Convalescent Growth Differentiation Factor-15 and Long-Term Outcomes after an Acute Coronary Syndrome

BACKGROUND

Growth differentiation factor-15 (GDF-15) has been shown to be associated with adverse clinical outcomes in patients after an acute coronary syndrome when measured soon after an event. Although dynamic in the acute phase after myocardial injury, GDF-15 has been shown to remain stable during convalescence. In this study, we aimed to assess the value of GDF-15 as a long-term prognostic marker for clinical outcomes when measured in the convalescent phase following an acute coronary syndrome.

METHODS

GDF-15 concentrations were measured in 1945 patients who were recruited between 2002 and 2009 to the Coronary Disease Cohort Study. For this analysis, follow-up was curtailed at 10 years and association of GDF-15 with all-cause death, cardiovascular death, recurrent myocardial infarction, and heart failure hospitalizations were assessed with multivariate Cox proportional hazard regression analysis.

RESULTS

After 10 years of follow-up, there were 648 deaths (348 from cardiovascular causes), 500 admissions for myocardial infarction, and 436 for heart failure. Four-month convalescent GDF-15 demonstrated a robust independent association with all endpoints, which remained after adjustment for Global Registry of Acute Coronary Events score and other convalescent biomarkers. When compared to the lowest quartile of GDF-15 concentrations, those in the highest quartile had a 3-fold increased risk of all-cause death.

CONCLUSIONS

Convalescent plasma GDF-15 is a strong and independent predictor of 10-year all-cause death, cardiovascular death, recurrent myocardial infarction, and heart failure admission following an acute coronary syndrome.

AUSTRALIAN NEW ZEALAND CLINICAL TRIALS REGISTRY TRIAL ID

ACTRN12605000431628.

Cardiac effects of myoregulin in ischemia-reperfusion

Myoregulin is a recently discovered micropeptide that controls calcium levels by inhibiting the intracellular calcium pump sarco-endoplasmic reticulum Ca2+-ATPase (SERCA). Keeping calcium levels balanced in the heart is essential for normal heart functioning, thus myoregulin has the potential to be a crucial regulator of cardiac muscle performance by reducing the rate of intracellular Ca2+ uptake. We provide the first report of myoregulin mRNA expression in human heart tissue, absence of expression in human plasma, and the effects of myoregulin on cardiac hemodynamics in an ex vivo Langendorff isolated rat heart model of ischemia/reperfusion. In this preliminary study, myoregulin provided a cardio-protective effect, as assessed by preservation of left ventricular contractility and relaxation, during ischemia/reperfusion. This study provides the foundation for future research in this area.

Comparison of Fecal Calprotectin and Myeloperoxidase in Predicting Outcomes in Inflammatory Bowel Disease

BACKGROUND

Biomarkers have been proposed as surrogate treatment targets for the management of inflammatory bowel disease (IBD); however, their relationship with IBD-related complications remains unclear. This study investigated the utility of neutrophil biomarkers fecal calprotectin (fCal) and fecal myeloperoxidase (fMPO) in predicting a complicated IBD course.

METHODS

Participants with IBD were followed for 24 months to assess for a complicated IBD course (incident corticosteroid use, medication escalation for clinical disease relapse, IBD-related hospitalizations/surgeries). Clinically active IBD was defined as Harvey-Bradshaw index >4 for Crohn's disease (CD) and simple clinical colitis activity index >5 for ulcerative colitis (UC). Area under the receiver-operating-characteristics curves (AUROC) and multivariable logistic regression assessed the performance of baseline symptom indices, fCal, and fMPO in predicting a complicated disease IBD course at 24 months.

RESULTS

One hundred and seventy-one participants were included (CD, n = 99; female, n = 90; median disease duration 13 years [interquartile range, 5-22]). Baseline fCal (250 μg/g; AUROC = 0.77; 95% confidence interval [CI], 0.69-0.84) and fMPO (12 μg/g; AUROC = 0.77; 95% CI, 0.70-0.84) predicted a complicated IBD course. Fecal calprotectin (adjusted OR = 7.85; 95% CI, 3.38-18.26) and fMPO (adjusted OR = 4.43; 95% CI, 2.03-9.64) were associated with this end point after adjustment for other baseline variables including clinical disease activity. C-reactive protein (CRP) was inferior to fecal biomarkers and clinical symptoms (pdifference < .05) at predicting a complicated IBD course. A combination of baseline CRP, fCal/fMPO, and clinical symptoms provided the greatest precision at identifying a complicated IBD course.

CONCLUSIONS

Fecal biomarkers are independent predictors of IBD-related outcomes and are useful adjuncts to routine clinical care.

The Disease Severity Index for Inflammatory Bowel Disease Is a Valid Instrument that Predicts Complicated Disease

BACKGROUND

The disease severity index (DSI) for inflammatory bowel disease (IBD) combines measures of disease phenotype, inflammatory activity, and patient-reported outcomes. We aimed to validate the DSI and assess its utility in predicting a complicated IBD course.

METHODS

A multicenter cohort of adults with IBD was recruited. Intraclass correlation coefficients (ICCs) and weighted Kappa assessed inter-rater reliability. Cronbach's alpha measured internal consistency of DSI items. Spearman's rank correlations compared the DSI with endoscopic indices, symptom indices, quality of life, and disability. A subgroup was followed for 24 months to assess for a complicated IBD course. Area under the receiver operating characteristics curve (AUROC) and multivariable logistic regression assessed the utility of the DSI in predicting disease progression.

RESULTS

Three hundred and sixty-nine participants were included (Crohn's disease [CD], n = 230; female, n = 194; mean age, 46 years [SD, 15]; median disease duration, 11 years [interquartile range, 5-21]), of which 171 (CD, n = 99; ulcerative colitis [UC], n = 72) were followed prospectively. The DSI showed inter-rater reliability for CD (ICC 0.93, n = 65) and UC (ICC 0.97, n = 33). The DSI items demonstrated inter-rater agreement (Kappa > 0.4) and internal consistency (CD, α > 0.59; UC, α > 0.75). The DSI was significantly associated with endoscopic activity (CDn=141, r = 0.65, P < .001; UCn=105, r = 0.80, P < .001), symptoms (CDn=159, r = 0.69, P < .001; UCn=132, r = 0.58, P < .001), quality of life (CDn=198, r = -0.59, P < .001; UCn=128, r = -0.68, P < .001), and disability (CDn=83, r = -0.67, P < .001; UCn=52, r = -0.74, P < .001). A DSI of 23 best predicted a complicated IBD course (AUROC = 0.82, P < .001) and was associated with this end point on multivariable analyses (aOR, 9.20; 95% confidence interval, 3.32-25.49).

CONCLUSIONS

The DSI reliably encapsulates factors contributing to disease severity and accurately prognosticates the longitudinal IBD course.

Is MRI screening for bone marrow oedema useful in predicting lumbar bone stress injuries in adult male professional cricketers? A New Zealand pilot study

OBJECTIVES

The aims were to (1) prospectively observe the incidence of bone marrow oedema in asymptomatic adult male domestic professional cricketers during a season and evaluate its relationship to the development of lumbar bone stress injury and (2) further understand the practicalities of implementing a Magnetic Resonance Imaging-based screening program to prevent lumbar bone stress injury in New Zealand cricket.

DESIGN

Prospective observational cohort.

METHODS

Adult male pace bowlers received 6-weekly pre-planned Magnetic Resonance Imaging scans over a single season to determine the presence and intensity of bone marrow oedema in the posterior vertebral arches of the lumbar spine. The participants bowling volume and back pain levels were monitored prospectively.

RESULTS

22 participants (mean age 25.3 years (range 20-32 years)) completed all 4 scans. Ten participants had a prior history of lumbar bone stress injury. Ten participants (45 %, 95 % confidence interval 24-68 %) had bone marrow oedema evident on at least one scan, with 9 (41 %) participants recording a bone marrow oedema intensity ≥ 2 and 5 (23 %) participants demonstrated an intensity ≥ 3. During the study one participant was diagnosed with a lumbar bone stress reaction. No participants developed a lumbar bone stress fracture.

CONCLUSIONS

Due to the lower incidence of lumbar bone stress injuries in adult bowlers coupled with uncertainty over appropriate threshold values for bone marrow oedema intensity, implementation of a resource intense screening program aimed at identifying adult domestic cricketers at risk of developing a lumbar bone stress injury is not currently supported.

The Strongest Oxford Knee Score Predictors of Subsequent Revision are 'Overall Pain,' 'Limping when Walking,' and 'Knee Giving Way'

BACKGROUND

The Oxford Knee Score (OKS) is used to measure knee arthroplasty outcomes, however, it is unclear which questions are more relevant. Our aims were to: 1) identify which OKS question(s) were the strongest predictors of subsequent revision and 2) compare predictive ability of the 'pain' and 'function' domains.

PATIENTS AND METHODS

All primary total (TKAs) and unicompartmental knee arthroplasties (UKAs) in the New Zealand Joint Registry between 1999 and 2019 with an OKS at six months (TKA n=27,708, UKA n=8,415), five years (TKA n=11,519, UKA n=3,365) or ten years (TKA n=6,311, UKA n=1,744) were included. Prediction models were assessed using logistic regressions and receiver operating characteristic analyses.

