Hypertension after the Menopause: What Can We Learn from Experimental Studies?

Hypertension is the most prevalent cardiovascular disease of the adult population and is closely associated with serious cardiovascular events. The burden of hypertension with respect to vascular and other organ damage is greater in women. These sex differences are not fully understood. The unique feature in women is their transition to menopause accompanied by profound hormonal changes that affect the vasculature that are also associated with changes of blood pressure. Results from studies of hormone replacement therapy and its effects on the cardiovascular system are controversial, and the timing of treatment after menopause seems to be important. Therefore, revealing potential sex- and sex hormone-dependent pathophysiological mechanisms of hypertension in experimental studies could provide valuable information for better treatment of hypertension and vascular impairment, especially in postmenopausal women. The experimental rat models subjected to ovariectomy mimicking menopause could be useful tools for studying the mechanisms of blood pressure regulation after menopause and during subsequent therapy.

Impact of treatment timing on the risk of cerebral infarction in patients with aneurysmal subarachnoid hemorrhage

BACKGROUND

Cerebral infarction is a major contributor to poor outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). Timing of treatment has been discussed as a possible contributor. We aimed to analyze the impact of treatment timing on the risk of cerebral infarction and poor outcome following aSAH.

METHODS

Consecutive aSAH cases treated at our institution between 01/2003 and 06/2016 were included. The cohort was divided into two groups, depending on the treatment during (day 4 - 14 after ictus) or beyond the vasospasm phase. Statistical assessment included a 1:1 propensity-score matching analysis and multivariable logistic regression analysis within the whole cohort.

RESULTS

Out of 943 aSAH patients included, 111 individuals underwent treatment in the vasospasm phase. In the propensity-score matching analysis, patients treated during the vasospasm phase were at higher risk of vasospasm requiring intra-arterial spasmolysis (IAS) (p<0.0001), cerebral infarction distal to the treated vessel (p<0.0001), and poor outcome (mRS>2) at 6 months follow-up (p=0.025). In the multivariable analysis, aneurysm treatment in the vasospasm phase was independently associated with higher risk of cerebral vasospasm necessitating IAS (p<0.0001; aOR=3.62), cerebral infarction distal to the treated aneurysm (p=0.01; aOR=2.02) and poor outcome (p=0.03; aOR=2.05).

CONCLUSIONS

Our data confirm a considerable risk of cerebral infarction and poor outcome in case of aneurysm treatment between day 4 and 14 post-aSAH. A more intense surveillance and prophylactic treatment of cerebral vasospasm might be necessary in case of aneurysm treatment in the "vasospasm phase".

Outcomes among preterm infants with patent ductus arteriosus: Relationship with treatment, gestational age, hemodynamic status and timing of treatment

BACKGROUND

There remains controversy regarding the outcomes resulting from treatment versus conservative management of patent ductus arteriosus (PDA) among preterm infants. The effects of extreme prematurity, hemodynamic status of the PDA, and age at treatment remain poorly defined.

STUDY DESIGN

This retrospective case-control study including infants <  1250 gm who were categorized into 3 groups: Group 1: without PDA, Group 2: with untreated PDA, and Group 3: treated PDA. Diagnosis and treatment of PDA extracted from the medical records. Demographics, clinical characteristics, and outcomes compared using chi-square and analysis of variance. Logistic regression used to estimate adjusted odds ratios.

RESULTS

The study included 734 infants, with 141(19%) in Group 1, 329 (45%) in 2, and 264 (36%) in 3. Group 3 had higher incidence of bronchopulmonary dysplasia (BPD) (aOR, 2.9; 95%CI 1.7-4.8). Infant treated for hemodynamically significant PDA (HSPDA) had higher incidence of BPD (aOR, 1.9; 95%CI 1.0-3.8) and retinopathy of prematurity (ROP) (aOR, 3.4; 95%CI 1.6-6.9). There were no differences in outcome associated with treatment among≤26 weeks gestation and the age when treated.

CONCLUSION

Infants with PDA who were treated had higher incidence of BPD. Among those who were treated, those with HSPDA had a higher incidence of BPD and ROP.

