155 Fracture of Pubic Rami During Hip Fracture Fixation - a Rare Case of Traction Table Related Injury

Background

Traction tables form the mainstay of closed reduction techniques for lower limb fracture and in particular hip fractures. They offer a versatile solution to continuous traction required in a variety of operations such as closed intramedullary femoral fixation and hip fixation. Counter traction on the table is provided by the perineal post, this has been associated with significant complications such as neuropraxia, erectile dysfunction, cutaneous necrosis, and urethral injuries.

Case presentation

We present a case of an elderly and co-morbid patient who was scheduled to undergo a hip fracture fixation using an intramedullary nail. Unfortunately, this was delayed by 3 weeks as the patient was unfit to undergo this procedure. She was placed onto the traction table and intra-operatively sustained a superior and inferior pubic rami fracture while attempting reduction on the traction table.

Conclusions

Closed reduction techniques using traction tables and perineal posts are not without morbidity. Risk factors such as osteoporosis and delayed fixation should be accounted for when managing this complex and often frail group of patients.

Sodium-glucose co-transporter-2 inhibitors improve cardiovascular outcomes in heart failure with reduced ejection fraction regardless of ischemic etiology

Background

Coronary artery disease remains the main underlying cause of heart failure (HF), despite the progress in prevention, diagnosis and treatment. Sodium-glucose co-transporter-2 inhibitors have been shown to improve surrogate cardiovascular outcomes in patients with HF with reduced ejection fraction (HFrEF), regardless of diabetes status.

Purpose

We sought to determine the effect of SGLT-2 inhibitors on the primary composite endpoint (cardiovascular death or hospitalization for HF) across the two hallmark trials in the HFrEF population (EMPEROR Reduced and DAPA-HF), according to ischemic or non-ischemic etiology of HF.

Methods

We pooled data from EMPEROR reduced and DAPA-HF trials in a total of 8,474 patients with HFrEF, performing a sub-analysis according to the presence of ischemic cardiomyopathy as the underlying cause of HFrEF.

Results

Treatment with SGLT-2 inhibitors resulted in a significant decrease in the risk for the primary composite outcome in patients with HFrEF of ischemic etiology, equal to 18% (RR=0.82, 95% CI: 0.73–0.92, I2=0%). In patients with HFrEF of non-ischemic etiology, SGLT-2 inhibitors produced a significant decrease in the risk for the primary composite outcome equal to 18% (RR=0.72, 95% CI: 0.63–0.82, I2=0%). Despite the greater effect in patients with non-ischemic HFrEF, no subgroup difference was detected (p=0.16). Generated results are summarized in Figure 1.

Conclusions

SGLT-2 inhibitors improve surrogate cardiovascular outcomes both in patients with ischemic and non-ischemic HFrEF.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Risk of death with sodium-glucose co-transporter-2 inhibitors across the hallmark cardiovascular and renal outcome trials: an updated meta-analysis

Background

Patients with type 2 diabetes mellitus (T2DM) experience a 15% increase in the risk for death compared to the general population, with age less than 55 years, insufficient glycemic control and albuminuria representing the major risk factors for all-cause and cardiovascular mortality. Despite progression in diagnosis and treatment, mortality remains elevated among affected individuals. Sodium-glucose co-transporter 2 (SGLT-2) inhibitors are considered as the optimal treatment option for patients with T2DM and concomitant cardiovascular or renal disease, while these regimens demonstrated a clear benefit in all-cause and cardiovascular mortality compared to placebo.

Purpose

As we recently welcomed the publication of large-scale randomized controlled trials (RCTs) with SGLT-2 inhibitors addressing surrogate, hard endpoints, we sought to perform an updated meta-analysis, investigating the effect of SGLT-2 inhibitors on all-cause, cardiovascular and renal death among the high- or very-high risk patients enrolled in those trials.

Methods

We pooled data from the relevant, recent hallmark RCTs; 10 trials were included in our analysis encompassing a total of 71,533 enrolled participants, assigned either to SGLT-2 inhibitor treatment or placebo. We set cardiovascular death as the primary efficacy outcome, while we assessed all-cause death and renal death as secondary efficacy outcomes.