RESULTS

A reduced model with three questions ('overall pain,' 'limping when walking,' 'knee giving way') showed better diagnostic ability than full OKS for predicting UKA revision at six months (area under the curve (AUC): 0.80 vs. 0.78; P<0.01) and five years (0.81 vs. 0.77; P=0.02), and comparable diagnostic ability for predicting TKA revision at all timepoints (6 months, 0.77 vs. 0.76; 5 years, 0.78 vs. 0.75; 10 years, 0.76 vs. 0.73; all not significant (NS)), and UKA revision at 10 years (0.80 vs. 0.77; NS). The pain domain had better diagnostic ability for predicting subsequent revision for both procedures at five and ten years.

CONCLUSION

Questions on 'overall pain', 'limping when walking', and 'knee 'giving way' were the strongest predictors of subsequent revision. Attention to low scores from these questions during follow-up may allow for prompt identification of patients most at risk of revision.

Comparative Study of ACL Reconstruction With Hamstring Versus Patellar Tendon Graft in Young Women: A Cohort Study From the New Zealand ACL Registry

BACKGROUND

Young female athletes are a specific population that is at high risk of primary anterior cruciate ligament (ACL) rupture and subsequent graft failure. Despite large numbers of ACL reconstructions being carried out in young women, there is limited analysis of outcomes in this group, leading to low levels of evidence for graft choice.

PURPOSE

To assess the effect of graft choice on ACL reconstruction failure rates among young women in New Zealand.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Prospective data captured by the New Zealand ACL Registry between April 2014 and March 2022 were reviewed. Young women aged 15 to 20 years were included. The primary outcome measure was ACL graft failure during the study period, with the key independent variable being graft type, either patellar or hamstring tendon autograft. This is presented as the rate per 100 patient-years and is compared between the 2 groups using the hazard ratio generated from a Cox proportional hazards regression. Secondary outcome measures were Marx activity scores and the Knee injury and Osteoarthritis and Outcome Score patient-reported outcome measure.

RESULTS

A total of 1261 primary ACL reconstructions in young women aged 15 to 20 years were reviewed. Hamstring tendon grafts were used in 797 (63%) reconstructions and patellar tendon graft in 464 (37%) reconstructions. Patients with a hamstring tendon graft had a graft failure rate of 7.7% compared with 1.1% in patients with a patellar tendon graft (hazard ratio, 6.1; 95% CI, 2.4-15.1; P < .001). The number of failures per 100 person-years was significantly higher in the hamstring group (2.05) compared with the patellar tendon group (0.37). No difference was noted at final follow-up between the hamstring tendon and patellar tendon groups when comparing patient-reported outcome measures during the follow-up period.

CONCLUSION

In the young female population of this study, the use of a patellar tendon graft was associated with reduced risk of graft failure and was not associated with an increase in knee morbidity. This highlights the importance of informed decision-making in this high-risk population when considering ACL reconstruction graft type.

Short-Term outcomes following 159 stemmed pyrocarbon shoulder hemiarthroplasties and how do they compare with conventional hemiarthroplasties and total shoulder arthroplasties in patients younger than 60 years of age with osteoarthritis: Results from The New Zealand National Joint Registry

BACKGROUND

Despite the increasing usage of Pyrocarbon hemiarthroplasty (PyCHA), clinical data reporting on its outcome remains scarce. To date, there has not been any studies comparing the outcomes of stemmed PyCHA to conventional hemiarthroplasty (HA) and anatomic total shoulder arthorplasty (aTSA) in young patients. The primary aim of this study was to report on the outcomes of the first 159 stemmed PyCHA performed in New Zealand. The secondary aim was to compare the outcomes of stemmed PyCHA with HA and aTSA for patients younger than 60 years of age with osteoarthritis. We hypothesized that the stemmed PyCHA is associated with a low revision rate. We further hypothesized that in young patients, PyCHA is associated with lower revision and superior functional outcomes compared with HA or aTSA.

METHODS

Data from the New Zealand National Joint Registry was used to identify patients who underwent PyCHA, HA and aTSA between January 2000 and July 2022. The total number of revisions in the PyCHA group was identified and the indications for surgery, reasons for revision and the type of revision was recorded. In patients younger than 60 years of age, a matched cohort analysis was performed comparing the functional outcomes using the Oxford Shoulder Score (OSS). The revision rate was compared with HA and aTSA as calculated with revision/100 component-years.

RESULTS

In total, 159 cases of stemmed PyCHA were performed and five cases were revised, resulting in an implant retention rate of 97%. In patients younger than 60 years of age with shoulder osteoarthritis, 48 patients were treated with PyCHA compared with 150 patients treated with HA and 550 patients treated with aTSA. Patients treated with aTSA had superior OSS compared with PyCHA and HA. The differences in OSS between aTSA and PyCHA exceeded the minimally clinically important difference (MCID) of 4.3.²² There was no difference in the revision rate between the groups.

CONCLUSIONS

This study represents the largest cohort of patients treated with PyCHA and the first to compare stemmed PyCHA to HA and aTSA in young patients. In the short term, PyCHA appear to be a promising implant with excellent implant retention rate. In patients younger than 60 years of age, the revision rate is comparable between PyCHA and aTSA. However, aTSA remains the implant of choice to optimize early postoperative function. Further studies are required to elucidate the long term outcome of PyCHA, particularly how they compare with HA and aTSA in young patients.

Associations of the Oxford Knee Score and knee arthroplasty revision at long-term follow-up

BACKGROUND

Self-reported outcome measures are increasingly being collected for healthcare evaluation therefore it is prudent to understand their associations with patient outcomes. Our aims were to investigate: (1) if Oxford Knee Score (OKS) is associated with impending revision at long-term (5 and 10 years) follow-up, and (2) if decreased OKS at subsequent follow-ups is associated with higher risk of revision.

PATIENTS AND METHODS

All total knee (TKAs) and unicompartmental knee arthroplasties (UKAs) between 1999 and 2019 in the New Zealand Joint Registry with an OKS at 6 months (TKA n = 27 708, UKA n = 8415), 5 years (TKA n = 11 519, UKA n = 3365) or 10 years (TKA n = 6311, UKA n = 1744) were included. Logistic regression determined associations of the OKS with revision within 2 years of each score. Change in OKS between timepoints were compared with revision risk.

RESULTS

For every one-unit increase in OKS, the odds of TKA and UKA revision decreased by 10% and 11% at 6 months, 10% and 12% at 5 years and 9% and 5% at 10 years. For both procedures a decrease of seven or more OKS points from previous follow-up was associated with higher risk of revision (5 years: TKA 4.7% versus 0.5%, UKA 8.7% versus 0.9%; 10 years: TKA 4.4% versus 0.7%, UKA 11.3% versus 1.5%; all P < 0.01).

CONCLUSION

The OKS had a strong negative association with risk of impending TKA and UKA revision from early to long-term (10+ years) follow-up. A decrease of seven or more points when compared with the previous follow-up was also associated with higher revision risk.

Identifying Candidate Circulating RNA Markers for Coronary Artery Disease by Deep RNA-Sequencing in Human Plasma

Advances in RNA sequencing (RNA-Seq) have facilitated transcriptomic analysis of plasma for the discovery of new diagnostic and prognostic markers for disease. We aimed to develop a short-read RNA-Seq protocol to detect mRNAs, long non-coding RNAs (lncRNAs) and circular RNAs (circRNAs) in plasma for the discovery of novel markers for coronary artery disease (CAD) and heart failure (HF). Circulating cell-free RNA from 59 patients with stable CAD (half of whom developed HF within 3 years) and 30 controls was sequenced to a median depth of 108 paired reads per sample. We identified fragments from 3986 messenger RNAs (mRNAs), 164 long non-coding RNAs (lncRNAs), 405 putative novel lncRNAs and 227 circular RNAs in plasma. Circulating levels of 160 mRNAs, 10 lncRNAs and 2 putative novel lncRNAs were altered in patients compared with controls (absolute fold change >1.2, p < 0.01 adjusted for multiple comparisons). The most differentially abundant transcripts were enriched in mRNAs encoded by the mitochondrial genome. We did not detect any differences in the plasma RNA profile between patients who developed HF compared with those who did not. In summary, we show that mRNAs, lncRNAs and circular RNAs can be reliably detected in plasma by deep RNA-Seq. Multiple coding and non-coding transcripts were altered in association with CAD, including several mitochondrial mRNAs, which may indicate underlying myocardial ischaemia and oxidative stress. If validated, circulating levels of these transcripts could potentially be used to help identify asymptomatic individuals with established CAD prior to an acute coronary event.

The Impact of Disease Activity on SD and ED in Patients With Inflammatory Bowel Disease

BACKGROUND

Increased disease activity may be a risk factor for sexual dysfunction (SD) in patients with inflammatory bowel disease (IBD). This study investigated associations between objective measures of disease activity and sexual function.

METHODS

Adults with IBD undergoing ileocolonoscopy were prospectively recruited. Demographic, sexual function (Female Sexual Function Index and International Index of Erectile Function), disease activity (endoscopic, biomarker, and symptoms), psychological symptoms, and quality-of-life data were collected. Rates of SD and erectile dysfunction (ED) were compared between patients with active and inactive inflammation and symptoms using the Fisher's exact test. Logistic regression examined associations between SD and ED, and disease characteristics and psychological symptoms.

