promote the recommended clinical practice in preventive cardiology by serving as an integrated part of the lifestyle consultation.

Recovery of autonomic nervous activity after myocardial infarction demonstrated by short-term measurements of SDNN

OBJECTIVE

Heart rate variability (HRV) has been demonstrated to be a risk factor after acute myocardial infarction (AMI). In the present study serial measurement of SDNN (standard deviation of the mean of qualified NN-interval) in short intervals was used to assess HRV changes after AMI, and determine the role of these as independent risk factors compared to clinical, arrhythmic, ischemic and anamnestic variables. Measurements from a normal healthy middle-aged male population were used as reference (n = 63).

METHODS

SDNN from a five-minute period during day and night-time, respectively, was examined in 103 patients 1 week (n = 54), 1 month (n = 72) and 12-16 months (n = 54) after infarction.

RESULTS

Day SDNN did not change during one-and-a-half years after AMI, and was significantly reduced compared with healthy males. Night SDNN, low after 1 week, with recovery 1 month after AMI, was significantly reduced compared with healthy males early, but not late after AMI. Thus, the study indicated during day-time a continuous abnormal sympathetic preponderance in the course of 16 months after AMI, and during night-time a gradual recovery of parasympathetic preponderance beginning early after AMI.

CONCLUSION

One week after AMI day-time SDNN of <30 ms, and night-time SDNN of < 18 ms, age > or =60 years, and myocardial ischemia (Holter monitoring) were independent predictors of 9 years' mortality. One and 12-16 months after AMI reduced day and night-time SDNN had no prognostic implication.

[Beer, wine, spirits and mortality]

A population based cohort study investigates the association between alcohol intake and mortality from all causes, coronary heart disease and cancer. The design is prospective with baseline assessment of intake of beer, wine and spirits, smoking habits, educational level, physical activity, and body mass index and a total of 257,859 person-years follow-up on mortality. A total of 4,833 participants died, of these 1,075 from coronary heart disease and 1,552 of cancer. Compared with non-drinkers, light drinkers who avoided wine, had a relative risk of death from all causes of 0.90 (0.82-0.99) and those who drank wine had a relative risk of 0.66 (0.55-0.77). Heavy drinkers who avoided wine were at higher risk of death from all causes than were heavy drinkers who included wine in their alcohol intake. Wine drinkers had significantly lower mortality from both coronary heart disease and cancer than did non-wine drinkers (p = 0.007 and p = 0.004, respectively). In conclusion, wine intake may have a beneficial effect on all cause mortality that is additive to that of alcohol. This effect may be attributable to a reduction in death from both coronary heart disease and cancer.

Elevated urinary albumin excretion is associated with impaired arterial dilatory capacity in clinically healthy subjects

BACKGROUND

Elevated urinary albumin excretion (UAE) predicts atherosclerotic cardiovascular disease. It is hypothesized that elevated UAE is associated with a generalized vascular dysfunction. This study tested this hypothesis for conduit arteries.

METHODS AND RESULTS

Clinically healthy subjects were selected: 19 with UAE >90th percentile in the background population (6.6 microgram/min<UAE<150 microgram/min) and 41 with normoalbuminuria (UAE <6.6 microgram/min). External ultrasound was used to measure the dilatory response of the brachial artery to postischemic increased blood flow (endothelium-dependent, flow-associated dilation) and to nitroglycerin (endothelium-independent, nitroglycerin-induced dilation). Plasma concentrations of the endothelial markers nitrate/nitrite, thrombomodulin, and von Willebrand factor antigen were also measured. Both flow-associated and nitroglycerin-induced dilations were significantly impaired in subjects with elevated UAE as compared with normoalbuminuric control subjects: 102.0+/-1.0% (mean+/-SEM) versus 104.3+/-0.6% (P<0.05) and 120.1+/-1.5% versus 123.8+/-1.0% (P<0.05). No differences in the plasma concentrations of endothelial markers were found. Conclusions-Slightly elevated UAE is associated with impaired conduit arterial dilatory capacity in clinically healthy subjects, and this impairment may be explained by a reduced dilatory response to nitric oxide of both endogenous and exogenous origin. Impaired arterial dilatory capacity may contribute to the increased cardiovascular risk in subjects with elevated UAE.