Diagnosis of myocardial infarction following hospitalisation for exacerbation of COPD

Cardiovascular disease is common in chronic obstructive pulmonary disease (COPD) and raised troponin is common in exacerbations. However, the prevalence of myocardial infarction following hospitalisation for exacerbation of COPD is unknown. Patients aged ≥ 40 yrs hospitalised with acute exacerbation of COPD (n = 242) with ≥ 10 pack-yrs of cigarette smoking were included in a prospective case series conducted in four hospitals. Patients whose primary presenting complaint was chest pain or who had an alternative diagnosis were excluded. Chest pain histories, serial ECGs and troponin levels were obtained. The mean ± SD age was 69 ± 9 yrs; 108 (45%) patients were male and almost half were current smokers. 124 (51%; 95% CI 48-58%) patients had chest pain, which was exertional in 62 (26%). 24 (10%) had raised troponin, among whom, 20 (8.3%; 95% CI 5.1-12.5%) had chest pain and/or serial ECG changes, fulfilling the 2007 Universal Definition of Myocardial Infarction. Neither chest pain (p = 0.77) nor serial ECG changes (p = 0.39) were associated with raised troponin. Raised troponin, chest pain and serial ECG changes are common in patients admitted to hospital with exacerbation of COPD. Overall, one in 12 patients met the criteria for myocardial infarction. Whether these patients would benefit from further cardiac investigation is unknown.     

Indian salutation test in acute dorsal carpometacarpal joint dislocation of the ulnar four fingers

Complete dislocation of the ulnar 4 carpometacarpal joints of the hand (excluding the thumb) is an uncommon injury. Anatomic reduction of the carpometacarpal joint (CMCJ) is essential to maintain function of the hand, and this can often be accomplished by prompt closed reduction and percutaneous Kirschner-wire fixation. The diagnosis is sometimes delayed or missed in the emergency department (ED), and a true lateral radiograph is mandatory in suspected cases. We present a case of dorsal unilateral dislocation of the ulnar 4 CMCJs without associated fracture. The injury was difficult to diagnose because of gross swelling of the hand. We describe a simple clinical test (Indian salutation test) that we found to be very helpful in raising the index of suspicion and hence increasing the likelihood of avoiding any clinical and medicolegal difficulties in such cases. A true lateral radiograph of the wrist confirmed the diagnosis, and prompt closed reduction and percutaneous Kirschner-wire fixation resulted in a good outcome in the case described here.     

Bonded versus banded first molar attachments: a randomized controlled clinical trial

OBJECTIVE: To compare the clinical failure rates of bonded first molar tubes with those of cemented bands during fixed appliance therapy. DESIGN: Prospective randomized controlled clinical trial. SETTING: Two UK hospital orthodontic clinics, February 2001-December 2004. PARTICIPANTS: Hospital waiting list patients needing fixed appliances (n = 110). METHOD: Patients were randomly allocated to two groups. Experimental group patients (n = 55) received single first molar tubes (n = 181) bonded with a no-mix chemically cured composite (Rely-A-Bond) after a 30-second etch. Control group patients (n = 55) were treated with bands (n = 186) cemented with Intact glass ionomer cement (GIC). First-time failures were recorded together with the time of failure. All patients were followed to the end or discontinuation of treatment. RESULTS: First-time failures: bands = 18.8%; bonds = 33.7 %. Bonded tubes were more likely to fail [RR 2.4; 95% CI (1.4, 4.1)] compared with bands. Experimental group patients also had more bracket failures (P = 0.009), when analysed at patient level. CONCLUSION: First molar tubes bonded with Rely-A-Bond composite showed a significantly higher first-time failure rate than bands cemented with Intact GIC.     

The prevalence of fibromyalgia in axial spondyloarthritis

Rheumatology International - Comorbid fibromyalgia, in axial spondyloarthritis (axSpA) has been shown to influence disease activity and function, and quality of life. Although several papers exist,...     

Haploidentical Bone Marrow Transplantation with Post-Transplant Cyclophosphamide Using Non–First-Degree Related Donors

Outcomes of nonmyeloablative (NMA) haploidentical (haplo) blood or marrow transplant (BMT) with post-transplantation cyclophosphamide (PTCy) using non–first-degree relatives are unknown. We evaluated 33 consecutive adult patients (median age, 56 years) with hematologic malignancies who underwent NMA haplo T cell–replete BMT with PTCy at Johns Hopkins using second- or third-degree related donors. Donors consisted of 10 nieces (30%), 9 nephews (27%), 7 first cousins (21%), 5 grandchildren (15%), and 2 uncles (6%). Thirty-one patients (94%) reached full donor chimerism by day 60. The estimated cumulative incidence (CuI) of grades II to IV acute graft-versus-host disease (aGVHD) at day 180 was 24% (90% confidence interval [CI], 9% to 38%). Only 1 patient experienced grades III to IV aGVHD. At 1 year the CuI of chronic GVHD was 10% (90% CI, 0% to 21%). The CuI of nonrelapse mortality at 1 year was 5% (90% CI, 0% to 14%). At 1 year the probability of relapse was 31% (90% CI, 12% to 49%), progression-free survival 64% (90% CI, 48% to 86%), and overall survival 95% (90% CI, 87% to 100%). The 1-year probability of GVHD-free, relapse-free survival was 57% (90% CI, 41% to 79%). NMA haplo BMT with PTCy from non–first-degree relatives is an acceptably safe and effective alternative donor platform, with results similar to those seen with first-degree relatives.     

A national confidential enquiry into community acquired pneumonia deaths in young adults in England and Wales. British Thoracic Society Research Committee and Public Health Laboratory Service

BACKGROUND: The aim of this study was to describe the frequency, causal pathogens, management, and outcome of a population of young adults who died from community acquired pneumonia (CAP). METHODS: Pneumonia deaths in England and Wales in adults aged 15-44 were identified between September 1995 and August 1996. Patients with underlying chronic illness including HIV infection were excluded. Clinical details for each case were collected from the hospital and general practitioner records. RESULTS: Death from CAP was identified in 27 previously well young adults (1.2 per million population per year). Twenty were known to have consulted a GP for this illness. Nine received antibiotics before hospital admission. A causative pathogen was identified in 17 cases (Streptococcus pneumoniae in eight). Bacteraemia was present in seven. All patients who reached a hospital ward received antibiotics (69% within two hours of admission). The British Thoracic Society antibiotic guidelines for severe CAP were followed in only 10 cases. Cardiac arrest at home or on arrival at hospital occurred in six cases, one of whom was successfully resuscitated. Of the remaining 21 patients, 71% had two or more markers of severe CAP. All 22 who were admitted reached an intensive care unit, but 11 of these required transfer to another hospital for some aspect of intensive care. One third of patients died within 24 hours of presenting to the hospital. CONCLUSIONS: Death from CAP in previously fit young adults still occurs. While some deaths might be preventable by better patient management, most are unlikely to be preventable by current management practices.