RESULTS

A total of 159 participants were included, 97 had Crohn's disease and 85 were women. SD was reported in 36 of 59 and 13 of 59 sexually active women and men, respectively and ED in 22 of 59 sexually active men. Rates of SD and ED were similar between individuals with active and inactive IBD based on endoscopic indices (P > .05) and biomarkers (P > .05). Women with active IBD symptoms experienced significantly higher rates of SD (P < .05), but men did not (P > .05). Multivariable logistic regression identified that symptoms of severe depression (odds ratio, 5.77; 95% confidence interval, 1.59-20.94) were associated with SD in women, and severe anxiety (odds ratio, 15.62; 95% confidence interval, 1.74-140.23) was associated with ED in men.

CONCLUSIONS

Objective measures of disease activity are not associated with SD or ED in patients with IBD. Clinicians should consider concomitant psychological symptoms contributing to the sexual health of patients with IBD.

Circulating cardiac biomarkers improve risk stratification for incident cardiovascular disease in community dwelling populations

Background

Plasma cardiac markers may assist in prediction of incident cardiovascular disease.

Methods

The incremental value of cardiac Troponins (T and I) and NT-proBNP added to risk factors in the PREDICT score for incident cardiovascular disease (CVD) in primary care, was assessed in 4102 asymptomatic participants in a randomised controlled trial of Vitamin D (ViDA). Findings were corroborated in 2528 participants in a separate community-based observational registry of CVD-free volunteers (HVOLS).

Findings

Hazard ratios for first cardiovascular events adjusted for PREDICT risk factors, comparing fifth to first quintiles of marker plasma concentrations, were 2.57 (95% CI 1.47-4.49); 3.01 (1.66-5.48) and 3.38 (2.04-5.60) for hs-cTnI, hs-cTnT and NT-proBNP respectively. The C statistic for discrimination of the primary endpoint increased from 0.755 to 0.771 (+0.016, p = 0.01). Cardiac marker data correctly reclassified risk upwards in 6.7% of patients and downwards in 3.3%. These findings were corroborated by results from HVOLS.

Interpretation

Increments in plasma cardiac biomarkers robustly and reproducibly predicted increased hazard of incident CVD, independent of established risk factors, in two community-dwelling populations. Cardiac markers may augment risk assessment for onset of CVD in primary care.

Funding

ViDA was funded by the Health Research Council of New Zealand (grant 10/400) and the Accident Compensation Corporation. HVOLS was funded by the Health Research Council of NZ Programme Grants (grants 02/152 and 08/070) and by grants from the Heart Foundation of NZ and the Christchurch Heart Institute Trust. Roche Diagnostics provided in-kind support for NT-proBNP and hs-cTnT assays and Abbott Laboratories for hs-cTnI assays.

The disease severity index for inflammatory bowel disease is associated with psychological symptoms and quality of life, and predicts a more complicated disease course

BACKGROUND

The Disease Severity Index (DSI) is a novel tool to predict disease severity in inflammatory bowel disease (IBD). However, its ability to predict disease complications and the presence of psychosocial comorbidity is unclear.

AIMS

To assess prospectively associations between the DSI and psychological symptoms, quality-of-life (QoL) and disease outcomes in an IBD cohort.

METHODS

Patients with IBD undergoing ileocolonoscopy were followed prospectively for 12 months. DSI, psychological symptoms (perceived stress (PSS-10), depression (PHQ-9), anxiety (GAD-7)) and QoL (IBDQ-32) scores were assessed at baseline. Logistic regression identified variables predicting a complicated IBD course at 12 months (composite outcome of need for escalation of biological/immunomodulator for disease relapse, recurrent corticosteroid use, IBD-related hospitalisation and surgery). Receiver operating characteristics (ROC) analysis identified optimal DSI thresholds predicting a complicated disease course and multivariable logistic regression assessed the risk of reaching this outcome.

RESULTS

One hundred and seventy-two patients were recruited (100 Crohn's disease, 91 female). Median DSI was 21 (IQR 11-32) and 97 patients had endoscopically active disease at baseline. The DSI was significantly higher in patients with symptoms of moderate-severe stress (PSS-10 > 14, p < 0.01), depression (PHQ-9 ≥ 10, p < 0.01), anxiety (GAD-7 ≥ 10, p < 0.05) and impaired quality-of-life (IBDQ-32 < 168, p < 0.01). Only the baseline DSI (OR 1.05, p < 0.01) and endoscopically active disease (OR 6.12, p < 0.01) were associated with a complicated IBD course. A DSI > 23 was strongly predictive of a complicated IBD course (OR 8.31, p < 0.001).

CONCLUSIONS

The DSI is associated with psychological distress, impaired QoL and predicts a more complicated disease course in patients with IBD.

Habitual Green Kiwifruit Consumption Is Associated with a Reduction in Upper Gastrointestinal Symptoms: A Systematic Scoping Review

Kiwifruit have known positive effects on digestion. During clinical intervention trials using kiwifruit to improve constipation, upper gastrointestinal (GI) symptoms such as abdominal discomfort and pain, indigestion, and reflux were also alleviated. We aimed to evaluate the evidence for upper GI symptom relief by kiwifruit in clinical trials on participants with functional constipation (FC), irritable bowel syndrome with constipation (IBS-C), and healthy participants, and to elucidate which symptoms may be relieved and whether a difference exists between the effects of gold and green kiwifruit. We executed a systematic scoping review of 3 electronic databases from 1947 through January 2021 to identify clinical trials that reported effects of green or gold kiwifruit or kiwifruit compounds on upper GI symptoms as secondary outcomes in healthy participants or participants with FC or IBS-C. Studies were divided into those using the Gastrointestinal Symptom Rating Scale (GSRS) and those using alternative measurement tools. GSRS outcomes were pooled and statistically analyzed; non-GSRS outcomes were summarized. We identified 12 clinical trials with a total of 661 participants (124 controls, 537 receiving intervention) providing evidence for symptom relief of upper GI symptoms by kiwifruit intake. Only 5 of the 12 clinical trials used the GSRS to assess upper GI symptom relief. We found good evidence that green kiwifruit may reduce abdominal discomfort and pain, and some evidence that kiwifruit consumption may attenuate indigestion. Pooled GSRS outcome analysis indicates an average reduction of -0.85 (95% CI: -1.1, -0.57; Z = 6.1) in abdominal pain scores and -0.33 (95% CI: -0.52, -0.15; Z = -3.5) in indigestion scores with habitual kiwifruit consumption. While the number of studies reporting on upper GI symptom relief with a comparable measurement is limited, there is consistent evidence for the efficacy of kiwifruit on upper GI symptom relief. More research to strengthen the evidence is recommended.

Does surgical approach affect early outcomes following primary total hip replacement in obese patients?

AIM

The aim of this study was to assess whether obese patients undergoing primary total hip replacement (THR) via a posterior approach had superior revision rates and Oxford Hip Scores (OHS) compared to those via a lateral approach.

PATIENTS AND METHODS

This is a retrospective cohort study using prospective data from the New Zealand Joint Registry applying STROBE and RECORD guidelines. Patients undergoing THR since 2010 were stratified by body mass index (BMI) into obese (BMI 30-39 kg/m²), and morbidly obese (BMI ⩾40 kg/m²) groups. All-cause revision rates, and 6-month OHS post-surgery were compared between groups. Multivariate analysis was performed.

RESULTS

12,109 unilateral THRs in obese patients were identified. The mean follow-up was 2.8 years (range 0.01-6.95 years). Univariate analysis in the BMI ⩾ 40 group showed the posterior approach had a significantly lower all-cause revision rate (0.99/100 observed component years (ocys); 95% CI, 0.65-1.44/100 ocys) than the lateral approach (1.71/100 ocys (95% CI, 0.98-2.77/100 ocys), p < 0.05). There was no significant difference in dislocation rates between the surgical approaches. OHS was statistically higher in the posterior approach group in BMI 30-39 patients (p < 0.001) but not clinically significant. Multivariate analysis showed femoral head size significantly influenced all-cause revision rates and mitigated against the increased risk associated with the surgical approach.

CONCLUSION

The choice of surgical approach in obese patients conveys no advantage in overall revision rates in the short-term. Choosing an appropriate size of femoral head may be of greater importance than choice of surgical approach for obese patients in primary THR.

Quality of life preferences in colorectal cancer patients aged 80 and over

BACKGROUND

Management of patients with colorectal cancer (CRC) is about not only survival, but also quality of life (QoL). What patients want is important but is not well researched or understood for elderly patients where it is very relevant. This study aimed to measure and compare what patients with CRC aged 80 and over and surgeons consider important in terms of survivorship after surgery for CRC.

METHODS

Patients aged 80 and over who were having surgery for CRC were recruited and interviewed using closed and open questions about their expectations of surgery and various QoL dimensions. These were assessed preoperatively and 3 months post-operatively. Surgeons ranked the same QoL dimensions of patients by questionnaire.

RESULTS

Nineteen patients (median age 87.5, range 80-95, eight males and 11 females) were recruited. Patients rated items relating to health, mobility and independence (n = 23) as top three items most often followed by people outside self (n = 13). Surgeons underestimated importance in 17 domains with the biggest discrepancy being in 'avoiding a stoma' (4.11 versus 2.3, P < 0.01).