Results

Treatment with SGLT-2 inhibitors resulted in a significant decrease in the risk of cardiovascular death, equal to 14% (RR = 0.86, 95% CI; 0.80 to 0.93, I2=22%). Only canagliflozin produced a significant result, while dapagliflozin led to a marginally non-significant reduction in cardiovascular mortality (Figure 1). Notably, SGLT-2 inhibitors led to a significant decrease in the risk for all-cause death, equal to 14% (RR=0.86, 95% CI; 0.81 to 0.92, I2=34%) the result was significant only for canagliflozin and dapagliflozin, while none of the rest SGLT-2 inhibitors resulted in a significant decrease in the risk for all-cause death (Figure 1). SGLT-2 inhibitors also produced a non-significant decrease in the risk for renal death (RR=0.36, 95% CI; 0.12 to 1.14, I2=0%). Neither canagliflozin nor dapagliflozin had a significant impact on risk reduction for renal death, while no cases of renal death were reported in VERTIS CV trial. No subgroup differences were identified for any of the three comparisons (Figure 2).

Conclusions

Antidiabetic treatment with SGLT-2 inhibitors provides a clear benefit in terms of cardiovascular and all-cause mortality for the very high-risk patients enrolled in the cardiovascular and renal outcome trials. Canagliflozin seems to be associated with the greatest impact on risk reduction for all-cause and cardiovascular death, followed by dapagliflozin.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Meta-analysis assessing cardiovascular outcomes with febuxostat versus allopurinol for patients with gout

Background

Gout, the most common inflammatory arthritis in the USA, represents an established risk factor for cardiovascular disease and coronary artery disease mortality. In addition, patients with gout experience an increased risk for non-fatal myocardial infarction, while they might also feature increased risk for stroke. Recent real-world data also highlight the association between gout and atrial fibrillation, which inevitably augments cardiovascular burden. Allopurinol, a xanthine oxidase inhibitor, remains the uric acid-lowering treatment option of first choice, while febuxostat is prescribed, when allopurinol is contraindicated or not tolerated. Unfortunately, medication adherence among gout patients is poor, associated with age and related co-morbidities.

Purpose

We sought to determine the comparative efficacy of febuxostat versus allopurinol across surrogate cardiovascular outcomes of interest, by pooling data from the 2 dedicated cardiovascular outcome trials available so far. The motive for this analysis was the U.S. Food and Drug Administration (FDA) warning raised after the publication of the CARES trial, regarding the increased risk for cardiovascular and all-cause death with febuxostat compared to allopurinol.

Methods

We pooled data from the 2 dedicated cardiovascular outcome trials (CARES and FAST) and we assessed the following cardiovascular outcomes of interest: cardiovascular death, all-cause death, non-fatal myocardial infarction (MI), non-fatal stroke, fatal MI, fatal stroke, transient ischemic attack, hospitalization for heart failure, coronary revascularization, cerebrovascular revascularization and atrial fibrillation. Risk of bias was low across the included studies.

Results

Our analysis in a total of 12,318 patients with gout showed that febuxostat compared to allopurinol treatment does not confer significant risk reduction for any of the assessed, prespecified surrogate outcomes in a study population with significant cardiovascular co-morbidities (Figure 1). One third of patients enrolled in the FAST trial and 40% of the patients enrolled in the CARES trial had pre-existing cardiovascular disease, as depicted in Figure 2. Heterogeneity was low for the vast majority of the assessed outcomes, except for cardiovascular and all-cause death and fatal MI.

Conclusions

There is no significant difference across surrogate cardiovascular outcomes of interest between febuxostat and allopurinol in patients with gout and cardiovascular co-morbidities. Febuxostat seems to be a safe treatment alternative to allopurinol, despite initial concerns in terms of its cardiovascular safety.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Meta-analysis of cardiovascular outcome trials assessing the cardiovascular efficacy and safety of dipeptidyl peptidase-4 inhibitors in patients with type 2 diabetes mellitus

Background

Type 2 diabetes mellitus (T2DM) represents an independent risk factor for the development of cardiovascular disease, which accounts for half of deaths among the affected patients. Patients with T2DM experience higher incidence of vascular interventions compared to high-risk patients without T2DM or cardiovascular disease at baseline, underscoring the necessity for targeted therapeutic interventions. Dipeptidyl peptidase-4 (DPP-4) inhibitors constitute a safe treatment option with fair glycemic efficacy in T2DM whose cardiovascular efficacy has been doubted over recent years. A series of randomized controlled trials (RCTs) addressing cardiovascular outcomes with DPP-4 inhibitors have been recently published, while previous meta-analyses failed to show any cardiovascular benefit with their use in patients with T2DM.