The 'Timing of Androgen-Deprivation therapy in incurable prostate cancer' protocol (TOAD)--where are we now? Synopsis of the Victorian Cooperative Oncology Group PR 01-03 and Trans-Tasman Radiation Oncology Group 03.06 clinical trial

OBJECTIVE

To outline the development of the 'Timing of Androgen Deprivation' (TOAD) protocol, a collaborative randomised clinical trial under the auspices of the Cancer Council Victoria, the Trans-Tasman Radiation Oncology Group, and the Urological Society of Australia and New Zealand (USANZ), which opened to recruitment in 2004.

PATIENTS AND METHODS

The principal hypothesis for the trial was that the early introduction of androgen-deprivation therapy (ADT; experimental arm) at the time when curative therapies are no longer considered an option, would improve overall survival for these patients, whilst maintaining an acceptable quality of life; compared with waiting for disease progression or the development of symptoms (control arm). An increase in overall survival at 5 years of 10% was judged to be clinically worthwhile.

RESULTS

Recruitment was slow, with fewer than half of the protocol requirement of 750 patients eventually accrued, but nonetheless it is considered that the trial will still contribute a major source of evidence in this area. The study closed to follow-up at the end of 2013, with data analysis commencing mid-2014, and with the primary publication anticipated to be submitted by the end of 2014.

CONCLUSION

The question of timing of ADT remains relevant in the current era of newer and more varied treatment methods. Even with the advent of novel chemotherapy and the biological agents that are undergoing investigation for progressively earlier disease stages, the dilemma of when to commence palliative treatment in an asymptomatic patient will remain, unless or until these agents are shown to increase overall survival. The TOAD trial will contribute to answering at least in part, some of these questions.

Can tibial nonunion be predicted at 3 months after intramedullary nailing?

OBJECTIVE

The purpose of this study was to determine if surgeons could reliably predict if patients with tibia fractures treated with intramedullary nails will proceed to nonunion based on their clinical scenario and radiographs at 3 months.

DESIGN

Blinded randomized questionnaire based on a retrospective cohort.

SETTING

University level 1 trauma center.

PATIENTS/PARTICIPANTS

Fifty-six patients who underwent intramedullary fixation for tibia fractures with incomplete healing at 3 months.

METHODS

A questionnaire was applied to 56 consecutive patients treated between 2005 and 2009 with intramedullary fixation for tibia fractures who had incomplete healing at 3 months. Each case was developed into a vignette that included the 3-month radiographs and detailed clinical histories. The questionnaire was distributed to 3 fellowship-trained trauma surgeons who were asked to predict if the fracture would go onto nonunion.

MAIN OUTCOME MEASUREMENTS

Diagnostic accuracy of predicting nonunion in patients with incomplete healing of their tibia fracture at 3 months.

RESULTS

The combined overall diagnostic accuracy of all 3 surgeons was 74%. Sensitivity and specificity was 62% and 77%, respectively. Radiographic features and injury mechanism were the most commonly cited clinical information used to predict fracture healing. The average positive predictive value was 73%. In 9 patients with diabetes, the diagnostic accuracy was 88%.

CONCLUSIONS

Clinical judgment at 3 months allows for correct prediction of eventual nonunion development in a majority of patients. We suggest that analysis of the entire clinical picture be used to predict fracture healing at 3 months. A protocol of waiting for 6 months before reoperation in all patients treated with intramedullary nailing for tibia fractures may subject patients to prolonged disability and discomfort.

LEVEL OF EVIDENCE

Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Activator reloaded - Myofunctional appliance at its best

Orthodontics from time immemorial has always been considered as the first speciality of dentistry. Diagnosis and treatment planning from Dr. Tweed's time always required extraction of four vital and functional premolar teeth. However, many patients, parents and general dentists have failed to understand that orthodontic treatment at an early age can help save the extraction teeth to achieve a full functional and esthetic harmonius dentition. Our case demonstrates a non-extraction orthodontic treatment plan of a developing skeletal Class II malocclusion. The results of this case show a successful correction of Class II molar malocclusion with excellent form and function, which resulted in improvement of the patient's frontal and facial profile, which, thereby boosted her personality and self-confidence.