CONCLUSION

With patients over 80 years having surgery for CRC, there is a lack of concordance between what surgeons think is important and what patients think is important. Despite this, CRC patients aged 80 and older are almost always satisfied with the outcome of surgery. Surgeons should ensure that they understand patients' expectations and that they are aligned with likely outcomes of surgery.

Surgical site infection rate is higher following hip and knee arthroplasty when cefazolin is underdosed

PURPOSE

While many guidelines recommend higher doses of cefazolin for patients with higher body weights, there are scant outcome data showing the benefit of higher doses. Surgical site infection (SSI) rates by dose of cefazolin used for surgical prophylaxis after hip or knee arthroplasty were analyzed.

METHODS

Analysis of patient data entered into New Zealand's national, prospective, surveillance and quality improvement SSI Improvement Programme database for the period July 2013 through December 2017 was conducted. The US Centers for Disease Control and Prevention's National Healthcare Safety Network SSI definitions were used, and patients were followed for 90 days after surgery. Underdosing was defined as use of 1 g of cefazolin in patients weighing 80 kg or more or a cefazolin dose of <3 g in those weighing 120 kg or more.

RESULTS

There were 38,288 procedures where cefazolin was used for prophylaxis; patient body weight was known for all these procedures. Of the 1,840 patients who received 1 g of cefazolin, 676 (37%) weighed 80 kg or more. Of the 2,011 patients weighing 120 kg or more, 1,464 (73%) were underdosed. After multivariable analysis, male gender, higher total surgical risk scores, performance of revision and hip arthroplasties, and cefazolin underdosing were associated with higher SSI rates. For the 2,106 underdosed patients, the odds ratio for SSI was 2.19 (95% confidence interval, 1.61-2.99; P < 0.0001). The number of higher-weight patients needed to treat to prevent 1 SSI was 83, with an estimated cost of <NZ$500 to prevent 1 infection costing an estimated NZ$40,000.

CONCLUSION

Patients undergoing hip or knee arthroplasty and with weights of ≥80 kg and those with weights of ≥120 kg should receive cefazolin doses of 2 g and ≥3 g, respectively, for SSI prophylaxis. The question of whether a dose of ≥4 g is needed in patients weighing 120 kg or more or who are above a given body mass index threshold (eg, >35 kg/m2 or >40 kg/m2) remains unanswered.

150 ProBNP glycosylation of threonine 71 is increased with obesity in patients with heart failure

Funding Acknowledgements

The National Heart Foundation of New Zealand

Background

Heart failure (HF) is a leading cause of morbidity and mortality worldwide. Plasma levels of B-type natriuretic peptide (BNP) or its amino terminal congener (NT-proBNP) are used for HF diagnosis and risk stratification.  Circulating levels of both BNP and NT-proBNP are reduced by obesity and this phenomenon is one of the key weaknesses of the diagnostic performance of the natriuretic peptides in HF.  Formation of BNP from enzymatic cleavage of proBNP1-108 between residues 76 and 77 by corin and/or furin is influenced by the degree of proBNP glycosylation, therefore we investigated the relationship between proBNP glycosylation, plasma NT-proBNP and body mass index (BMI) in HF patients.

Methods

Three assays were developed to distinguish between total proBNP (glycosylated plus non-glycosylated proBNP), proBNP not glycosylated at threonine 71 (NG-T71) and proBNP not glycosylated in the central region (NG-C). Intra and inter-assay CVs were &lt;15%, limits of detection were &lt;2 pmol/L and samples diluted in parallel.

Results

Applying these assays and an NT-proBNP assay to plasma samples from 106 healthy volunteers and 238 patients with HF determined that concentrations (median(IQR)) of proBNP, NG-T71 and NT-proBNP were greater in HF patients compared to controls (24.9 (3.6-55), 9.4 (1.5-21) and 212 (104-409) pmol/L vs 3.0 (1.5-19), 3.0 (1.5-14.5) and 4.7 (2-8) pmol/L respectively, all p &lt; 0.012).  NG-C was undetectable in most samples. ProBNP levels in HF patients with BMI above and below 30 kg/m2 were not different (21.9 (2.6-70) pmol/L and 25.7 (3.9-53) pmol/L respectively, p = 0.85), whereas HF patients with BMI &gt; 30 had lower NT-proBNP and NG-T71 levels (121 (64-248) and 3 (1.5-16) pmol/L verse 271 (178-486) and 13.5 (1.5-24.2) pmol/L respectively, p &lt; 0.003) and higher proBNP:NT-proBNP and proBNP:NG-T71 ratios  (p = 0.001 and p = 0.02 respectively) than those with BMI &lt; 30.

Discussion and Conclusion

Using three new assays specific for different glycosylated forms of proBNP we have shown that the processing of proBNP is dysregulated in heart failure compared to controls due to increased glycosylation at threonine 71 of proBNP.  Obese patients with HF have even greater dysregulation, demonstrated by decreased concentrations of proBNP that is not glycosylated at T71 (NG-T71), and concomitant decreases in NT-proBNP.  Thus, we have shown for the first time that increased BMI is associated with increased proBNP glycosylation at T71 in patients with heart failure.  Glycosylation-induced impairment of proBNP processing explains, at least in part, the reduction in plasma concentrations of B-type cardiac natriuretic peptides observed in obesity. Using these assays to evaluate the proBNP profile of larger patient cohorts will further develop understanding of the relationships between BNP production, BMI and heart failure pathogenesis, which would be expected to lead to increased diagnostic performance.

P1756The protein APRIL predicts adverse outcomes in DAPT patients better than NT-proBNP and troponin

Aim

Dual antiplatelet therapy (DAPT) is a mainstay of post-ACS treatment. However, prediction of adverse events in these patients needs improving. We show here that the TNFα-related protein APRIL (which is produced in platelets and atherosclerotic plaque) is a superior predictor of MACE and new MI in DAPT recipients post-ACS.

Methods

We prospectively recruited 518 patients presenting with the primary complaint of acute chest pain to our hospital ED. Patients were adjudicated to have ACS by 2 independent cardiologists in accordance with ESC guidelines with hsTnI as biomarker. Plasma EDTA samples taken at presentation and 2 hours after were interrogated for APRIL measurements using a two site ELISA. Clinical data/variables, standard biochemistry analytes, hsTnT and NT-proBNP were also measured. Statistical assessments were made using SPSS v23 (IBM). Data for all biomarkers were treated as continuous variables and are presented as median (interquartile range, (IQR)). Statistical assessment of the comparative diagnostic abilities of APRIL, hsTnT, NT-proBNP and hsTnI were assessed using receiver operator curve (ROC) area under the curve (AUC) analysis. The comparative power of each biomarker (log values) to predict new MACE, MI, bleeding and mortality in 1) the whole group and in 2) DAPT recipients alone, within 2 yrs of index presentation was undertaken using a logistic regression base model (95% CI) that included all clinical variables and hsTnI and hsTnT, with APRIL and NT-proBNP each included in additional multivariate analyses.

Results

Of the 518 recruited patients (median age 63 (IQR: 54–73, 35% female), 152 were adjudicated to have ACS (29%, 115 MI, 37 UAP). Presentation APRIL levels were higher in those with a cardiac versus non-cardiac cause for presentation (3.0, (2.0–4.7) vs. 2.4, (1.6–3.8) ng/mL, P=0.001) and positively correlated with hsTnT and NT-proBNP (all P<0.001), but it did not add to the hsTnI (ROC = 0.96) or hsTnT (ROC =0.92) assisted diagnosis of ACS. In all 518 patients, in the multivariate regression model, APRIL was a significant independent predictor of mortality (n=54, P=0.032), new MI (n=43, P=0.006), new ADHF (n=24, P=0.016) and MACE (n=71, P=0.005) that was additive to NT-proBNP and troponin. In DAPT recipients alone (n=156), APRIL was the only biomarker to independently predict new MI (n=27, 95% CI: 1.125–3.982, P=0.020) and MACE (n=37, 95% CI: 1.058–3.389, P=0.031). None of the markers, only age, predicted bleeding episodes.

Conclusion

APRIL is an platelet/plaque derived marker that provides independent risk assessment in ACS patients. In DAPT recipients, the ability of APRIL to predict new MI and MACE is superior to that of cardiac troponins and NT-proBNP and could be used to identify high risk individuals.

Acknowledgement/Funding

Health Research Council of New Zealand; Heart Foundation of New Zealand

Earthquake brain: Impairment of spatial memory following long-term earthquake-related stress

OBJECTIVES

The primary aim of this study was to investigate neuropsychological function in patients with earthquake-related posttraumatic stress disorder, compared with earthquake-exposed but resilient controls. We hypothesised that individuals with posttraumatic stress disorder would have poorer neuropsychological performance on tests of verbal and visuospatial learning and memory compared with the earthquake-exposed control group. The availability of groups of healthy patients from previous studies who had been tested on similar neuropsychological tasks prior to the earthquakes allowed a further non-exposed comparison.

METHOD

In all, 28 individuals with posttraumatic stress disorder and 89 earthquake-exposed controls completed tests of verbal and visuospatial learning and memory and psychomotor speed. Further comparisons were made with non-exposed controls who had been tested before the earthquakes.