Purpose

The purpose of our analysis was to report the impact of antidiabetic treatment with DPP-4 inhibitors on different cardiovascular efficacy outcomes.

Methods

We searched PubMed for all published RCTs assessing cardiovascular outcomes after antidiabetic treatment with DPP-4 inhibitors. We extracted data related to the following efficacy outcomes: fatal and non-fatal myocardial infarction, fatal and non-fatal stroke, hospitalization for heart failure, hospitalization for unstable angina, hospitalization for coronary revascularization and cardiovascular death.

Results

We pooled data from a total of 6 trials in a total of 52,520 patients. Antidiabetic treatment with DPP-4 inhibitors did not significantly affect any of the prespecified cardiovascular efficacy outcomes. More specifically, DPP-4 inhibitors compared to control led to a non-significant increase in the risk for fatal and non-fatal myocardial infarction (RR=1.02, 95% CI: 0.94–1.11, I2=0%), hospitalization for heart failure (RR=1.09, 95% CI: 0.92–1.29, I2=65%) and cardiovascular death (RR=1.02, 95% CI: 0.93–1.11, I2=0%), as shown in figures 1a, 1c and 1f. In addition, DPP-4 inhibitors produced a non-significant decrease in the risk for fatal and non-fatal stroke (RR=0.96, 95% CI: 0.85–1.08, I2=0%) and coronary revascularization (RR=0.99, 95% CI: 0.90–1.09, I2=0%), as depicted in figures 1b and 1e. Finally, DPP-4 inhibitors demonstrated a neutral effect on the risk for hospitalization due to unstable angina (RR=1.00, 95% CI: 0.85–1.18, I2=0%), as shown in figure 1d.

Conclusions

Antidiabetic treatment with DPP-4 inhibitors does not seem to confer any significant cardiovascular benefit for patients with T2DM.

Funding Acknowledgement

Type of funding sources: None. Figure 1

First results from the CERN axion solar telescope

Hypothetical axionlike particles with a two-photon interaction would be produced in the sun by the Primakoff process. In a laboratory magnetic field ("axion helioscope"), they would be transformed into x-rays with energies of a few keV. Using a decommissioned Large Hadron Collider test magnet, the CERN Axion Solar Telescope ran for about 6 months during 2003. The first results from the analysis of these data are presented here. No signal above background was observed, implying an upper limit to the axion-photon coupling g(agamma)<1.16x10(-10) GeV-1 at 95% C.L. for m(a) less, similar 0.02 eV. This limit, assumption-free, is comparable to the limit from stellar energy-loss arguments and considerably more restrictive than any previous experiment over a broad range of axion masses.

Region-based image watermarking

We introduce a novel method for embedding and detecting a chaotic watermark in the digital spatial image domain, based on segmenting the image and locating regions that are robust to several image manipulations. The robustness of the method is confirmed by experimental results that display the immunity of the embedded watermark to several kinds of attacks, such as compression, filtering, scaling, cropping, and rotation.

Immunological studies in children with acute viral hepatitis

Sera from 116 consecutive unselected cases of sporadic acute viral hepatitis in children were examined for hepatitis B antigen (HBAg), smooth-muscle autoantibodies (SMA), other autoantibodies and immunoglobulins, and skin tests were performed with dinitrochlorobenzene (DNCB). HBAg was detected in twenty-one and SMA in ninety-eight out of 116 sera that had been obtained during the 1st or 2nd week from the onset of jaundice. Hepatitis B antigen was present in seventeen out of the eighteen SMA negative patients (94-4%) and in only four out of the ninety-eight SMA-positive patients (4-1%). The presence of SMA was not related to the sex and age of the patients or to the serum bilirubin and transaminase levels. SMA did not persist for more than 6 weeks from the onset of jaundice in most of the cases. In twenty-eight out of forty-one sera which were tested the IgM level was found to be elevated during the acute phase of illness and within normal limits during the recovery stage. A negative correlation between the presence of SMA and the elevated serum IgM level and the presence of HB Ag in the same patients was observed. The DNCB skin test was found to be positive in all fifty-two patients who did not have HBAg in their serum and in twenty out of the twenty-one patients who had circulating HbAg. From these findings there appears to be no gross impairment of cell-mediated immunity in acute viral hepatitis, and hepatitis A is associated with SMA production and an increase in serum IgM levels, when compared to hepatitis associated with HBAg.