RESULTS

No significant difference in performance on tests of verbal or visuospatial memory was found between the earthquake-exposed groups (with and without posttraumatic stress disorder), but the posttraumatic stress disorder group was significantly slowed on tests of psychomotor speed. Supplementary comparison with historical, non-exposed control groups showed that both earthquake-exposed groups had poorer performance on a test of visuospatial learning.

CONCLUSION

The key finding from this study is that there were no differences in verbal or visuospatial learning and memory in individuals with posttraumatic stress disorder compared with similarly earthquake-exposed controls. Compared with non-exposed controls, both earthquake-exposed groups had poorer performance on a test of visuospatial (but not verbal) learning and memory. This offers preliminary evidence suggesting that it is earthquake (trauma) exposure itself, rather than the presence of posttraumatic stress disorder that affects aspects of neuropsychological functioning. If replicated, this may have important implications for how information is communicated in a post-disaster context.

Psychological distress and psychiatric disorder after natural disasters: systematic review and meta-analysis

BACKGROUND

Natural disasters are increasing in frequency and severity. They cause widespread hardship and are associated with detrimental effects on mental health.AimsOur aim is to provide the best estimate of the effects of natural disasters on mental health through a systematic review and meta-analysis of the rates of psychological distress and psychiatric disorder after natural disasters.

METHOD

This systematic review and meta-analysis is limited to studies that met predetermined quality criteria. We required included studies to make comparisons with pre-disaster or non-disaster exposed controls, and sample representative populations. Key studies were identified through a comprehensive search of PubMed, EMBASE and PsycINFO from 1980 to 3 March 2017. Random effects meta-analyses were performed for studies that reported key outcomes with appropriate statistics.

RESULTS

Forty-one studies were identified by the literature search, of which 27 contributed to the meta-analyses. Continuous measures of psychological distress were increased after natural disasters (combined standardised mean difference 0.63, 95% CI 0.27-0.98, P = 0.005). Psychiatric disorders were also increased (combined odds ratio 1.84, 95% CI 1.43-2.38, P < 0.001). Rates of post-traumatic stress disorder and depression were significantly increased after disasters. Findings for anxiety and alcohol misuse/dependence were not significant. High rates of heterogeneity suggest that disaster-specific factors and, to a lesser degree, methodological factors contribute to the variance between studies.

CONCLUSIONS

Increased rates of psychological distress and psychiatric disorders follow natural disasters. High levels of heterogeneity between studies suggest that disaster variables and post-disaster response have the potential to mitigate adverse effects.Declaration of interestNone.

Plasma levels of soluble VEGF receptor isoforms, circulating pterins and VEGF system SNPs as prognostic biomarkers in patients with acute coronary syndromes

Background

Development of collateral circulation in coronary artery disease is cardio-protective. A key process in forming new blood vessels is attraction to occluded arteries of monocytes with their subsequent activation as macrophages. In patients from a prospectively recruited post-acute coronary syndromes cohort we investigated the prognostic performance of three products of activated macrophages, soluble vascular endothelial growth factor (VEGF) receptors (sFlt-1 and sKDR) and pterins, alongside genetic variants in VEGF receptor genes, VEGFR-1 and VEGFR-2.

Methods

Baseline levels of sFlt-1 (VEGFR1), sKDR (VEGFR2) and pterins were measured in plasma samples from subgroups (n = 513; 211; 144, respectively) of the Coronary Disease Cohort Study (CDCS, n = 2067). DNA samples from the cohort were genotyped for polymorphisms from the VEGFR-1 gene SNPs (rs748252 n = 2027, rs9513070 n = 2048) and VEGFR-2 gene SNPs (rs2071559 n = 2050, rs2305948 n = 2066, rs1870377 n = 2042).

Results

At baseline, levels of sFlt-1 were significantly correlated with age, alcohol consumption, NTproBNP, BNP and other covariates relevant to cardiovascular pathophysiology. Total neopterin levels were associated with alcohol consumption at baseline. 7,8 dihydroneopterin was associated with BMI. The A allele of VEGFR-2 variant rs1870377 was associated with higher plasma sFlt-1 and lower levels of sKDR at baseline. Baseline plasma sFlt-1 was univariately associated with all cause mortality with (p < 0.001) and in a Cox’s proportional hazards regression model sFlt-1 and pterins were both associated with mortality independent of established predictors (p < 0.027).

Conclusions

sFlt-1 and pterins may have potential as prognostic biomarkers in acute coronary syndromes patients. Genetic markers from VEGF system genes warrant further investigation as markers of levels of VEGF system components in these patients.

Trial registration

Australian New Zealand Clinical Trials Registry. ACTRN12605000431628. 16 September 2005, Retrospectively registered.

Electronic supplementary material

The online version of this article (10.1186/s12872-018-0894-1) contains supplementary material, which is available to authorized users.

Clinical response to treatment in inpatients with depression correlates with changes in activity levels and psychomotor speed

BACKGROUND

Monitoring clinical response to treatment in depressed inpatients, particularly identifying early improvement, may be sub-optimal. This may impact adversely on patients through longer admissions and sub-optimal pharmacotherapy. Psychomotor speed is a prominent neuropsychological function which changes as recovery occurs. This study examines simple techniques used to quantify psychomotor change and their potential to contribute to monitoring recovery.

METHODS

Activity levels were continuously monitored in patients diagnosed with a major depressive episode from four acute psychiatric wards using two actigraphs (commercial and scientific) for 3 weeks and linear regression used to calculate a gradient to express rate of change. Psychomotor speed was assessed using the simple Coin Rotation Task. Mood and functioning were rated using the Quick Inventory of Depressive Symptoms, Clinical Global Impression Scale and Functioning Assessment Short Test. The assessments were completed at baseline and follow-up (3 weeks), and correlations were calculated for all change measures.

RESULTS

In all, 24 inpatients were recruited but not all completed baseline and follow-up measures. Change in activity count ( N = 16) and psychomotor speed ( N = 13) correlated significantly with improvement in clinical measures of depressive symptoms. Actigraphs were acceptable to hospital inpatients.

LIMITATIONS

The limited size of this pilot study precludes the analysis of predictive power or the influence of other variables such as depression subtypes, age, gender or variations related to medications.

CONCLUSION

Early change in simple activity and psychomotor speed warrant further investigation for utility in measuring treatment response in depressed inpatients.

Hair nicotine at 15 months old, tobacco exposure and wheeze or asthma from 15 months to 6 years old

OBJECTIVE

To investigate the relationship between hair nicotine levels at 15 months of age and prior parent-reported smoking exposure, and the risk of wheezing and current asthma from 15 months to 6 years of age.

STUDY DESIGN

We measured hair nicotine levels at 15 months of age in 376 of 535 infants enrolled in a prospective birth cohort in Christchurch, New Zealand. We obtained detailed information from parents about smoking exposure during pregnancy and in the home at 3 and 15 months of age. Data for demographics, wheezing, and asthma were obtained from yearly questionnaires up to age 6 years. We assessed hair nicotine levels in relation to reported smoke exposure in pregnancy and up to age 15 months, and the association between high levels of hair nicotine and annual reports of current wheeze and current asthma using multiple logistic regression.

RESULTS

Hair nicotine increased with numbers of smokers and daily cigarettes smoked at home, and was also strongly associated with smoking in pregnancy. High level of hair nicotine was associated with increased risk of wheeze (Odds ratio 2.30, P = 0.001) and, though not significant, of current asthma (Odds ratio 2.02, P = 0.056) at 15 months of age, after controlling for socio-economic status, ethnicity, body mass index, respiratory infections in the first 3 months of life, and duration of exclusive breastfeeding. At older ages the associations were non-significant.

CONCLUSION

In children aged 15 months hair nicotine level was related to smoking exposure, and was associated with increased risk of wheeze and asthma.

Vitamin-mineral treatment improves aggression and emotional regulation in children with ADHD: a fully blinded, randomized, placebo-controlled trial

BACKGROUND

Evaluation of broad-spectrum micronutrient (vitamins and minerals) treatment for childhood ADHD has been limited to open-label studies that highlight beneficial effects across many aspects of psychological functioning.

METHOD

This is the first fully blinded randomized controlled trial of medication-free children (n = 93) with ADHD (7-12 years) assigned to either micronutrients (n = 47) or placebo (n = 46) in a 1:1 ratio, for 10 weeks. All children received standardized ADHD assessments. Data were collected from clinicians, parents, participants and teachers across a range of measures assessing ADHD symptoms, general functioning and impairment, mood, aggression and emotional regulation.

RESULTS

Intent-to-treat analyses showed significant between-group differences favouring micronutrient treatment on the Clinical Global Impression-Improvement (ES = 0.46), with 47% of those on micronutrients identified as 'much' to 'very much' improved versus 28% on placebo. No group differences were identified on clinician, parent and teacher ratings of overall ADHD symptoms (ES ranged 0.03-0.17). However, according to clinicians, 32% of those on micronutrients versus 9% of those on placebo showed a clinically meaningful improvement on inattentive (OR = 4.9; 95% CI: 1.5-16.3), but no group differences on improvement in hyperactive-impulsive symptoms (OR = 1.0; 95% CI: 0.4-2.5). Based on clinician, parent and teacher report, those on micronutrients showed greater improvements in emotional regulation, aggression and general functioning compared to placebo (ES ranged 0.35-0.66). There were two dropouts per group, no group differences in adverse events and no serious adverse events identified. Blinding was successful with guessing no better than chance.

CONCLUSIONS

Micronutrients improved overall function, reduced impairment and improved inattention, emotional regulation and aggression, but not hyperactive/impulsive symptoms, in this sample of children with ADHD. Although direct benefit for core ADHD symptoms was modest, with mixed findings across raters, the low rate of adverse effects and the benefits reported across multiple areas of functioning indicate micronutrients may be a favourable option for some children, particularly those with both ADHD and emotional dysregulation. Trial registered with the Australian New Zealand Clinical Trials Registry ACTRN12613000896774.

MR Imaging Characteristics Associate with Tumor-Associated Macrophages in Glioblastoma and Provide an Improved Signature for Survival Prognostication

BACKGROUND AND PURPOSE

In glioblastoma, tumor-associated macrophages have tumor-promoting properties. This study determined whether routine MR imaging features could predict molecular subtypes of glioblastoma that differ in the content of tumor-associated macrophages.

MATERIALS AND METHODS

Seven internally derived MR imaging features were assessed in 180 patients, and 25 features from the Visually AcceSAble Rembrandt Images feature set were assessed in 164 patients. Glioblastomas were divided into subtypes based on the telomere maintenance mechanism: alternative lengthening of telomeres positive (ALT+) and negative (ALT-) and the content of tumor-associated macrophages (with [M+] or without [M-] a high content of macrophages). The 3 most frequent subtypes (ALT+/M-, ALT-/M+, and ALT-/M-) were correlated with MR imaging features and clinical parameters. The fourth group (ALT+/M+) did not have enough cases for correlation with MR imaging features.

RESULTS

Tumors with a regular margin and those lacking a fungating margin, an expansive T1/FLAIR ratio, and reduced ependymal extension were more frequent in the subgroup of ALT+/M- (P < .05). Radiologic necrosis, lack of cystic component (by both criteria), and extensive peritumoral edema were more frequent in ALT-/M+ tumors (P < .05). Multivariate testing with a Cox regression analysis found the cystic imaging feature was additive to tumor subtype, and O6-methylguanine methyltransferase (MGMT) status to predict improved patient survival (P < .05).

CONCLUSIONS

Glioblastomas with tumor-associated macrophages are associated with routine MR imaging features consistent with these tumors being more aggressive. Inclusion of cystic change with molecular subtypes and MGMT status provided a better estimate of survival.

An evaluation of Health of the Nation Outcome Scales data to inform psychiatric morbidity following the Canterbury earthquakes

OBJECTIVE

Following the onset of the Canterbury, New Zealand earthquakes, there were widespread concerns that mental health services were under severe strain as a result of adverse consequences on mental health. We therefore examined Health of the Nation Outcome Scales data to see whether this could inform our understanding of the impact of the Canterbury earthquakes on patients attending local specialist mental health services.

METHOD

Health of the Nation Outcome Scales admission data were analysed for Canterbury mental health services prior to and following the Canterbury earthquakes. These findings were compared to Health of the Nation Outcome Scales admission data from seven other large District Health Boards to delineate local from national trends. Percentage changes in admission numbers were also calculated before and after the earthquakes for Canterbury and the seven other large district health boards.

RESULTS

Admission Health of the Nation Outcome Scales scores in Canterbury increased after the earthquakes for adult inpatient and community services, old age inpatient and community services, and Child and Adolescent inpatient services compared to the seven other large district health boards. Admission Health of the Nation Outcome Scales scores for Child and Adolescent community services did not change significantly, while admission Health of the Nation Outcome Scales scores for Alcohol and Drug services in Canterbury fell compared to other large district health boards. Subscale analysis showed that the majority of Health of the Nation Outcome Scales subscales contributed to the overall increases found. Percentage changes in admission numbers for the Canterbury District Health Board and the seven other large district health boards before and after the earthquakes were largely comparable with the exception of admissions to inpatient services for the group aged 4-17 years which showed a large increase.

CONCLUSION

The Canterbury earthquakes were followed by an increase in Health of the Nation Outcome Scales scores for attendees of local mental health services compared to other large district health boards. This suggests that patients presented with greater degrees of psychiatric distress, social disruption, behavioural change and impairment as a result of the earthquakes.

Five-year follow-up of a prospective randomised trial comparing ceramic-on-metal and metal-on-metal bearing surfaces in total hip arthroplasty

AIMS

The primary aim of this independent prospective randomised trial was to compare serum metal ion levels for ceramic-on-metal (CoM) and metal-on-metal (MoM) bearing surfaces in total hip arthroplasty (THA). Our one-year results demonstrated elevation in metal ion levels above baseline with no significant difference between the CoM and MoM groups. This paper reviews the five-year data.

PATIENTS AND METHODS

The implants used in each patient differed only in respect to the type of femoral head (ceramic or metal). At five-year follow-up of the 83 enrolled patients, data from 67 (36 CoM, 31 MoM) was available for comparison.

RESULTS

The mean serum cobalt (Co) and chromium (Cr) ion levels remained above baseline in both groups (CoM: Co 1.16 μg/l (0.41 to 14.67), Cr 1.05 μg/l (0.16 to 12.58); MoM: Co 2.93 μg/l (0.35 to 30.29), Cr 1.85 μg/l (0.36 to 17.00)) but the increase was significantly less in the CoM cohort (Co difference p = 0.001, Cr difference p = 0.002). These medium-term results, coupled with lower revision rates from national joint registries, suggest that the performance of CoM THA may be superior to that of MoM.

CONCLUSION

While both bearing combinations have since been withdrawn these results provide useful information for planning clinical surveillance of CoM THAs and warrants continued monitoring. Cite this article: Bone Joint J 2017;99-B:1298-1303.

Metabolic and Blood Pressure Effects of Walnut Supplementation in a Mouse Model of the Metabolic Syndrome

There is extensive evidence that walnut consumption is protective against cardiovascular disease and diabetes in the healthy population, but the beneficial effects of walnut consumption in individuals with the metabolic syndrome (MetS) remain uncertain. We compared a range of cardio-metabolic traits and related tissue gene expression associated with 21 weeks of dietary walnut supplementation in a mouse model of MetS (MetS-Tg) and wild-type (WT) mice (n = 10 per genotype per diet, equal males and females). Compared to standard diet, walnuts did not significantly alter food consumption or body weight trajectory of either MetS-Tg or WT mice. In MetS-Tg mice, walnuts were associated with reductions in oral glucose area under the curve (gAUC, standard diet 1455 ± 54, walnut 1146 ± 91, p = 0.006) and mean arterial blood pressure (MAP, standard diet 100.6 ± 1.9, walnut 73.2 ± 1.8 mmHg, p < 0.001), with neutral effects on gAUC and MAP in WT mice. However, in MetS-Tg mice, walnuts were also associated with trends for higher plasma cholesterol (standard diet 4.73 ± 0.18, walnut 7.03 ± 1.99 mmol/L, p = 0.140) and triglyceride levels (standard diet 2.4 ± 0.5, walnut 5.4 ± 1.6 mmol/L, p = 0.061), despite lowering cholesterol and having no effect on triglycerides in WT mice. Moreover, in both MetS-Tg and WT mice, walnuts were associated with significantly increased liver expression of genes associated with metabolism (Fabp1, Insr), cell stress (Atf6, Ddit3, Eif2ak3), fibrosis (Hgf, Sp1, Timp1) and inflammation (Tnf, Ptpn22, Pparg). In conclusion, dietary walnuts were associated with modest favourable effects in WT mice, but a combination of beneficial and adverse effects in MetS-Tg mice, and up-regulation of hepatic pro-fibrotic and pro-inflammatory genes in both mouse strains.

Ibogaine treatment outcomes for opioid dependence from a twelve-month follow-up observational study

BACKGROUND

The psychoactive indole alkaloid ibogaine has been associated with encouraging treatment outcomes for opioid dependence. The legal status of ibogaine in New Zealand provides a unique opportunity to evaluate durability of treatment outcomes.

OBJECTIVE

To examine longitudinal treatment effects over a 12-month period among individuals receiving legal ibogaine treatment for opioid dependence.

METHOD

This observational study measured addiction severity as the primary outcome in 14 participants (50% female) over 12 months post-treatment using the Addiction Severity Index-Lite (ASI-Lite) following a single ibogaine treatment by either of two treatment providers. Secondary effects on depression were assessed via the Beck Depression Inventory-II (BDI-II). The Subjective Opioid Withdrawal Scale (SOWS) was collected before and immediately after treatment to measure opioid withdrawal symptoms.

RESULTS

Nonparametric comparisons via Friedman Test between baseline and 12-month follow-up for participants completing all interviews (n = 8) showed a significant reduction for the ASI-Lite drug use (p = 0.002) composite score. Reductions in BDI-II scores from baseline to 12-month follow-up were also significant (p < 0.001). Significant reductions in SOWS scores for all participants (n = 14) were also observed acutely after treatment (p = 0.015). Patients with partial data (n = 4) also showed reductions in ASI-Lite drug use scores and family/social status problems. One patient enrolled in the study died during treatment.

CONCLUSION

A single ibogaine treatment reduced opioid withdrawal symptoms and achieved opioid cessation or sustained reduced use in dependent individuals as measured over 12 months. Ibogaine's legal availability in New Zealand may offer improved outcomes where legislation supports treatment providers to work closely with other health professionals.

Vitamin-Mineral Treatment of ADHD in Adults

OBJECTIVE

Despite widespread use, there is little data investigating the long-term impact of micronutrients on psychiatric disorders. This study investigated the naturalistic outcome 1-year post-baseline of a randomized controlled trials (RCT) that compared micronutrients with placebo in 80 adults with ADHD.

METHOD

All participants were contacted and clinician-rated questionnaires completed.

RESULTS

A total of 72 (90%) of the sample participated; although there was significant regression in psychiatric functioning from the end-of-trial on all measures, outcomes remained significantly improved from baseline. Dominant treatment from the end-of-treatment to follow-up was investigated as a mediator of outcome; those staying on the micronutrients performed better than those who switched to medications or discontinued micronutrients. Cost was the most substantial reason why people stopped micronutrient treatment.

CONCLUSION

For the small number of participants who stayed on micronutrients, the benefits conferred through the controlled trial were maintained. The results are limited by small sample, lack of blinding, expectation, and reliance on self-report of symptoms.

Earthquake Brain: Altered Recognition and Misclassification of Facial Expressions Are Related to Trauma Exposure but Not Posttraumatic Stress Disorder

OBJECTIVES

The study investigated facial expression recognition (FER) in posttraumatic stress disorder (PTSD) caused by exposure to earthquakes, and in particular whether people with this condition showed a bias toward interpreting facial expressions as threat-related emotions (i.e., as anger, fear, or disgust). The study included a trauma-exposed control group who had been similarly exposed to the earthquakes but had not developed PTSD. We hypothesized that individuals with PTSD would have increased sensitivity to threat-related facial emotions compared with the trauma-exposed control group. This would be shown by increased accuracy in recognition of threat-related emotions and the misinterpretation of neutral expressions to these emotions (i.e., misidentifying them as anger, fear, or disgust). The availability of a group of healthy controls from a previous study who had been tested on a similar task before the earthquakes allowed a further non-exposed comparison.

METHOD

Twenty-eight individuals with PTSD (71% female, mean age 42.8 years) and 89 earthquake-exposed controls (66% female, mean age 50.1 years) completed an FER task, which featured six basic emotions. Further comparisons were made with 50 non-exposed controls (64% female, mean age 38.5 years) who had been tested before the earthquakes.

RESULTS

There was no difference in sensitivity to threat-related facial expressions (as measured by accuracy in recognition of threat-related facial expressions and the misinterpretation of neutral expressions as threatening) in individuals with PTSD compared with similarly earthquake-exposed controls. Supplementary comparison with an historical, non-exposed control group showed that both earthquake-exposed groups had increased accuracy for the identification of all facial emotions and showed a bias in the misclassification of neutral facial expressions to the threat-related emotions of anger and disgust.

CONCLUSION

These findings suggest that it is exposure to earthquakes and repeated aftershocks, rather than the presence of PTSD that affects FER accuracy and misinterpretation. The importance of these biases in both PTSD and trauma-exposed controls needs further exploration and is an area for future research.

C-Type Natriuretic Peptides in Coronary Disease

AIMS

C-type natriuretic peptide (CNP) is a paracrine growth factor expressed in the vascular endothelium. Although upregulated in atheromatous arteries, the predictive value of plasma CNP products for outcome in coronary disease is unknown. This study aimed to compare the prognostic value of plasma CNP products with those of other natriuretic peptides in individuals with coronary artery disease, and investigate their associations with cardiac and renal function.

METHODS AND RESULTS

Plasma concentrations of CNP and amino-terminal proCNP (NT-proCNP) were measured at baseline in 2129 individuals after an index acute coronary syndrome admission and related to cardiac and renal function, other natriuretic peptides [atrial NP (ANP) and B-type NP (BNP)] and prognosis (primary end point, mortality; secondary end point, cardiac readmission). Median follow-up was 4 years. At baseline, and in contrast to CNP, ANP, and BNP, plasma NT-proCNP was higher in males and weakly related to cardiac function but strongly correlated to plasma creatinine. All NPs were univariately associated with mortality. Resampling at 4 and 12 months in survivors showed stable concentrations of NT-proCNP whereas all other peptides declined. When studied by diagnosis (myocardial infarction, unstable angina) at index admission using a multivariate model, NT-proBNP predicted mortality and readmission in myocardial infarction. In unstable angina, only NT-proCNP predicted both mortality and cardiac readmission.

CONCLUSIONS

In contrast to the close association of NT-proBNP with cardiac function, and predictive value for outcome after myocardial infarction, plasma NT-proCNP is highly correlated with renal function and is an independent predictor of mortality and cardiac readmission in individuals with unstable angina.

Heart Fatty Acid Binding Protein and cardiac troponin: development of an optimal rule-out strategy for acute myocardial infarction

BACKGROUND

Improved ability to rapidly rule-out Acute Myocardial Infarction (AMI) in patients presenting with chest pain will promote decongestion of the Emergency Department (ED) and reduce unnecessary hospital admissions. We assessed a new commercial Heart Fatty Acid Binding Protein (H-FABP) assay for additional diagnostic value when combined with cardiac troponin (using a high sensitivity assay).

METHODS

H-FABP and high-sensitivity troponins I (hs-cTnI) and T (hs-cTnT) were measured in samples taken on-presentation from patients, attending the ED, with symptoms triggering investigation for possible acute coronary syndrome. The optimal combination of H-FABP with each hs-cTn was defined as that which maximized the proportion of patients with a negative test (low-risk) whilst maintaining at least 99 % sensitivity for AMI. A negative test comprised both H-FABP and hs-cTn below the chosen threshold in the absence of ischemic changes on the ECG.

RESULTS

One thousand seventy-nine patients were recruited including 248 with AMI. H-FABP < 4.3 ng/mL plus hs-cTnI < 10.0 ng/L together with a negative ECG maintained >99 % sensitivity for AMI whilst classifying 40.9 % of patients as low-risk. The combination of H-FABP < 3.9 ng/mL and hs-cTnT < 7.6 ng/L with a negative ECG maintained the same sensitivity whilst classifying 32.1 % of patients as low risk.

CONCLUSIONS

In patients requiring rule-out of AMI, the addition of H-FABP to hs-cTn at presentation (in the absence of new ischaemic ECG findings) may accelerate clinical diagnostic decision making by identifying up to 40 % of such patients as low-risk for AMI on the basis of blood tests performed on presentation. If implemented this has the potential to significantly accelerate triaging of patients for early discharge from the ED.

Telomere profiles and tumor-associated macrophages with different immune signatures affect prognosis in glioblastoma

Telomere maintenance is a hallmark of cancer and likely to be targeted in future treatments. In glioblastoma established methods of identifying telomerase and alternative lengthening of telomeres leave a significant proportion of tumors with no defined telomere maintenance mechanism. This study investigated the composition of these tumors using RNA-Seq. Glioblastomas with an indeterminate telomere maintenance mechanism had an increased immune signature compared with alternative lengthening of telomeres and telomerase-positive tumors. Immunohistochemistry for CD163 confirmed that the majority (80%) of tumors with an indeterminate telomere maintenance mechanism had a high presence of tumor-associated macrophages. The RNA-Seq and immunostaining data separated tumors with no defined telomere maintenance mechanism into three subgroups: alternative lengthening of telomeres like tumors with a high presence of tumor-associated macrophages and telomerase like tumors with a high presence of tumor-associated macrophages. The third subgroup had no increase in tumor-associated macrophages and may represent a distinct category. The presence of tumor-associated macrophages conferred a worse prognosis with reduced patient survival times (alternative lengthening of telomeres with and without macrophages P=0.0004, and telomerase with and without macrophages P=0.013). The immune signatures obtained from RNA-Seq were significantly different between telomere maintenance mechanisms. Alternative lengthening of telomeres like tumors with macrophages had increased expression of interferon-induced proteins with tetratricopeptide repeats (IFIT1-3). Telomerase-positive tumors with macrophages had increased expression of macrophage receptor with collagenous structure (MARCO), CXCL12 and sushi-repeat containing protein x-linked 2 (SRPX2). Telomerase-positive tumors with macrophages were also associated with a reduced frequency of total/near total resections (44% vs >76% for all other subtypes, P=0.014). In summary, different immune signatures are found among telomere maintenance mechanism-based subgroups in glioblastoma. The reduced extent of surgical resection of telomerase-positive tumors with macrophages suggests that some tumor-associated macrophages are more unfavorable.

Vitamin-mineral treatment of attention-deficit hyperactivity disorder in adults: double-blind randomised placebo-controlled trial

BACKGROUND

The role of nutrition in the treatment of attention-deficit hyperactivity disorder (ADHD) is gaining international attention; however, treatments have generally focused only on diet restriction or supplementing with one nutrient at a time.

AIMS

To investigate the efficacy and safety of a broad-based micronutrient formula consisting mainly of vitamins and minerals, without omega fatty acids, in the treatment of ADHD in adults.

METHOD

This double-blind randomised controlled trial assigned 80 adults with ADHD in a 1:1 ratio to either micronutrients (n = 42) or placebo (n = 38) for 8 weeks (trial registered with the Australian New Zealand Clinical Trials Registry: ACTRN12609000308291).

RESULTS

Intent-to-treat analyses showed significant between-group differences favouring active treatment on self- and observer- but not clinician-ADHD rating scales. However, clinicians rated those receiving micronutrients as more improved than those on placebo both globally and on ADHD symptoms. Post hoc analyses showed that for those with moderate/severe depression at baseline, there was a greater change in mood favouring active treatment over placebo. There were no group differences in adverse events.

CONCLUSIONS

This study provides preliminary evidence of efficacy for micronutrients in the treatment of ADHD symptoms in adults, with a reassuring safety profile.

Does Computer Assisted Navigation Improve Functional Outcomes and Implant Survivability after Total Knee Arthroplasty?

The objective of this study was to determine whether computer assisted navigation in total knee arthroplasty (TKA) improves functional outcomes and implant survivability using data from a large national database. We analysed 9054 primary TKA procedures performed between 2006 and 2012 from the New Zealand National Joint Registry. Functional outcomes were assessed using Oxford Knee Questionnaires at six months and five years. On multivariate analysis, there was no significant difference in mean Oxford Knee Scores between the navigated and non-navigated groups at six months (39.0 vs 38.1, P=0.54) or five years (42.2 vs 42.0, P=0.76). At current follow-up, there was no difference in revision rates between navigated and non-navigated TKA (0.46 vs 0.43 revisions 100 component years, P=0.8).

The use of a lipped acetabular liner decreases the rate of revision for instability after total hip replacement: a study using data from the New Zealand Joint Registry

We compared the rate of revision for instability after total hip replacement (THR) when lipped and non-lipped acetabular liners were used. We hypothesised that the use of a lipped liner in a modular uncemented acetabular component reduces the risk of revision for instability after primary THR. Using data from the New Zealand Joint Registry, we found that the use of a lipped liner was associated with a significantly decreased rate of revision for instability and for all other indications. Adjusting for the size of the femoral head, the surgical approach and the age and gender of the patient, this difference remained strongly significant (p < 0.001). We conclude that evidence from the New Zealand registry suggests that the use of lipped liners with modular uncemented acetabular components is associated with a decreased rate of revision for instability after primary THR.

Circulating miR-323-3p and miR-652: candidate markers for the presence and progression of acute coronary syndromes

BACKGROUND

The prognostic utility of circulating plasma microRNA in patients with acute coronary syndromes (ACS) has been proposed but not yet demonstrated. We set out to investigate circulating microRNA levels in patients incurring recent ACS and examined associations with neurohormones, cardiac structure and function, and survival over 5 years of follow-up.

METHODS

An initial screen of 375 microRNAs was performed in 35 ACS patients and 16 healthy controls. Candidates identified from the initial screen (miR-323-3p, miR-652, miR-27b, miR-103 and miR-208a) were validated in a further cohort of 200 patients at baseline (~ 30 days post-ACS) and at 4 and 12 months post-ACS, and compared with 100 controls.

RESULTS

In the validation cohort, significantly higher levels in patients were replicated for miR-323-3p, miR-652 and miR-27b (10-fold, 2.3-fold and 2.3-fold, respectively, adjusted p<0.05). Lower levels of miR-103 were not replicated and miR-208a was undetectable. From baseline to 4 months post-admission, miR-323-3p and miR-652 remained elevated in patients compared to controls (adjusted p<0.01), with no further change in levels between 4 and 12 months; whereas miR-27b fell to control levels by 4 months. Baseline levels of miR-652 in the lowest tertile were significantly associated with readmission for heart failure (log-rank p<0.001). In combination with NT-proBNP and LVEF, miR-652 significantly improved risk stratification (p<0.001).

CONCLUSIONS

Our study identifies miR-652 as a novel candidate biomarker for post-ACS prognosis beyond existing biomarkers of LVEF and NT-proBNP. Moreover circulating miR-323-3p was markedly elevated in patients for at least a year post-ACS and may be a stable biomarker for ACS.

Genetic polymorphism rs6922269 in the MTHFD1L gene is associated with survival and baseline active vitamin B12 levels in post-acute coronary syndromes patients

Background and Aims

The methylene-tetrahydrofolate dehydrogenase (NADP+ dependent) 1-like (MTHFD1L) gene is involved in mitochondrial tetrahydrofolate metabolism. Polymorphisms in MTHFD1L, including rs6922269, have been implicated in risk for coronary artery disease (CAD). We investigated the association between rs6922269 and known metabolic risk factors and survival in two independent cohorts of coronary heart disease patients.

Methods and Results

DNA and plasma from 1940 patients with acute coronary syndromes were collected a median of 32 days after index hospital admission (Coronary Disease Cohort Study, CDCS). Samples from a validation cohort of 842 patients post-myocardial infarction (PMI) were taken 24–96 hours after hospitalization. DNA samples were genotyped for rs6922269, using a TaqMan assay. Homocysteine and active vitamin B12 were measured by immunoassay in baseline CDCS plasma samples, but not PMI plasma. All cause mortality was documented over follow-up of 4.1 (CDCS) and 8.8 (PMI) years, respectively. rs6922269 genotype frequencies were AA n = 135, 7.0%; GA n = 785, 40.5% and GG n = 1020, 52.5% in the CDCS and similar in the PMI cohort. CDCS patients with AA genotype for rs6922269 had lower levels of co-variate adjusted baseline plasma active vitamin B12 (p = 0.017) and poorer survival than patients with GG or GA genotype (mortality: AA 19.6%, GA 12.0%, GG 11.6%; p = 0.007). In multivariate analysis, rs6922269 genotype predicted survival, independent of established covariate predictors (p = 0.03). However the association between genotype and survival was not validated in the PMI cohort.

Conclusion

MTHFD1L rs6922269 genotype is associated with active vitamin B12 levels at baseline and may be a marker of prognostic risk in patients with established coronary heart disease.

Autoimmune hepatitis: the role of environmental risk factors: a population-based study

PURPOSE

The etiology of autoimmune hepatitis (AIH) likely involves a complex interaction of genetic and environmental factors. We aim to investigate the associations between exposure to putative environmental factors and AIH and to quantify AIH risk in a first-degree relative.

METHODS

We conducted a population-based case-control study. Cases were AIH patients who were alive and resided in Canterbury, New Zealand, between 1 July 2011 and 30 June 2012. Controls were randomly selected from the Electoral Roll and were matched 2:1 to each case by age and gender. Self-reporting questionnaires that cover lifestyle factors, childhood factors and family history were used.

RESULTS

72 AIH cases and 144 controls were included. We found that exposure to antibiotics within 12 months prior to AIH diagnosis (OR 12.98, 95 % CI 2.49-67.67, p < 0.01) was an independent risk factor for the development of AIH. Alcohol consumption (OR 0.43, 95 % CI 0.28-0.68, p < 0.01) and childhood home with wood heating (OR 0.30, 95 % CI 0.14-0.63, p < 0.01) were independently associated with reduced risks of later development of AIH. The crude risk of AIH in first-degree relatives of a patient with AIH was 0.2 % (95 % CI <0.1-2.0).

CONCLUSIONS

We found that antibiotics are an independent risk factor for the development of AIH, whereas alcohol consumption and living in a childhood home with wood heating are independent protective factors against the later development of AIH.

Circulating microRNAs as candidate markers to distinguish heart failure in breathless patients

AIMS

Since their identification in the circulation, microRNAs have received considerable interest as putative biomarkers of cardiovascular disease. We have investigated the diagnostic utility of microRNAs in differentiating between patients with heart failure (HF) and non-HF-related breathlessness, and between HF with reduced (HF-REF) and preserved (HF-PEF) EF.

METHODS AND RESULTS

MicroRNA profiling was performed on plasma from 32 HF and 15 COPD patients, as well as 14 healthy controls. Seventeen microRNAs were selected for validation in 44 HF, 32 COPD, 59 other breathless, and 15 controls. Cases of HF were split evenly between HF-REF and HF-PEF. Diagnostic utility was compared with NT-proBNP and high sensitivity troponin T (hs-troponin T). MiR-103 [area under the curve (AUC) = 0.642, P = 0.007], miR-142-3p (AUC = 0.668, P = 0.002), miR-199a-3p (AUC = 0.668, P = 0.002), miR-23a (AUC = 0.637, P = 0.010), miR-27b (AUC = 0.642, P = 0.008), miR-324-5p (AUC = 0.621, P = 0.023), and miR-342-3p (AUC = 0.644, P = 0.007) were associated with HF diagnosis in regression and receiver operating characteristic (ROC) analyses. Individually, NT-proBNP (AUC = 0.896, P = 9.68 × 10(-14)) and hs-troponin T (AUC = 0.750, P = 2.50 × 10(-6)) exhibited greater sensitivity and specificity. However, combining significantly associated microRNAs with NT-proBNP improved the AUC of NT-proBNP by 4.6% (P = 0.013). Four microRNAs, miR-103, miR-142-3p, miR-30b, and miR-342-3p, were differentially expressed between HF and controls, COPD, and other breathless patients (P = 0.002-0.030). Eight microRNAs that distinguished between HF-REF and HF-PEF in screening (P = 0.017-0.049) were not replicated in the validation.

CONCLUSIONS

Four microRNAs distinguished between HF and exacerbation of COPD, other causes of dyspnoea, and controls. Seven were associated with HF diagnosis in regression and ROC analysis. Although individually NT-proBNP was far superior in predicting HF, combining microRNA levels with NT-proBNP may add diagnostic value.